Fetomaternal Medicine(Maternal-fetal Medicine)
CIMAR maternal-fetal medicine unit is unique and probably the first and only unit in South India that combines the maternal-fetal medicine experts in India and finesse of high risk pregnancy management. A group of committed obstetricians, radiologists, geneticists and neonatologists ensure that both the mother and child successfully complete their 9 month long journey from pregnancy to motherhood. Maternal-fetal medicine (MFM) (also known as perinatology) is a branch of medicine that focuses on managing health of the mother and fetus prior to, during, and shortly after pregnancy.
Who should schedule a visit to Maternal-fetal medicine specialist?
If the expectant mother is at risk for complications during pregnancy, caused by disorders of medical and surgical, her pregnancy could be high risk pregnancy. The disorders may be heart disease, high blood pressure, pre-eclamsia, diabetes, thyroid disorders, kidney disease, gastrointestinal disease, infectious diseases. A healthy women without any medical and surgical disorders may also see a maternal-fetal medicine specialist, if she is pregnant with multiple babies, history of recurrent pregnancy losses, suspected fetal growth restriction, or any possible birth defects. In these situations a maternal-fetal medicine specialist at CIMAR will provide and care to both the mother and fetus during complicated pregnancy.
What is the role of Maternal-fetal medicine in proving care to high risk pregnancies?
A maternal-fetal medicine specialist has knowledge on the most appropriate approach to the diagnosis and treatment to case to case high risk pregnancies. The maternal-fetal medicine unit at CIMAR works together with obstetricians, radiologists, geneticists and neonatologists to overcome the increased risk of serious medical complications. The maternal-fetal medicine specialist provides consultations and co-management or direct care for complicated situations both before and during pregnancy.
The services that are available at our centre are
- 3D-4D Scan
- First Trimester Screening
- Targeted Scan
- Fetal Echo
- Growth & Doppler Scan
- Prenatal Invasive Diagnostic tests
- Fetal Therapy
- High Risk Pregnancy Management
- Fetal Autopsy
First Trimester Screening
- All the consultants performing the NT scan are accredited with Fetal Medicine Foundation, UK
- Every pregnancy either normal/assisted carries a risk of anueploidies. A 12th week scan which measures the NT and combines it with maternal serum BHCG & PAPP-A is used to determine the risk of each individual woman. An increased risk would require INVASIVE TESTING
- A unique feature of the first trimester scan is that it allows us to pick up major structural anomalies at the earliest.
- A sophisticated high end USG machine with state of the art 3D & 4D capabilities is used to detect congenital abnormalities in the fetus.
- This scan is usually done at 18 to 22 weeks and has a high sensitivity to pick up malformations.
After ensuring that the fetus is both structurally and genetically normal, the next important step is to ascertain adequate growth and development of the fetus. This is achieved through serial Doppler assessment which scrutinizes well being of the fetus.
A highly specialized evaluation of the foetal heart is done at 20-22 wks gestation.
- Previous child with heart disease
- Mother with heart disease
- Mother with G.D.M.
Pre-natal Invasive Diagnostic Tests
Test – Amniocentesis
Timing – 16-24 wks
Indications – Karyotyping
Test – Chorionic Villous Sampling
Timing – 11-14 wks
Indications – Single gene studies, Karyotyping
Test – Percutaneous Umbilical Blood Sampling
Timing – 24 wks onwards
Indications – Karyotyping, single gene studies, Infection screening
Procedure – Amnioinfusion
Indications – Oligamnios
Procedure – Amnioreduction
Indications – Polyhydramnios, TITS
Procedure – Amniopatch
Indications – “PPROM”
Procedure – Fetal Reduction
Indications – Multiple Pregnancy
Procedure – Fetal Blood Transfusion
Indications – Rh Isoimmunisation/other fetal anaemia
Procedure – Intrauterine Shunt
Indications – Bladder outlet obstructions
High Risk Pregnancy Management
Pregnancy and child birth are a routine affair but for a certain group of women, this seemingly innocuous event requires specialized care. Women with Diabeties, high blood pressure, heart disease, autoimmune disorders, multiple pregnancies, etc., fall into this high risk group.
Our Feto Maternal Unit uses an integrated approach that utilizes various surveillance modalities like NST, BPP & Doppler to ensure that even these high risk groups have a safe and uneventful pregnancy.
