Fetal Treatments
The goal of the Texas Fetal Center offers is to ensure the well-being and safety of you and your baby. Although many prenatal diagnosis are treated after the baby is born, some life-threatening conditions may benefit from interventions during pregnancy. After a comprehensive evaluation, your physicians and specialists at the Center may recommend that fetal therapy is necessary without endangering the health and safety of mother. The Center currently offers the following fetal therapies.
What is an Ex Utero Intrapartum Treatment (EXIT) procedure?
An EXIT procedure is a well-organized multidisciplinary treatment plan for mothers and babies in which there are concerns for breathing difficulties at time of delivery. The EXIT is a treatment strategy that uses the mother’s placental support to maintain the baby’s oxygenation while the doctors assess and treat the baby in order to ensure its breathing capabilities. Although similar to a Cesarean delivery, the EXIT procedure requires special considerations and treatments for mother and baby. There have been several different diseases in which an EXIT procedure has been utilized.
Which conditions are treated with an EXIT procedure?
EXIT procedures are utilized when your doctors are concerned that your baby may not be able to breathe adequately on their own at time of delivery. This can be for several reasons including problems with the lungs or masses of the neck or chest that may be compressing the airway. Such indications have included, but not limited to:
- Large Fetal Neck Masses
- Congenital Diaphragmatic Hernias
- Congenital High Airway Obstructions
- Lung masses
- Chest or mediastinal tumors
The decision to perform an EXIT procedure at time of delivery will be determined by your team of doctors at the Center.
What special considerations should be made at time of delivery?
Type of delivery - EXIT procedures are performed through a Cesarean delivery. A team of adult and pediatric specialist will work together during the procedure to ensure the safety of mother and child.
Place of delivery - Babies that typically require an EXIT procedure should be cared for at a hospital with adult and pediatric specialists. Because of the concerns with breathing at birth and the potential need for further interventions, this requires specialists that can care for the mother and child at delivery as well as after birth. If the condition requires further surgery, the infant must be in a facility that has neonatal surgical and intensive care capabilities. Therefore, delivery should be in a facility with a neonatal intensive care unit and immediate access to a pediatric surgeon.
Time of delivery - Because an EXIT procedure is a well-planned strategy amongst many doctors and specialists, your delivery will be scheduled so that the entire team can prepare for the delivery of your baby. If there are no specific reasons to deliver early, your baby will be born at or near term. If the baby’s condition deteriorates, earlier delivery may be necessary.
What will happen at the EXIT procedure?
The entire team will carefully plan for the delivery of your baby with preparation to perform an EXIT procedure. Although an EXIT procedure utilizes an incision similar to a Cesarean, the goals of an EXIT are very different with special concerns. Instead of stopping blood flow and allowing the placenta to separate from the uterus, an EXIT procedure tries to ensure oxygenation between mother and baby. This maintains the circulation of blood, nutrients, and oxygen to the fetus so that your doctors have time to assess the airway and perform all necessary treatments. Special considerations are made to ensure that mother and child are provided adequate anesthesia. As the infant is delivered, mother and baby are placed on special monitors.
At this point, depending on the disease, one of three scenarios may occur.
- EXIT to Airway – Your doctors may assess the airway of your baby a try to place a breathing tube to ensure its ability to breathe. Sometimes, this maneuver can be very difficult or impossible. If your doctors are unable to place a breathing tube other surgical options may be necessary.
- EXIT to Surgery – After your doctors assess the airway and are unable to place a breathing tube, surgery may be necessary to place a breathing tube. A tube can be placed directly into the trachea (windpipe) if it is not able to be passed from the mouth. Occasionally, a large neck mass might prevent the surgical placement of the breathing tube. In this situation, the mass may need to be removed (resected) at the time of delivery while the fetus is still being supported by mother.
- EXIT to ECMO – Depending on the disease, the baby may not be able to breathe properly or obtain enough oxygen despite having an airway. In this case, the baby may require a heart-lung bypass (Extra-Corporeal Membrane Oxygenation (ECMO)) at time of delivery. This will ensure that the proper amount of oxygen is provided to the baby before separation from the mother.
The EXIT procedure is performed in the operating room with all the special equipment necessary to ensure the safety of you and your baby. Afterwards, the mother will be admitted to the Women’s Center and the baby to the Neonatal Intensive Care Unit at Children’s Memorial Hermann Hospital to monitor for complications. The mother’s recovery will be similar to those who undergo regular Cesarean delivery. A pediatric surgeon will evaluate the infant and discuss the next appropriate steps in therapy.
What is a Fetoscopy?
Fetoscopy is a technique that utilizes a small camera or scope to examine and perform procedures on the fetus during pregnancy. The scope is introduced through a small incision on the mother’s abdomen and placed into the amntiotic sac through the uterus. This allows a visual assessment of any abnormalities during pregnancy. Fetoscopy is used for several different diseases and has been used to perform surgical procedures and collecting biopsies.
Which conditions are treated with Fetoscopy?
Historically, fetoscopy has been utilized for many different fetal conditions. However, only three disease conditions routinely utilize this technique.
- Twin-Twin Transfusion Syndrome – A fetoscope is utilized to provide a visualization of the abnormal blood vessels between twins that cause this disease. The scope also allows the placement of the laser device which is utilized to disconnect abnormal blood vessel connections
- Amniotic Band Syndrome – Fetoscopy allows visualization of the abnormal bands of tissue from the amniotic membrane which are stuck to the fetus. These bands can cause strictures or amputations of vital organs and limbs. The scope allows the ability to release the bands.
- Congenital Diaphragmatic Hernia – A potential fetal therapy for CDH is the placement of a balloon in the trachea that promotes lung growth. This technique requires fetoscopy to visualize the fetal airway (trachea). Balloon occlusion for CDH remains experimental and is under clinical investigation at this point. This therapy is currently undergoing clinical trials.
