Multi-fetal Pregnancy Reduction
Triplet pregnancy and higher-order pregnancies carry a high-risk of premature births, miscarriages, stillbirths and neonatal deaths. Medical or surgical interventions have not shown to be of much help in reducing the above mentioned problems. The current standard treatment to improve the outcome of such pregnancies is to ‘reduce’ the pregnancy to a twin pregnancy. However, reduction may not be acceptable to some parents. At The Fetal Clinic, a detailed sensitive and scientifically accurate counseling is first given and the parents’ values and preferences are taken into account. Accordingly, a management plan is charted out.
When the fetuses have their own placenta each, then this reduction is done at 12 weeks using a simple technique; when the fetuses share a single placenta, then reduction is performed at 16 weeks using radiofrequency ablation technique (RFA).
The procedure related loss rate after fetal reduction is about 2% when done in the first trimester and is about 10% when done in the second trimester ( RFA). Typically, the patient preparation, duration, and postprocedure precautions are the same as that of amnio / CVS.
Direct Fetal Blood Transfusion
Also known as Intrauterine transfusion (IUT), the procedure is a life saving intervention when the fetus is affected with severe anemia. The most common situation where direct fetal blood transfusion is done is when the mother is Rh negative and the fetus is Rh positive. In about 1-2% of such pregnancies, the mother will produce antibodies (attacking proteins) that will go into the blood of the fetus and cause destruction of the red blood cells of the fetus. This makes the fetus anemic and when it becomes severe, the anemia can be lethal for the fetus. Correction of anemia through direct fetal transfusion is the treatment of choice. Depending on the stage of pregnancy at which the fetus becomes anemic, two to four tranfusions may be required during the pregnancy.
Typically the decision to do the procedure is taken after analysing various factors including what happened in a previous pregnancy, the blood flow velocity in the fetal brain vessel, and the stage of pregnancy. The procedure is done on an outpatient basis. The total duration of the procedure is around 1 hour, followed by another 1 hour of observation under bed rest.
Complicated Monochorionic Twins
In about 15% of single-placenta twins (monochorionic twins), there would serious complications affecting one or both fetuses, that if left untreated would end up damaging both fetuses. During serial monitoring of the monochorionic twins, timely identification of such complications allows us to intervene at the correct time to avoid losing both babies.
The aim of the interventions is to separate the two circulations: this can be achieved by the use of fetoscopic LASER coagulation of the connecting vessels on the surface of the placenta, occluding the umbilical cord of one of the fetus using electrical energy or radio frequency energy. Occlusion of the umbilical cord vessels results in the demise of that fetus while protecting the other fetus and is offered when the chances of saving two fetuses are low.
Chorioangiomata are benign tumors of the placenta that do not pose significant threat to the pregnancy in the vast majority of the cases. However, when they are relatively large (>5cm), they may affect the pregnancy in two ways: they act as bypass channels for blood circulation causing excess workload on the fetal heart leading to heart failure; they act as trap to entrap fetal red blood cells causing fetal anemia
Depending on the type of problem caused by the tumor, we offer two types of therapy: if anemia is significant, direct fetal blood transfusion; if heart failure is present without severe anemia, we offer tumor embolisation.
In tumor embolisation, a special glue is injected into the main vessel that ‘feeds’ the tumor thereby occluding the blood supply. This is also done on an outpatient basis using a fine needle. Typically, the procedure takes about half an hour followed by one hour of observation.
When fluid collects inside the fetal thorax, it is referred to as pleural effusion or hydrothorax. This fluid collection may increase in quantity within the fetal chest causing pressure effect on the heart and the main blood vessels leading to heart failure and ultimately fetal death. In such situations, insertion of a shunt tube that drains the fluid from within the chest to the outside of the fetus (i.e. into the amniotic sac) relieves the pressure and protects the baby from dying due to heart failure.
At The Fetal Clinic, fetuses presenting with pleural effusion undergo detailed evaluation to ascertain the cause of effusion and the parents are counseled at length over the pros and cons of different treatment options. Fetal Shunt insertion is also done on an outpatient basis. Typically the duration of the procedure is about 1 hour, followed by another hour of observation.