Fetal Articles of Interest

Articles

Fetal Diagnosis and Therapy during the COVID-19 Pandemic: Guidance on Behalf of the International Fetal Medicine and Surgery Society [1], Deprest et al. Fetal Diagn Ther 2020; 47(9):689-698.

The COVID-19 pandemic has stressed patients and healthcare givers alike and challenged our practice of antenatal care including fetal diagnosis and therapy.

Reviews relevant recent information to allow optimize prenatal care delivery. Potential modifications to obstetric management and fetal procedures in SARS-CoV2-negative and SARS-CoV2-positive patients with fetal anomalies or disorders are discussed as most fetal therapies are time-sensitive and cannot be delayed.

Summary of recommendations

  • Routine antenatal care should be adjusted by spacing out appointments and using telemedicine and home-based care. Ultrasound and noninvasive prenatal screening may also need re-arrangement.
  • If resources allow, there may be a place for generalized testing of pregnant women for SARS-CoV-2 infection. We do recommend testing prior to any operative procedure.
  • Pregnant women with SARS-CoV-2 infection may have a variable disease severity. It is uncertain whether they are at increased risk for COVID-19 disease. They should be managed based on the severity and nature of their complications. Cesarean delivery should be performed based on standard obstetric indications and considered in cases of septic shock or acute organ failure. Delivery may also facilitate maternal ventilation.
  • There is minimal and unconfirmed evidence for spontaneous vertical transmission. This risk theoretically may be increased by fetal procedures by disruption of either the feto-maternal barrier or the fetal skin. One should avoid transplacental instrument passage.
  • Fetal therapy is time sensitive and hence should not be considered as elective care. In SARS-CoV-2 positive patients one may consider delaying an intervention to avoid surgical morbidity, provided the procedure can wait. This applies, in particular, to complex procedures under general anesthesia and in symptomatic patients. Conversely, life-saving minimally invasive procedures should continue.
  • Procedures of unproven fetal benefit should not be offered.
  • When caring for a neonate born to a mother with suspected or confirmed COVID-19, strict infection control measuresshould apply, including quarantine. Based on current data, the spectrum of COVID-19 infection in neonates is usually mild and their short term outcomes are favorable.
  • Health care workers incur a significant risk of SARS-CoV-2 infection which is an argument for testing patients. When caring for suspected or SARS-CoV-2-positive patients, appropriate personal protective equipment should always be used.
  • The COVID-19 pandemic does not strike equally around the world. Centers must periodically review and adjust their approach to fetal therapy as demands and available resources change.
  • When consenting women with SARS-CoV-2 infection for fetal procedures of proven benefit, there is no autonomy-based ethical obligation to provide information about theoretical risks. Informed consent provides information about reasonable options and their benefits and risks and supports patient understanding and evaluation based on their own values and beliefs.
  • Termination of pregnancy is time sensitive and should not be considered as “elective.”
  • Registration of maternal and fetal outcomes is recommended because large cohort data will rapidly boost our knowledge.

Diagnostic and therapeutic procedures, estimated risks and benefits and position based on the current knowledge and available resources [1]

Procedure

Benefit to the fetus/mother

Theoretical risk of vertical transmission

Risk to healthcare provider

Maternal ICU need

Resource
Utilization

Recommendation

Amniocentesis

high

low

low

unlikely

minimal

offer to asymptomatic patients; others: consider delay if possible

Chorionic villus sampling

high

moderate

low

unlikely

minimal

offer to screen negative patients; delay to amniocentesis in symptomatic and screen-positive patients

Fetal blood transfusion

high

moderate

low

unlikely

moderate

offer to screen negative patients; adjust for symptomatic patients or screen positive patients if it cannot be delayed

Fetal cardiac procedures

unknown

moderate

low

unlikely

moderate

consider not offering

Fetal cystoscopy

unknown

moderate/high

low

unlikely

moderate

consider not offering screening

Laser for TTTS

high

low

low

unlikely

moderate

offer to screen asymptomatic patients; adjust for symptomatic patients or screen positive patients if it cannot be delayed

Selective feticide in monochorionic twins

variable

low

low

Unlikely

moderate

offer to screen asymptomatic patients; adjust for others

Spina bifida closure

high

high

moderate/high

low

high

delay if gestational age allows; if not, offer only to screen negative patients if sufficient local resources are available.

Thoraco-amniotic shunting

high

moderate/high

low

unlikely

moderate

offer to screen negative patients, adjust for symptomatic patients or screen positive patients if it cannot be delayed

Tracheal occlusion for CDH

unknown

low

low

unlikely

moderate

consider not offering screening

Vesico-amniotic shunting

low

moderate/high

low

unlikely

moderate

consider not offering screening

Ethical Challenges in Invasive Maternal-fetal Intervention [2], Austin et al. Semin Pediatr Surg. 2019;28(4):150819.

The field of maternal-fetal intervention is rapidly progressing and with it comes new and often complex ethical considerations that must be addressed.

Reviews the ethical issues that arise in maternal-fetal intervention and provides a list recommended resources that any institutional offering maternal-fetal intervention should have in place to meet the ethical obligations of such work.

