Treatment for the Tiniest Patients

January 13, 2015

Johns Hopkins Gynecology
January 13, 2015 Treatment for the Tiniest Patients

“Our multidisciplinary team of fetal, maternal, neonatal and pediatric experts care for mother and fetus at every stage, from pregnancy to delivery and beyond,” says Ahmet Baschat.

Maternal-fetal medicine specialist Ahmet Baschat has little use for the word can’t.

As one of the leaders in a specialty that as recently as three decades ago was still largely in the “what if” stages, he’s been a prominent contributor to the exponential growth in the number of fetal diseases and anomalies that today can not only be detected but corrected in utero. And Baschat, who directs Johns Hopkins’ Center for Fetal Therapy, is equally at home advancing both diagnosis and treatment.

For example, second-trimester echocardiography has been the preferred method for diagnosing the presence of congenital heart disease because by that stage of gestation it can show the needed cardiac planes, landmarks and anatomic details. Baschat and colleagues, however, recently showed that in a selected group of high-risk patients, a first-trimester 4D echo technique using spatiotemporal image correlation, tomographic ultrasound imaging display and color Doppler could detect a number of serious heart problems, including atrioventricular canal defect, pulmonary stenosis and transposition of the great arteries, with 91% sensitivity and 100% specificity.

Proper diagnosis is also essential for twin-to-twin transfusion syndrome, which can exist as a pure disease by itself in monochorionic twins or present along with twin-anemia polycythemia sequence, in which one twin has a successively increasing blood count and the other a progressive blood loss or anemia. There could also be unequal sharing of the placenta or twin reversed arterial perfusion in which the cardiac system of one twin does the work of supplying blood for both fetuses.

Fetoscopic laser photocoagulation to close placental anastomoses that connect monochorionic twins and prevent further transfusion is the treatment of choice for advanced-stage TTTS. However, says Baschat, initial techniques for performing the procedure didn’t achieve effective occlusion of vessels. He and colleagues have shown that a recent advance called equatorial laser dichorionization, which targets the entire shared zone of the placenta, appears to be better at separating the fetal circulations and reducing the risk of TTTS recurrence.

Although outcomes for any fetal therapy procedure naturally are focused on the baby or babies, the mother’s health and well-being must also remain paramount. “Our multidisciplinary team of fetal, maternal, neonatal and pediatric experts care for mother and fetus at every stage, from pregnancy to delivery and beyond,” says Baschat. “Our treatment plans include not only fetal surgery and other interventions, but management of the mother’s health, individualized birth plans, and postnatal care plans for both mother and baby, including long-term follow-up care.”

In one recent case of TTTS in which Baschat performed a laser ablation, one of the twins developed a residual heart problem. “Fortunately, the mother delivered here, so we were able to prepare her doctors for the care the baby would need,” says Baschat. “That’s the beauty of having the whole spectrum of care available in one location.” 

For more information or to refer a patient 24/7, call toll-free 1-800-JH-FETAL (1-844-543-3825).

Fetal Conditions and Treatments

At the Johns Hopkins Center for Fetal Therapy, maternal and pediatric teams diagnose and manage a variety of complex conditions before birth:

Conditions

  • Complications from monochorionic twin pregnancies
  • Twin-to-twin transfusion syndrome (TTTS)
    • Twin anemia polycythemia sequence (TAPS)
    • Selective intrauterine growth restriction (SIUGR)
    • Twin reversed arterial perfusion (TRAP)
    • Discordant anomalies
  • Congenital diaphragmatic hernia
  • Spina bifida and myelomeningocele
  • Lower urinary tract obstruction
  • Fetal chest masses and hydrothorax
  • Fetal anemia
  • Fetal hydrops
  • Fetal growth restriction and placental dysfunction
  • Fetal tumors
  • Amniotic band syndrome

Interventions and Procedures

  • Fetoscopic laser surgery
  • Fetal shunt placement
  • Intrauterine transfusion and fetal blood sampling
  • Transplacental therapies
  • Amnioinfusion
  • Ex-utero intrapartum treatment
  • First- and second-trimester fetal echocardiography
  • Advanced 3 and 4D ultrasound
  • Advanced fetal cardiovascular assessment
  • Complex genetic workup

The fetal therapy goal

  • Prenatal diagnosis
  • Advanced imaging
  • Genetic diagnostics
  • Prenatal interventions
  • Disease-specific assessment of fetal well-being
  • Interdisciplinary care team
  • Maternal-fetal management
  • Pediatric medical and surgical expertise