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dokter_nudi@yahoo.com /
nurwansyah.nudi@gmail.com
Fetal Therapy: Options and Medical
                            Treatment
  Pacemakers In the past two decades,
     the goal of prenatal diagnosis has
  changed from merely deciding about
terminating the pregnancy to possible
 active intervention for improving the
       long-term outcome of the fetus.
   Recently, medical and surgical fetal
 therapy has emerged as an option for
      the management of various fetal
                       malformations.



   dokter_nudi@yahoo.com /
  nurwansyah.nudi@gmail.com
dokter_nudi@yahoo.com /
nurwansyah.nudi@gmail.com
dokter_nudi@yahoo.com /
nurwansyah.nudi@gmail.com
dokter_nudi@yahoo.com /
nurwansyah.nudi@gmail.com
dokter_nudi@yahoo.com /
nurwansyah.nudi@gmail.com
dokter_nudi@yahoo.com /
nurwansyah.nudi@gmail.com
dokter_nudi@yahoo.com /
nurwansyah.nudi@gmail.com
IVT
Survival rate in Rh Isoimmunized Fetuses




               dokter_nudi@yahoo.com /
              nurwansyah.nudi@gmail.com
Survival for In-Vitro Transfused
      Hydroponic Fetuses




             dokter_nudi@yahoo.com /
            nurwansyah.nudi@gmail.com
Pathophysiology of Transfusion
                                       To calculate the
                                       volume of donor
                                       blood necessary to
                                       achieve a post-
                                       tranfusion fetal
                                       hematocrit of 40%,
                                       the estimated
                                       fwtoplacental blood
                                       volume (left, e.g.,
                                       100mL at 27 weeks)
                                       is multiplied by DF
                                       (right, e.g., 0,8 for a
                                       pretransfusion fetal
                                       hematocrit of 10%
                                       and a donor
                                       hematocrit of 80%).

            dokter_nudi@yahoo.com /
           nurwansyah.nudi@gmail.com
Hydrocepha
   l us
Fetal Obstructive Hydrocephalus: Distribution by
Primary Diagnosis and Survival in 41 Treated Cases




                   dokter_nudi@yahoo.com /
                  nurwansyah.nudi@gmail.com
Fetal Obstructive Hydrocephalus: Outcome in 34
            Treated Surviving Infants




                 dokter_nudi@yahoo.com /
                nurwansyah.nudi@gmail.com
Fetal Obstructive Hydrocephalus: Relationship of
       Duration of Treatment to Outcome




                  dokter_nudi@yahoo.com /
                 nurwansyah.nudi@gmail.com
Pleural
Effusions
 Hal 315 Tab
             el   29.1, 29.2
Clinical Data Summary




         dokter_nudi@yahoo.com /
        nurwansyah.nudi@gmail.com
Prognostic Indicator




       dokter_nudi@yahoo.com /
      nurwansyah.nudi@gmail.com
Obstructive
 Uropathy
Antenatal Sonographic Features of Fetuses
       with Urethral Obstruction




               dokter_nudi@yahoo.com /
              nurwansyah.nudi@gmail.com
Prognostic Criteria for The Fetus with Bilateral
            Obstructive Uropathy




                       dokter_nudi@yahoo.com /
                      nurwansyah.nudi@gmail.com
Management
                            scheme for the
                            fetus with bilateral
                            hydronephrosis.
                            Note that the
                            development of
                            prognostic criteria
                            based on the
                            assessment of fetal
                            renal function
                            allows improved
                            counseling and
                            management.

 dokter_nudi@yahoo.com /
nurwansyah.nudi@gmail.com
dokter_nudi@yahoo.com /
nurwansyah.nudi@gmail.com
Surgical Interventions

Three approaches are currently used for

invasive



A.Ultrasonography-guided vesicoamniotic
and, less commonly, thoracoamniotic shunt

placement, is used in a fetus from 16 weeks'

gestation to when lung maturity makes

postnatal treatment the best option.

Complications are inadequate function,
                            dokter_nudi@yahoo.com /
migration, and iatrogenic gastroschisis.
                           nurwansyah.nudi@gmail.com
B.   Fetoscopic techniques now have a

     clinical application in the ligation of

     umbilical cords in acardiac twins, in

     selective laser photocoagulation of

     communicating vessels in twin-to-

     twin transfusions, and in the

     ablation of posterior urethral valves.



                            dokter_nudi@yahoo.com /
                           nurwansyah.nudi@gmail.com
1.     The procedure is performed

              inside the uterus using

          endoscopes, with a much

     smaller hysterotomy than that

      needed for open procedures.