Please keep in mind that fetoscopy is a rarely utilized procedure and for each patient diagnosed with any of the above conditions, only a few will need fetal intervention. The recommendation to perform fetal intervention and fetoscopy will be determined by your team of doctors at the Center and discussed with you.
What special considerations should be made at time of delivery?
Type of delivery - If all goes well with the fetoscopic intervention, your pregnancy will be allowed to progress to term and depending on the condition, delivery usually does not require a Cesarean delivery. The need for this fetal intervention should not impact your type of delivery. The delivery plan should be carefully discussed between the mother and the obstetrician.
Place of delivery - Depending on the condition, your baby may or may not need special medical care after birth. If all the prenatal monitoring suggests that your baby is doing well, the baby can be delivered at the hospital of your choice. However, the hospital should be prepared to handle any intensive care of your newborn and have a neonatal intensive care unit with the capability to provide specialized care.
Time of delivery - There is no reason to intentionally induce early delivery. After the fetoscopic procedure, your pregnancy will be closely monitored. The team at the Center may recommend early delivery for pregnancies that appear to be in danger.
What will happen at the Fetoscopy procedure?
The entire team will carefully plan for the fetoscopy procedure with preparation to handle all potential complications. Generally, the procedure is performed under sedation and local anesthesia. Your doctors will repeat a detailed ultrasound to confirm the problem and identify the abnormalties. A small skin incision is made to allow the placement of the scope. Once inside the amniotic sac, your doctors will perform the necessary procedure. On occasion, the fetoscopy procedure cannot be performed with a small skin incision due to the location of the fetuses and placenta in the uterus. In these situations, the procedure requires a larger incision to expose the uterus in order to provide a safe window for the scope.
The fetoscopy procedure is performed in the operating room with all the special equipment necessary to ensure the safety of you and your baby. Afterwards, the mother will be admitted to the Women’s Center to monitor for preterm labor and complications at Children’s Memorial Hermann Hospital.
What are the risks and considerations?
The major risk of fetoscopy is injuring and losing the fetus during the procedure. The risks and benefits of the procedure will be carefully explained. If all goes well with the procedure, your pregnancy will be carefully monitored for preterm labor and premature delivery.
What is a Radio-Frequency Ablation (RFA)?
RFA is a procedure utilized to stop the blood flow in an abnormal fetus. It uses a small needle device that is inserted by ultrasound guidance to identify the insertion of the umbilical cord to the fetus. The needle is turned “on” until there is no more blood flow going to the fetus. The advantage of this technique is the small size of the RFA needle which minimizes the risks of preterm labor. The remains of the abnormal fetus will either become smaller or pass during delivery.
Which conditions are treated with RFA?
RFA procedures are typically utilized in abnormal twin pregnancies. Your doctors may have identified a condition in which one abnormal twin is threatening the life of the other normal twin. In these situations, it may be necessary to stop the blood flow to the abnormal twin. RFA has been utilized in many obstetrical diseases but has mostly been performed for Twin Reverse Arterial Perfusion Sequence (TRAP). For twin pregnancies with an acardiac/acephalic twin, the abnormal fetus can be a cardiac burden on the normal twin and cause heart failure. As a result, RFA can be utilized to stop the connection between the two fetuses.
The recommendation to perform RFA for TRAP sequence will be determined by your team of doctors at the Center.
What special considerations should be made at time of delivery?
Type of delivery - Typically, RFA procedures do not require Cesarean delivery. The need for this fetal intervention should not impact your type of delivery. The delivery plan should be carefully discussed between the mother and the obstetrician.
Place of delivery - If all the prenatal monitoring suggests that your baby is doing well, the baby can be delivered at the hospital of your choice. However, the hospital should be prepared to handle any intensive care of your newborn and have a neonatal intensive care unit with the capability to provide specialized care.
Time of delivery - Unless there are signs of fetal heart failure due to the TRAP sequence or complications from the RFA procedure, there is no reason to intentionally induce early delivery. After the RFA procedure, your pregnancy will be continual to be monitored. If your baby is far enough along to survive delivery, the team at the Center may recommend early delivery for pregnancies that appear to be in danger.
What will happen at the RFA procedure?
The entire team will carefully plan for the RFA procedure with preparation to handle all potential complications. Generally, the procedure is performed under IV sedation and local anesthesia. Your doctors will repeat a detailed ultrasound to confirm the problem and identify the abnormal twin and identify a pathway for the RFA needle that avoids the other twin and the placenta. A small skin incision is made to allow the placement of the RFA needle. The RFA needle is activated until blood flow is stopped in the abnormal twin. On occasion, the RFA procedure cannot be performed with a small skin incision due to the location of the fetuses and placenta in the uterus. In these situations, the procedure requires a larger incision to expose the uterus in order to provide a safe window for the RFA needle.
The RFA procedure is performed in the operating room with all the special equipment necessary to ensure the safety of you and your baby. Afterwards, the mother will be admitted to the Women’s Center to monitor for preterm labor and complications at Children’s Memorial Hermann Hospital.
What will happen at birth?
Your pregnancy should continue normally. The normal twin can be delivered without special considerations. Although your team of doctors at the Center will continue to closely follow your pregnancy, the plan for delivery can be made with your personal obstetrician.
What are the long-term outcomes and considerations?
Utilizing RFA to treat TRAP sequence has been shown to be extremely effective. Our colleagues at the University of California, San Francisco have reported a success rate of greater than 90% survival of the normal twin with an average gestational age of delivery of 35 weeks. Although not every pump twin survives this condition or the procedure, there have not been any reported harmful long-term outcomes regarding RFA and pregnancies with TRAP sequence.