Anhydramnios in the Setting of Renal Malformations: The National Institutes of Health Workshop Summary [3], Moxey-Mims et al. Obstet Gynecol 2018 Jun;131(6):1069-1079.

Anhydramnios is a lack of amniotic fluid surrounding the developing fetus defined as the deepest pocket of amniotic fluid measuring two cm or less in the second trimester. Anhydramnios due to fetal renal or urinary tract anomalies can result in severe pulmonary hypoplasia upon delivery. Amnioinfusion to restore amniotic fluid volume in pregnant women who carry a fetus with such anomalies may be a way to prevent pulmonary hypoplasia. This paper is a summary of a meeting of a panel of experts to further discuss this topic and to suggest an appropriate path to obtain meaningful research on the subject.

Ethical Considerations Concerning Amnioinfusions for Treating Fetal Bilateral Renal Agenesis [4], Sugarman et al. Obstet Gynecol 2018;131(1):130-134.

Legal and Ethical Issues in Fetal Surgery [5], Dickens et al. Int J Gynaecol Obstet 2011 Oct;115(1):80-3.

Weighing the Social and Ethical Considerations of Maternal-Fetal Surgery [6], Antiel et al. Pediatrics 2017 Dec;140(6).

Ethical Challenges in the New World of Maternal-Fetal Surgery [7], Antiel Semin Perinatol 2016 Jun;40(4):227-33.

Prevalence, Correlates, and Outcomes of Omphalocele in the United States, 1995-2005 [8], Marshall et al. Obstet Gynecol 2015 Aug;126(2):284-93.

Fetal MRI-Calculated Total Lung Volumes in the Prediction of Short-Term Outcome in Giant Omphalocele: Preliminary Findings [9], Danzer et al. Fetal Diagn Ther. 2012;31(4):248-53.

Management of Giant Omphaloceles: A Systematic Review of Methods of Staged Surgical vs. Nonoperative Delayed Closure [10], Bauman et al. J Pediatr Surg 2016 Oct;51(10):1725-30.

Giant Omphaloceles: Surgical Management and Perinatal Outcome [11], Akinkuotu et al. J Surg Res 2015 Oct;198(2):388-92.

Prenatal Steroids for Microcystic Congenital Cystic Adenomatoid Malformations [12], Curran et al. J Pediatr Surg 2010 Jan;45(1):145-50.

Cystic Adenomatoid Malformation Volume Ratio Predicts Outcome in Prenatally Diagnosed Cystic Adenomatoid Malformation of the Lung [13], Crombleholme et al. J Pediatr Surg 2002 Mar;37(3):338-8.

Congenital Lung Malformations: Informing Best Practice [14], Baird Ret al. Semin Pediatr Surg 2014 Oct; 23(5):270-7.

Gastroschisis outcomes in North America: a comparison of Canada and the United States [15], Youssef et al. J Pediatr Surg 2016 Jun;51(6):891-5.

Delivery planning for pregnancies with gastroschisis: findings from a prospective national registry [16], Al-Kaff et al. Am J Obstet Gynecol 2015 Oct;213(4):557.e1-8.

Effect of gestational age at birth on neonatal outcomes in gastroschisis [17], Carnaghan et al. J Pediatr Surg 2016 May;51(5):734-8.

Prenatal management of the fetus with isolated congenital diaphragmatic hernia in the era of the TOTAL trial [18], Deprest et al. Semin Fetal Neonatal Med 2014 Dec; 19(6):338-48.

Observed to expected lung area to head circumference ratio in the prediction of survival in fetuses with isolated diaphragmatic hernia [19], Jani et al. Ultrasound Obstet Gynecol. 2007 Jul;30(1):67-71.

Use of magnetic resonance imaging in prenatal prognosis of the fetus with isolated left congenital diaphragmatic hernia [20], Victoria et al. Prenat Diagn 2012 Aug;32(8):715-23.

Unique Considerations: Preterm Prelabor Rupture of Membranes in the Setting of Fetal Surgery and Higher Order Pregnancies [21], Forde et al. Obstet Gynecol Clin North Am 2020 Dec;47(4):653-669.

Fetal Surgery and Delayed Cord Clamping: Neonatal Implications [22], Frank et al. Crit Care Nurs Clin North Am 2018 Dec;30(4):499-507.

Postoperative imaging following fetal open myelomeningocele repair: The clinical utility of magnetic resonance imaging and sonographic amniotic fluid volumes in detecting suspected hysterotomy scar dehiscence [23], Seaman et al. Prenat Diagn 2020 Jan;40(1):66-70.

