Women are usually very excited once they know they are pregnant. Missing a period and having a positive pregnancy test could be one of their happiest moments in their lives. Their visit to the obstetrician, getting to see the first signs of pregnancy on the ultrasound machine is a happy event. This is usually shared with the husband and other family members. Women usually read a lot about pregnancy, what to eat what to avoid.
They get offered screening for Down syndrome, where most women rush to do without thinking or realising the consequences.They are then offered a detailed scan around 19-20 weeks, to get to know the sex of the baby but more important to check that the baby is healthy. The detailed scan which may be a 3 or 4 D scan is usually a family outing. All making comments on the looks of the baby, whether he or she resembles mum or dad, the size of the nose and mouth, and how cute the baby is.
Diagnosing a problem
The possibility of something wrong with the baby is very remote and surely not in our baby. The ultrasound findings may be devastating to the couple, finding a major or even a minor abnormality in the baby is very difficult for parents to accept. We all want babies and we want them perfect.
Picking up an abnormality in the baby is equally difficult for the obstetrician. Having known the couple for the previous 4 months or more. Shared all the happy moments early in pregnancy, makes it very difficult to reveal the abnormality to the couple. One has to be able to break the news gently, explain what abnormality exists, what effect it has on the baby and the pregnancy. The doctor must have enough knowledge to explain the full problem, whether it will have a major effect on the baby after delivery, whether the baby will be mentally normal or affected. Termination of pregnancy cant be simply mentioned to a couple 20 minutes earlier were sitting excited in the waiting area ready to rush in. If the obstetrician is in doubt he has to seek second opinion before fully discussing findings with the couple. He usually mentions the part of the body where the problem is for example the brain. He then refers the couple to a more specialized ultrasound center with more sophisticated equipment and more skilled doctors at examining fetuses.
On confirming the diagnosis or even adding more abnormalities, to the initial diagnosis, the patient is referred back to her obstetrician to discuss the findings. This is usually an awkward time, as the obstetrician is often left with two options either continuing the pregnancy and accepting a severely handicapped baby or terminating the pregnancy. Termination of the pregnancy is a very difficult decision to make; it is dependant on the severity of the problem, how far in the pregnancy the diagnosis is made and on the cultural and religious beliefs of both the couple and the doctor. This unfortunately may be conflicting. On reaching that point the patient is usually passed over from one doctor to the other. Or the couple may start seeking second or third opinion.
Many pregnant women or even doctors are not fully aware of a speciality called fetal medicine. Fetal medicine specialists who are a small group of obstetricians that can diagnose abnormalities in the babies and more important can offer treatment when available. The scope of this article is about treatment options available for affected fetuses. Many people may not be aware that interventions during pregnancy are available and more important that they are done on regular basis in Egypt. These services are available in the private sector but more important they are provided free of charge at the governmental hospitals.
Bladder outlet obstruction
One of the common abnormalities detected is the presence of an obstruction at the outlet of the bladder, stopping the fetus from passing urine. As a result the bladder of the fetus gets very distended, as urine can’t come out. The kidneys, which normally drain into the bladder, become distended as well. They can’t empty their urine and thus keep on swelling until they stop working. The baby after delivery as a result may suffer from renal failure. Since a major component of the fluid around the fetus is urine. Thus as a result of the obstruction the fluid around the fetus is dramatically reduced. This in turn can have an effect on the development of the lung, which needs fluid around it to allow expansion and growing. The baby after delivery may suffer from inability to breath due to small under developed lungs, which is usually fatal. The presence of the obstruction can be picked up on the scan from the forth month of pregnancy onwards.
What are the consequences?