             This lessens the risks of

             preterm labor and fetal

 hypothermia and improves fetal

               hemostasis during the
         dokter_nudi@yahoo.com /
        nurwansyah.nudi@gmail.com   procedure
2.   The success of the procedure depends

      on the use of both a transabdominal

     ultrasonographic intraoperative view

      and a simultaneous endoscopic view

     to guide placement of the trocars and

                                           cannulae.




                dokter_nudi@yahoo.com /
               nurwansyah.nudi@gmail.com
3.    The drawbacks of fetoscopic surgery

     are the risk of bleeding (avoiding the

       transplacental route decreases this

         risk), rupture of membranes, and

     chorioamnionitis. Fetoscopy may also

      be difficult because of poor access to

          the fetus due to fetal position or

                               polyhydramnios.




                dokter_nudi@yahoo.com /
               nurwansyah.nudi@gmail.com
C.   Open fetal surgery is currently

     performed at select centers in

     instances in which the risk of the

     procedure to the mother and fetus is

     overridden by a diagnosis with a

     known poor outcome. Complications

     such as chorioamnionitis, preterm

     labor, bleeding, and direct trauma to

     the fetus are risks in most of these

     procedures.
                                dokter_nudi@yahoo.com /
                               nurwansyah.nudi@gmail.com
Monitoring During Surgery

    The parameters monitored during and after surgery

    include the following:



    •Myometrial contractions and intrauterine pressures.
    • Maternal blood pressure, ECG, and pulse oximetric and
    blood gas levels.

    • Fetal pulse oximetric measurement (50%-60%
    saturation), heart rate, blood gases, and ECG



                              dokter_nudi@yahoo.com /
                             nurwansyah.nudi@gmail.com
Monitoring During Surgery


       •   Ultrasonographic findings in

           cases of fetoscopic surgery



       •   Fetal temperature (Maintain

           temperature with continuous

           warm sodium chloride irrigation,

           minimized exposure, and

           increased ambient temperature.)
                     dokter_nudi@yahoo.com /
                    nurwansyah.nudi@gmail.com
These surgical techniques are considered

appropriate for 9 lesions.


         1.   Obstructive uropathy
         2.   Hydrocephalus
         3.   Pleural effusion
         4.   Twin-To-Twin Transfusion syndrome
         5.   Amniotic band syndrome
         6.   Congenital Diaphragmatic Hernia
         7.   Congenital high airway obstruction syndrome
         8.   Sacrococcygeal teratoma.
         9.   Congenital Cystic Adenomatoid Maformartions




                          dokter_nudi@yahoo.com /
                         nurwansyah.nudi@gmail.com
Author
Experiences
“In Indones
              ia”
NO   Author        Procedure                      D/                 Outcome
1.   Nurwansyah,   Cephalocentesis                Hydrocephaly       Harapan Kita
     Gatot AR                                                        hospital
2.   Nurwansyah,   Serial Vesicosentesis          PUV                Harapan Kita
     Gatot AR                                                        Hospital
3.   Nurwansyah,   Thoracocentesis                Isolated           Harapan Kita
     Gatot AR                                     hydrothorax        Hospital
4.   Nurwansyah,   Paracentesis                   Isolated Ascites   Harapan Kita
     Gatot AR                                                        Hospital
5.   Nurwansyah,   Amniotic-septostomi            TTTS               YPK Hospital
     Trijatmo R.
6.   Nurwansyah,   IUT                            Hydropsfoetalis    Harapan Kita
     Gatot AR                                     ec Rh              Hospital
                                                  Incompatibility




                           dokter_nudi@yahoo.com /
                          nurwansyah.nudi@gmail.com
NO   Author        Procedure                 D/                   Outcome
7,   Nurwansyah,   Amnioinfusion             Renal Agenesis bil   ASIH
     Ari Waluyo                                                   Maternity
                                                                  Hospital
8.   Nurwansyah,   IUT                       Hydrops foetalis     ASIH
     Ari Waluyo,                             ec. ABO              Maternity
     Indriani                                Incomptblt           Hospital
9.   Nurwansyah,   IUT                       Hydrops foetalis /   BWCH
     Uf Bagasi                               Thallasemia




                          dokter_nudi@yahoo.com /
                         nurwansyah.nudi@gmail.com
Terima Kasih




   dokter_nudi@yahoo.com /
  nurwansyah.nudi@gmail.com

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Fetal therapy indonesian experiences

