Intrauterine Therapy

Abstract

Since the first intrauterine interventions were carried out in the 1970 s under what today would be considered basic conditions, the range of prenatal interventions has steadily expanded, as has the frequency with which these interventions are carried out at specialized centers. Although most of these procedures are minimally invasive, they are invariably associated with considerable risks for the fetus and, depending on the surgical method, also for the expectant mother. For this reason, most centers worldwide limit themselves to interventions for fetal diseases which, if untreated, have a fatal course or experience a significant deterioration in the postnatal prognosis during the course of intrauterine development. This is all the more significant as only a small proportion of prenatal interventions have been successfully investigated in controlled clinical trials. The only exceptions are laser therapy for feto-fetal transfusion syndrome, intrauterine closure of spina bifida, and tracheal occlusion for diaphragmatic hernia with severe pulmonary hypoplasia. This article is intended to provide an overview of the fetal conditions that are candidates for intrauterine therapy and of the evidence for the individual interventions.

Publication History

Received: 11 October 2024

Accepted after revision: 02 January 2025

Article published online:
14 March 2025

• References

• 1 Bamberg C, Hecher K. Twin-to-twin transfusion syndrome: Controversies in the diagnosis and management. Best Practice & Research Clinical Obstetrics & Gynaecology 2022; 84: 143-154
• 2 WAPM Consensus Group on Twin-to-Twin Transfusion, Baschat A, Chmait RH, et al. Twin-to-twin transfusion syndrome (TTTS). J Perinat Med 2011; 39: 107-112
• 3 Senat M-V, Deprest J, Boulvain M. et al. Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome. N Engl J Med 2004; 351: 136-144
• 4 Diehl W, Diemert A, Grasso D. et al. Fetoscopic laser coagulation in 1020 pregnancies with twin–twin transfusion syndrome demonstrates improvement in double-twin survival rate. Ultrasound in Obstetrics & Gynecology 2017; 50: 728-735
• 5 Ruano R, Rodo C, Peiro JL. et al. Fetoscopic laser ablation of placental anastomoses in twin-twin transfusion syndrome using “Solomon technique”. Ultrasound Obstet Gynecol 2013; 25: n/a-n/a
• 6 Akkermans J, De Vries SM, Zhao D. et al. What is the impact of placental tissue damage after laser surgery for twin-twin transfusion syndrome?. A secondary analysis of the Solomon trial. Placenta 2017; 52: 71-76
• 7 Stirnemann J, Slaghekke F, Khalek N. et al. Intrauterine fetoscopic laser surgery versus expectant management in stage 1 twin-to-twin transfusion syndrome: an international randomized trial. American Journal of Obstetrics and Gynecology 2021; 224: 528
• 8 Berg C, Holst D, Mallmann MR. et al. Early vslate intervention in twin reversed arterial perfusion sequence. Ultrasound Obstet Gynecol 2014; 43: 60-64
• 9 Lewi L, Valencia C, Gonzalez E. et al. The outcome of twin reversed arterial perfusion sequence diagnosed in the first trimester. Am J Obstet Gynecol 2010; 203: 213
• 10 Tavares de Sousa M, Glosemeyer P, Diemert A. et al. First‐trimester intervention in twin reversed arterial perfusion sequence. Ultrasound Obstet Gynecol 2020; 55: 47-49
• 11 Weber EC, Recker F, Gottschalk I. et al. Outcome of TRAP Sequence Treated in the First Trimester – A Ten-Year Single-Center Experience. Ultraschall in Med 2021; a-1526-a-1775
• 12 Weber EC, Recker F, Gottschalk I. et al. Outcome of Monochorionic Monoamniotic Twin Reversed Arterial Perfusion Sequence Diagnosed in the First Trimester. Fetal Diagn Ther 2021; 48: 778-784
