Fetal Therapy: Hyaline Membrane Disease
Fetal Therapy: Hyaline Membrane Disease
A therapeutic intervention for the purpose of correcting or treating a fetal anomaly or condition
is called fetal therapy.
Types
a) Pharmacological fetal therapy (non invasive)
Preventive pharmacotherapy
Therapeutic pharmacotherapy
b) Surgical fetal therapy - (Invasive)
PREVENTIVE PHARMACOTHERAPY
1. CARDIAC
Cardiac arrhythmia, PSVT, atrial flutter, atrial fibrillation and ventricular tachy-cardia can be treated by
giving anti-arrhythmic drugs to mother orally or by trans-placental route.
PSVT; atrial flutter & fibrillation: Digoxin : Oral – if fetus is normal. If fetus have feature of
hydrops, Digoxin is given either parenteral or transplacental, 0.5- 1 mg, Adenosine : per umbilical 0.05 to
0.2mg, Flecanide : oral 200- 300mg, Amiodarone : parenteral 600-800mg, Sotatlol : oral; 80-320 mg
Complete A-V Block (CAVB)
Prevalence: 1/15,000- 1/22,000 live birth.
At the time of diagnosis of heart block in fetus, maternal dexamethasone (4 or 8 mg/d for 2 weeks, then 4
mg/day should be initiated, maintained for the duration of the pregnancy, tapering at times (2 mg/d) in the
third trimester. If the average heart rate declined below 55 bpm, a ß-sympathomimetic agent should be
given - salbutamol 40mg/ day for 2 weeks.
In the presence of maternal anti-Ro/La antibodies : There are no known markers that will predict which
fetus will develop an AV conduction defect. Little evidence suggests that the administration of steroids,
immunoglobulins or plasmapheresis in the mother can reverse third-degree AV block. However, these
therapies are helpful if given in early to treat first-degree and second-degree heart block.
Treatment for complete fetal A-V block:
Delivary at tetriary care center
Uneventful fetal course - LSCS at 37 wks
If fetus develop hydrops- Paracentesis, LSCS
Low CO out - Immediate Pacing, Isoprenline
Features of SLE - oral prednisolone
Endocardial fibroelastosis – IV IgG
Fetus with isolated Complete A –V block
Prevalence: The fetal mortality rate of isolated CAVB may be as much as 30 - 50%. Patients diagnosed and
treated in the neonatal period have a survival rate of 94%, and patients who are diagnosed and treated in
childhood have a survival rate of 100%.
• HR > 55/min with normal LV function; Treatment - Dexamethasone - orally to mother
• HR < 55/min with abnormal LV function; Rx - Dexamethasone - orally with β agonist weekly follow up
by obstetrician with fetal echocardiography
Premature ventricular contraction in fetus: A benign condition either resolve spontaneously before
birth or after birth of baby. If number of PVC is more, and fetus develop Hydrops: - then β blocker can be
used orally.
Ventricular tachycardia: Fetal therapy for VT is administration of β – blocker; Flecanide = 200-
300mg/day orally and Amiodarone = 600-800mg/day I.V. to mother.
2. FETAL THYROID GOITER
Fetal cord blood for thyroid status TSH,T3,T4.
If hyperthyrodism Rx - carbimazole methimazole
If hypothyroidism –Levothyroxin 250-500 mg weekly intra amniotic between 29-37 weeks. This will
result in regression of thyroid goiter.
2. FETAL VISUALIZATION ;
EMBRYOSCOPY
Embryoscopy is performed in the first trimester of pregnancy (up to 12 weeks’ gestation). In this
technique, a rigid endoscope is inserted via the cervix in the space between the amnion and the chorion,
under sterile conditions and ultrasound guidance, to visualize the embryo for the diagnosis of structural
malformations.
FETOSCOPY
Fetoscopy is performed during the second trimester (after 16 weeks’ gestation). In this technique, a
fine-caliber endoscope is inserted into the amniotic cavity through a small maternal abdominal incision,
under sterile conditions and ultrasound guidance, for the visualization of the embryo to detect the presence
of subtle structural abnormalities. An injection will be given in the lower abdomen to numb the skin where
the fetoscope will be inserted. An ultrasound will be used to determine the position of both the fetus and
the placenta.A camera is attached to the fetoscope to take pictures. The fetus is seen through a small
incision made in the belly, and a fetal ultrasound guides the placement of the fetoscope.
5. PLEURAL EFFUSION:
One option in the management of fetuses with pleural effusion is thoracocentesis and drainage of the
effusions. However, in the majority of cases the fluid reaccumulates within 24-48 hours requiring repeated
procedures and it is therefore preferable to achieve chronic drainage by the insertion of pleural- amniotic
shunts.
6. GENE THERAPY
Gene therapy means replacement of missing gene by introduction of foreign nucleic acid sequence. It is
divided into two categories, classic gene therapy and stem cell gene therapy.
In most gene therapy a normal gene is inserted into genome to replace an abnormal, disease causing gene.
A carrier molecule called a vector (virus- lenti virus) must be used to deliver the therapeutic gene to the
patient’s target cells.
There have been several modes of gene delivery used in experimental efforts at fetal gene transfer. These
include intratracheal, intravascular, intraventricular, intracardiac, intraperitoneal, intraplacental,
intramuscular and intra-amniotic injection.
Intra-amniotic gene transfer (IAGT) has been used to target organs exposed to amniotic fluid, that is, the
skin, amniotic membranes and the respiratory and digestive systems