If these babies are left without treatment they usually die immediately after delivery usually due to underdeveloped lungs and due to renal failure as well as mentioned above. The management of these cases includes first withdrawing fluid from the bladder of the baby and testing it to check that the kidneys are still functioning properly. This is done by introducing a very fine needle through the tummy of the mother passing into the womb then into baby’s bladder. The procedure is done under ultrasound guidance, which means that the needle is seen through out its course from entry till exit. This is to ensure no damage is done to either baby or mum. The procedure takes few minutes to complete. It is usually done without any anaesthesia, as the needle is so thin that the procedure is less painful than taking blood from the arm of the mum. But if the patient wishes local anaesthetic it can be administered. She may even be put to sleep if she wishes, but this is rarely done for such a simple technique.
Placing a tube into the fetus
Once the urine testing results confirm that the kidneys are working well the next step is to insert a little tube called catheter. This is put into the babies’ bladder to drain fluid from the bladder into the womb. The catheter needs more skill to place, it takes longer time and the needle used is a bit bigger than that used for withdrawing fluid. Thus this procedure is usually done under local anaesthetic where an agent is injected in abundance to numb the whole area and pathway for the needle. The procedure may be done under general anaesthetic where the patient is put to sleep for few minutes. In that case it is done in an operating room to safely give anaesthesia. The procedure may take up to 10 or 15 minutes. After recovery the patient will have a little abdominal discomfort for which she may receive painkillers or sedation.
The idea of the catheter is to drain the fluid from the baby’s bladder into the mothers’ womb, thus the fluid around the baby will stay normal, which allows the development of the lungs. Since the bladder will empty its contents thus the kidneys as well will be draining adequately into the bladder. This will save the kidneys and stop them from failing. The catheter will be left in place till delivery but has to be followed up by regular scans.
What about after delivery?
Following delivery the baby is usually checked by a baby doctor called paediatrician and by a paediatric surgeon. The baby is thoroughly checked to decide the site of the block. Treatment may be very simple using a specific catheter or a telescope. However fixing the problem may entail a more major type of surgery, which is not usually the case.
Swollen fetus known as hydrops
Some babies may become anaemic while inside the womb. There are various reasons why this may happen. A common cause is usually the blood group of the mother being what is known as Rh negative. Anaemia means that the level of a substance called haemoglobin is significantly reduced. Thus the baby starts to accumulate fluid all over the body and if not treated eventually could die.
How to avoid?
Therefore all pregnant women should have their bloods tested for Rh factor early in pregnancy. If they turn up to be negative, their husbands need to be tested as well. If the husband’s blood group turns out to be negative then there is no problem. But on the other hand if the husband’s blood group is Rh positive then her obstetrician will offer the mother special advice. She will need an injection during pregnancy and immediately following delivery. Those who fail to take the injections, their future babies may suffer from anaemia as mentioned above. If the baby gets severely anaemic and is still far from term or the end of the pregnancy then the only management available to save the baby is blood transfusion.
Transfusing fetus with blood
Blood transfusion is done as well by introducing a long fine needle into the womb and baby. The blood is given either in the umbilical cord or in a large vessel into the baby. The blood may be put as well into babies’ tummy to be slowly absorbed over the next few days. The procedure needs a lot of skill and patience but can still be done without any anaesthesia since the needle is a fine one. The baby may require a repeat blood transfusion every 2-3 weeks till maturity is reached and the baby is big enough to be delivered. After delivery the baby will usually need what is known as exchange transfusion, a procedure where most of the babies blood is replaced. Those babies do very well afterwards.
There are many other procedures, which can be done to correct abnormalities within babies while still inside their mother’s wombs. Surgery may be performed with the aid of a telescope known as fetoscope. This is introduced into the womb and can be used to block certain vessels or correct certain deformities. In rare cases laparotomy may be performed where the tummy and womb are opened in a similar way to caesarean section. The surgeon operates on the fetus then the womb and tummy are sutured to continue with the pregnancy.
The aim of this article is to raise awareness about the speciality called fetal medicine. I have mentioned only two abnormalities as an example but there are many other treatable problems. The public and specially the expecting mums should know that if god forbid an abnormality is diagnosed there may be treatment available. More important is that these management options are offered and performed in Egypt.