References

  1. Deprest J, Choolani M, Chervenak F, et al. Fetal Diagnosis and Therapy during the COVID-19 Pandemic: Guidance on Behalf of the International Fetal Medicine and Surgery Society. Fetal Diagn Ther. 2020;47(9):689-698.  [PMID:32375144]
  2. Austin MT, Cole TR, McCullough LB, et al. Ethical challenges in invasive maternal-fetal intervention. Semin Pediatr Surg. 2019;28(4):150819.  [PMID:31451174]
  3. Moxey-Mims M, Raju TNK. Anhydramnios in the Setting of Renal Malformations: The National Institutes of Health Workshop Summary. Obstet Gynecol. 2018;131(6):1069-1079.  [PMID:29742659]
  4. Sugarman J, Anderson J, Baschat AA, et al. Ethical Considerations Concerning Amnioinfusions for Treating Fetal Bilateral Renal Agenesis. Obstet Gynecol. 2018;131(1):130-134.  [PMID:29215523]
  5. Dickens BM, Cook RJ. Legal and ethical issues in fetal surgery. Int J Gynaecol Obstet. 2011;115(1):80-3.  [PMID:21839453]
  6. Antiel RM, Flake AW, Collura CA, et al. Weighing the Social and Ethical Considerations of Maternal-Fetal Surgery. Pediatrics. 2017;140(6).  [PMID:29101225]
  7. Antiel RM. Ethical challenges in the new world of maternal-fetal surgery. Semin Perinatol. 2016;40(4):227-33.  [PMID:26804036]
  8. Marshall J, Salemi JL, Tanner JP, et al. Prevalence, Correlates, and Outcomes of Omphalocele in the United States, 1995-2005. Obstet Gynecol. 2015;126(2):284-93.  [PMID:26241416]
  9. Danzer E, Victoria T, Bebbington MW, et al. Fetal MRI-calculated total lung volumes in the prediction of short-term outcome in giant omphalocele: preliminary findings. Fetal Diagn Ther. 2012;31(4):248-53.  [PMID:22572017]
  10. Bauman B, Stephens D, Gershone H, et al. Management of giant omphaloceles: A systematic review of methods of staged surgical vs. nonoperative delayed closure. J Pediatr Surg. 2016;51(10):1725-30.  [PMID:27570242]
  11. Akinkuotu AC, Sheikh F, Olutoye OO, et al. Giant omphaloceles: surgical management and perinatal outcomes. J Surg Res. 2015;198(2):388-92.  [PMID:25918004]
  12. Curran PF, Jelin EB, Rand L, et al. Prenatal steroids for microcystic congenital cystic adenomatoid malformations. J Pediatr Surg. 2010;45(1):145-50.  [PMID:20105595]
  13. Crombleholme TM, Coleman B, Hedrick H, et al. Cystic adenomatoid malformation volume ratio predicts outcome in prenatally diagnosed cystic adenomatoid malformation of the lung. J Pediatr Surg. 2002;37(3):331-8.  [PMID:11877643]
  14. Baird R, Puligandla PS, Laberge JM. Congenital lung malformations: informing best practice. Semin Pediatr Surg. 2014;23(5):270-7.  [PMID:25459011]
  15. Youssef F, Cheong LH, Emil S, et al. Gastroschisis outcomes in North America: a comparison of Canada and the United States. J Pediatr Surg. 2016;51(6):891-5.  [PMID:27004440]
  16. Al-Kaff A, MacDonald SC, Kent N, et al. Delivery planning for pregnancies with gastroschisis: findings from a prospective national registry. Am J Obstet Gynecol. 2015;213(4):557.e1-8.  [PMID:26116872]
  17. Carnaghan H, Baud D, Lapidus-Krol E, et al. Effect of gestational age at birth on neonatal outcomes in gastroschisis. J Pediatr Surg. 2016;51(5):734-8.  [PMID:26932253]
  18. Deprest J, Brady P, Nicolaides K, et al. Prenatal management of the fetus with isolated congenital diaphragmatic hernia in the era of the TOTAL trial. Semin Fetal Neonatal Med. 2014;19(6):338-48.  [PMID:25447987]
  19. Jani J, Nicolaides KH, Keller RL, et al. Observed to expected lung area to head circumference ratio in the prediction of survival in fetuses with isolated diaphragmatic hernia. Ultrasound Obstet Gynecol. 2007;30(1):67-71.  [PMID:17587219]
  20. Victoria T, Bebbington MW, Danzer E, et al. Use of magnetic resonance imaging in prenatal prognosis of the fetus with isolated left congenital diaphragmatic hernia. Prenat Diagn. 2012;32(8):715-23.  [PMID:22674674]
  21. Forde B, Habli M. Unique Considerations: Preterm Prelabor Rupture of Membranes in the Setting of Fetal Surgery and Higher Order Pregnancies. Obstet Gynecol Clin North Am. 2020;47(4):653-669.  [PMID:33121651]
  22. Frank KM. Fetal Surgery and Delayed Cord Clamping: Neonatal Implications. Crit Care Nurs Clin North Am. 2018;30(4):499-507.  [PMID:30447809]
  23. Seaman RD, Cassady CI, Yepez Donado MC, et al. Postoperative imaging following fetal open myelomeningocele repair: The clinical utility of magnetic resonance imaging and sonographic amniotic fluid volumes in detecting suspected hysterotomy scar dehiscence. Prenat Diagn. 2020;40(1):66-70.  [PMID:31600420]