- Fetal autopsy aids USG in reaching a final diagnosis in babies with structural abnormalities.
- An accurate diagnosis helps in predicting the recurrence risk for each couple
- Fetal autopsy is carried out by fetal medicine specialists with special training in fetal autopsy.
- Our Feto Maternal Unit uses an integrated approach that utilizes various surveillance modalities like NST, BPP & Doppler to ensure that even these high risk groups have a safe and uneventful pregnancy.
In the present era, risks of Monochorionic pregnancies are on the rise all over the state. Monochorionic pregnancies have an inherent complication rate of 10-15%. Therein lies the importance of treating these complications with fetoscopy
Treatment modalities available in Monochorionic pregnancy management are:
- Interstitial laser
- Bipolar Cord Coagulation
- Laser photo coagulation
Fetoscopic Laser Photocoagulation
Fetoscopic laser photocoagulation is usually performed using endoscopes from 1.2mm to 3.3mm in diameter that directly visualize the vessels on the placental surface. Once these intertwin communicating vessels are identified, they are photocoagulated using laser energy. The procedure stops the transfer of blood between fetuses, often halting the progression of TTTS. Thorough evaluation, including ultrasound and fetal echocardiogram will be conducted and the TTTS staged according to quintero staging to decide if fetoscopic laser photo coagulation is an appropriate option. Generally, the fetus should be between 16 and 26 wks gestation with no other significant anomalies and the mother should be healthy and have normal cervical length.
Bipolar Cord Coagulation
In monochorionic pregnancies, demise of one twin in uterus can cause severe hemodynamic imbalance and intra uterine death for the healthy co-twin in atleast 12% of cases and around 18% of survivors have neurological sequelae. Selective feticide in monochorionic pregnancies can only be performed by using cord occlusion techniques.
Bipolar umbilical cord coagulation is performed using a 2.5mm diameter bipolar forceps. The procedure aims at coagulating the cord at the placenta or abdominal insertion.
TRAP sequence otherwise called asacardiac twinning is the most extreme form of intertwin transfusion occurring in 1% of monochorionic pregnancies.
This sequence is characterized by an acardiac perfused twin, which receive its arterial blood supply parasitically via a large A-A anastomosis from a normal ‘pump’ co-twin. The perfused twin’s blood supply is by definition deoxygenated and results in absent or rudimentary development of head, heart and upper limb structures. The pump twin develops normally but is at risk of high output cardiac failure and polyhydramnios. Laser is used to burn the connection between the pump twin and acardiac twin.
Fetal Intrauterine Transfusion
Intrauterine transfusion is a procedure in which red blood cells from a donor are injected into the fetus after being prepared. Intrauterine transfusion may be recommended when a fetus has anemia (low red blood cell count).
Fetalanemia may be caused by:
- Rh icompatibility: When the mother and fetus have different blood types, the antibodies in the mother’s blood may destroy blood cells in the fetus.
- Parvovirus B19 viral infection in the mother.
- Twin Anemia Polycythemia sequence.
Goals of intrauterine transfusion are to prevent or treat fetal heart failure (hydrops), which can be caused by anemia and to allow the pregnancy to continue so the baby can be more developed when it is born.
About the procedure
Intrauterine transfusion is performed in the hospital. The mother is given antibiotics, local anesthesia and IV sedation which also sedates the fetus. The fetus may be given additional medicine to stop movement. Using ultrasound to determine the position of the fetus and placenta, the surgeon inserts a needle into the mother’s abdomen and then into the umbilical cord vein. Red blood cells that are compatible with the fetus’ blood type are passed through the needle into the fetus. Fetal transfusions may need to be repeated every few weeks until the fetus is ready to be born.
The chance of problems is rare, but there are risks in every procedure. In intrauterine transfusion, these may include:
- Fetal distress and the need for caesarean section delivery
- Premature labour.
- Cramping or vaginal bleeding or discharge.
Fetal shunt placement
In fetal shunt placement, a shunt (hollow tube) is inserted through the mother’s abdomen and uterus into the fetus to drain pathological fluid collection within the fetus.Currently,the most common type of shunt placement in thoracoamniotic shunting done for abnormal fluid collection in the lung. This helps in maturation of lungs so that baby is able is able to breath immediately after birth.
Previously vesicoamniotic shunting was done for urinary tract obstruction which is largely being abandoned because of poor long term prognosis