• 13 Tollenaar LSA, Slaghekke F, Lewi L. et al. Treatment and outcome of 370 cases with spontaneous or post-laser twin anemia-polycythemia sequence managed in 17 fetal therapy centers. Ultrasound Obstet Gynecol 2020; 56: 378-387
• 14 Weber EC, Strizek B, Recker F. et al. Outcome of Monochorionic Pregnancies after Selective Feticide with Bipolar Cord Coagulation: A German Single Center Experience. J Clin Med 2022; 11: 1516
• 15 Guilbaud L, Carreras E, Garel C. et al. Proposal for standardized prenatal assessment of fetal open dysraphisms by the European reference network for Intellectual disability, TeleHealth, Autism and Congenital Anomalies (ITHACA) and eUROGEN. Prenatal Diagnosis 2024;
• 16 Meuli M, Meuli-Simmen C, Hutchins GM. et al. The spinal cord lesion in human fetuses with myelomeningocele: Implications for fetal surgery. Journal of Pediatric Surgery 1997; 32: 448-452
• 17 Oliver ER, Heuer GG, Thom EA. et al. Myelomeningocele sac associated with worse lower‐extremity neurological sequelae: evidence for prenatal neural stretch injury?. Ultrasound Obstet Gynecol 2020; 55: 740-746
• 18 Chaoui R, Benoit B, Mitkowska-Wozniak H. et al. Assessment of intracranial translucency (IT) in the detection of spina bifida at the 11–13-week scan. Ultrasound Obstet Gynecol 2009; 34: 249-252
• 19 Ushakov F, Sacco A, Andreeva E. et al. Crash sign: new first‐trimester sonographic marker of spina bifida. Ultrasound in Obstet & Gyne 2019; 54: 740-745
• 20 Nicolaides KH, Gabbe SG, Campbell S. et al. ULTRASOUND SCREENING FOR SPINA BIFIDA: CRANIAL AND CEREBELLAR SIGNS. The Lancet 1986; 328: 72-74
• 21 Adzick NS, Thom EA, Spong CY. et al. A Randomized Trial of Prenatal versus Postnatal Repair of Myelomeningocele. N Engl J Med 2011; 364: 993-1004
• 22 Moehrlen U, Ochsenbein-Kölble N, Stricker S. et al. Prenatal Spina Bifida Repair: Defendable Trespassing of MOMS Criteria Results in Commendable Personalized Medicine. Fetal Diagn Ther 2023; 50: 454-463
• 23 Kohl T. Percutaneous minimally invasive fetoscopic surgery for spina bifida aperta. Part I: surgical technique and perioperative outcome. Ultrasound Obstet Gynecol 2014; 44: 515-524
• 24 Belfort MA, Whitehead WE, Shamshirsaz AA. et al. Fetoscopic Open Neural Tube Defect Repair: Development and Refinement of a Two-Port, Carbon Dioxide Insufflation Technique. Obstetrics & Gynecology 2017; 129: 734-743
• 25 Sanz Cortes M, Lapa DA, Acacio GL. et al. Proceedings of the First Annual Meeting of the International Fetoscopic Myelomeningocele Repair Consortium: International Fetoscopic Myelomeningocele Repair Consortium. Ultrasound Obstet Gynecol 2019; 53: 855-863
• 26 Sanz Cortes M, Chmait RH, Lapa DA. et al. Experience of 300 cases of prenatal fetoscopic open spina bifida repair: report of the International Fetoscopic Neural Tube Defect Repair Consortium. American Journal of Obstetrics and Gynecology 2021; 225: 678
• 27 Botelho RD, Imada V, Rodrigues Da Costa KJ. et al. Fetal Myelomeningocele Repair through a Mini-Hysterotomy. Fetal Diagn Ther 2017; 42: 28-34
• 28 Deprest J, Brady P, Nicolaides K. et al. Prenatal management of the fetus with isolated congenital diaphragmatic hernia in the era of the TOTAL trial. Semin Fetal Neonatal Med 2014; 19: 338-348
• 29 Deprest JA, Nicolaides KH, Benachi A. et al. Randomized Trial of Fetal Surgery for Severe Left Diaphragmatic Hernia. N Engl J Med 2021; 385: 107-118
• 30 Deprest JA, Benachi A, Gratacos E. et al. Randomized Trial of Fetal Surgery for Moderate Left Diaphragmatic Hernia. N Engl J Med 2021; 385: 119-129
• 31 Van Calster B, Benachi A, Nicolaides KH. et al. The randomized Tracheal Occlusion To Accelerate Lung growth (TOTAL)-trials on fetal surgery for congenital diaphragmatic hernia: reanalysis using pooled data. American Journal of Obstetrics and Gynecology 2022; 226: 560