  • 2. Fetal Therapy: Options and Medical Treatment Pacemakers In the past two decades, the goal of prenatal diagnosis has changed from merely deciding about terminating the pregnancy to possible active intervention for improving the long-term outcome of the fetus. Recently, medical and surgical fetal therapy has emerged as an option for the management of various fetal malformations. dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 9. IVT
  • 10. Survival rate in Rh Isoimmunized Fetuses dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 11. Survival for In-Vitro Transfused Hydroponic Fetuses dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 12. Pathophysiology of Transfusion To calculate the volume of donor blood necessary to achieve a post- tranfusion fetal hematocrit of 40%, the estimated fwtoplacental blood volume (left, e.g., 100mL at 27 weeks) is multiplied by DF (right, e.g., 0,8 for a pretransfusion fetal hematocrit of 10% and a donor hematocrit of 80%). dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 13. Hydrocepha l us
  • 14. Fetal Obstructive Hydrocephalus: Distribution by Primary Diagnosis and Survival in 41 Treated Cases dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 15. Fetal Obstructive Hydrocephalus: Outcome in 34 Treated Surviving Infants dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 16. Fetal Obstructive Hydrocephalus: Relationship of Duration of Treatment to Outcome dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 17. Pleural Effusions Hal 315 Tab el 29.1, 29.2
  • 18. Clinical Data Summary dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 19. Prognostic Indicator dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 21. Antenatal Sonographic Features of Fetuses with Urethral Obstruction dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 22. Prognostic Criteria for The Fetus with Bilateral Obstructive Uropathy dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 23. Management scheme for the fetus with bilateral hydronephrosis. Note that the development of prognostic criteria based on the assessment of fetal renal function allows improved counseling and management. dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 25. Surgical Interventions Three approaches are currently used for invasive A.Ultrasonography-guided vesicoamniotic and, less commonly, thoracoamniotic shunt placement, is used in a fetus from 16 weeks' gestation to when lung maturity makes postnatal treatment the best option. Complications are inadequate function, dokter_nudi@yahoo.com / migration, and iatrogenic gastroschisis. nurwansyah.nudi@gmail.com
  • 26. B. Fetoscopic techniques now have a clinical application in the ligation of umbilical cords in acardiac twins, in selective laser photocoagulation of communicating vessels in twin-to- twin transfusions, and in the ablation of posterior urethral valves. dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 27. 1. The procedure is performed inside the uterus using endoscopes, with a much smaller hysterotomy than that needed for open procedures. This lessens the risks of preterm labor and fetal hypothermia and improves fetal hemostasis during the dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com procedure
  • 28. 2. The success of the procedure depends on the use of both a transabdominal ultrasonographic intraoperative view and a simultaneous endoscopic view to guide placement of the trocars and cannulae. dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 29. 3. The drawbacks of fetoscopic surgery are the risk of bleeding (avoiding the transplacental route decreases this risk), rupture of membranes, and chorioamnionitis. Fetoscopy may also be difficult because of poor access to the fetus due to fetal position or polyhydramnios. dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 30. C. Open fetal surgery is currently performed at select centers in instances in which the risk of the procedure to the mother and fetus is overridden by a diagnosis with a known poor outcome. Complications such as chorioamnionitis, preterm labor, bleeding, and direct trauma to the fetus are risks in most of these procedures. dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 31. Monitoring During Surgery The parameters monitored during and after surgery include the following: •Myometrial contractions and intrauterine pressures. • Maternal blood pressure, ECG, and pulse oximetric and blood gas levels. • Fetal pulse oximetric measurement (50%-60% saturation), heart rate, blood gases, and ECG dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 32. Monitoring During Surgery • Ultrasonographic findings in cases of fetoscopic surgery • Fetal temperature (Maintain temperature with continuous warm sodium chloride irrigation, minimized exposure, and increased ambient temperature.) dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 33. These surgical techniques are considered appropriate for 9 lesions. 1. Obstructive uropathy 2. Hydrocephalus 3. Pleural effusion 4. Twin-To-Twin Transfusion syndrome 5. Amniotic band syndrome 6. Congenital Diaphragmatic Hernia 7. Congenital high airway obstruction syndrome 8. Sacrococcygeal teratoma. 9. Congenital Cystic Adenomatoid Maformartions dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 35. NO Author Procedure D/ Outcome 1. Nurwansyah, Cephalocentesis Hydrocephaly Harapan Kita Gatot AR hospital 2. Nurwansyah, Serial Vesicosentesis PUV Harapan Kita Gatot AR Hospital 3. Nurwansyah, Thoracocentesis Isolated Harapan Kita Gatot AR hydrothorax Hospital 4. Nurwansyah, Paracentesis Isolated Ascites Harapan Kita Gatot AR Hospital 5. Nurwansyah, Amniotic-septostomi TTTS YPK Hospital Trijatmo R. 6. Nurwansyah, IUT Hydropsfoetalis Harapan Kita Gatot AR ec Rh Hospital Incompatibility dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 36. NO Author Procedure D/ Outcome 7, Nurwansyah, Amnioinfusion Renal Agenesis bil ASIH Ari Waluyo Maternity Hospital 8. Nurwansyah, IUT Hydrops foetalis ASIH Ari Waluyo, ec. ABO Maternity Indriani Incomptblt Hospital 9. Nurwansyah, IUT Hydrops foetalis / BWCH Uf Bagasi Thallasemia dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com
  • 37. Terima Kasih dokter_nudi@yahoo.com / nurwansyah.nudi@gmail.com