• 32 Hellmund A, Berg C, Geipel A. et al. Prenatal Diagnosis and Evaluation of Sonographic Predictors for Intervention and Adverse Outcome in Congenital Pulmonary Airway Malformation. PLoS ONE 2016; 11: e0150474
• 33 Downard CD, Calkins CM, Williams RF. et al. Treatment of congenital pulmonary airway malformations: a systematic review from the APSA outcomes and evidence based practice committee. Pediatr Surg Int 2017; 33: 939-953
• 34 Mallmann MR, Geipel A, Bludau M. et al. Bronchopulmonary sequestration with massive pleural effusion: pleuroamniotic shunting vs intrafetal vascular laser ablation. Ultrasound Obstet Gynecol 2014;
• 35 Cavoretto P, Molina F, Poggi S. et al. Prenatal diagnosis and outcome of echogenic fetal lung lesions. Ultrasound Obstet Gynecol 2008; 32: 769-783
• 36 Cruz-Martinez R, Nieto-Castro B, Martínez-Rodríguez M. et al. Thoracic Changes after Full Laser Ablation of the Feeding Artery in Fetuses with Bronchopulmonary Sequestration. Fetal Diagn Ther 2018; 44: 166-172
• 37 Gottschalk I, Strizek B, Mallmann MR. et al. Outcome of Bronchopulmonary Sequestration with Massive Pleural Effusion after Intrafetal Vascular Laser Ablation. Fetal Diagn Ther 2018; 44: 149-155
• 38 Smith RP, Illanes S, Denbow ML. et al. Outcome of fetal pleural effusions treated by thoracoamniotic shunting: Fetal chest shunting. Ultrasound Obstet Gynecol 2005; 26: 63-66
• 39 Yinon Y, Grisaru-Granovsky S, Chaddha V. et al. Perinatal outcome following fetal chest shunt insertion for pleural effusion. Ultrasound Obstet Gynecol 2010; 36: 58-64
• 40 Grandt J, Gottschalk I, Geipel A. et al. Intrauterine Thoracoamniotic Shunting of Fetal Hydrothorax with the Somatex Intrauterine Shunt: Intrauterine Course and Postnatal Outcome. JCM 2022; 11: 2312
• 41 Roman KS, Fouron J-C, Nii M. et al. Determinants of Outcome in Fetal Pulmonary Valve Stenosis or Atresia With Intact Ventricular Septum. Am J Cardiol 2007; 99: 699-703
• 42 Tulzer A, Arzt W, Gitter R. et al. Immediate effects and outcome of in-utero pulmonary valvuloplasty in fetuses with pulmonary atresia with intact ventricular septum or critical pulm... – PubMed – NCBI. Ultrasound Obstet Gynecol 2018; 52: 230-237
• 43 Walter A, Strizek B, Weber EC. et al. Intrauterine Valvuloplasty in Severe Aortic Stenosis—A Ten Years Single Center Experience. JCM 2022; 11: 3058
• 44 Gottschalk I, Strizek B, Menzel T. et al. Severe Pulmonary Stenosis or Atresia with Intact Ventricular Septum in the Fetus: The Natural History. Fetal Diagn Ther 2019; 1-9
• 45 Chalouhi GE, Morency A, De Vlieger R. et al. Prenatal incision of ureterocele causing bladder outlet obstruction: a multicenter case series. Prenatal Diagnosis 2017; 37: 968-974
• 46 Strizek B, Spicher T, Gottschalk I. et al. Vesicoamniotic Shunting before 17 + 0 Weeks in Fetuses with Lower Urinary Tract Obstruction (LUTO): Comparison of Somatex vs. Harrison Shunt Systems. J Clin Med 2022; 11: 2359
• 47 Morris RK, Malin GL, Quinlan-Jones E. et al. The Percutaneous shunting in Lower Urinary Tract Obstruction (PLUTO) study and randomised controlled trial: evaluation of the effectiveness, cost-effectiveness and acceptability of percutaneous vesicoamniotic shunting for lower urinary tract obstruction. Health Technol Assess 2013; 17: 1-232
• 48 Gottschalk I, Berg C, Menzel T. et al. Single-center outcome analysis of 46 fetuses with megacystis after intrauterine vesico-amniotic shunting with the Somatex intrauterine shunt. Arch Gynecol Obstet 2023;
• 49 Strizek B, Gottschalk I, Recker F. et al. Vesicoamniotic shunting for fetal megacystis in the first trimester with a Somatex intrauterine shunt. Arch Gynecol Obstet 2020; 302: 133-140
• 50 Weber E, Recker F, Strizek B. et al. Fetoskopische Therapie einer kongenitalen Megalourethra. Frauenarzt 2020; 42-43