Michigan Medicine’s Fetal Diagnosis & Treatment Center offers the full range of fetal procedures from an expert team to diagnose and treat conditions before a child is born.
Our experienced team uses both traditional, or open fetal surgical techniques as well as minimally invasive techniques. The team works together with your family to determine the correct treatment plan for each individual mother and baby, and ensure that you are involved in the process each step of the way.
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Percutaneous fetal procedures refers to a technique that uses an ultrasound to guide a needle or needle-like instrument, or a small trocar (metal tube), into the womb.
One type of procedure in this category includes placing a shunt (tiny flexible tube) in the fetal bladder or chest for select cases of bladder outlet obstruction, pleural effusions, or cystic chest masses. A specially designed double pig-tail catheter is inserted with one end into the fetal chest or bladder and the other end outside the fetus allowing drainage of fluid into the amniotic cavity. The procedure is often performed using local anesthesia or maternal epidural anesthesia, combined with IV sedation.
RFA (radio frequency ablation) is another type of percutaneous procedure. RFA uses a needle-type electrode that attaches to an energy source and is guided by ultrasound to the affected area. The energy from the tip will occlude blood circulation in that region. It is often used to occlude the blood flow to the acardiac twin in TRAP sequence, and can also be used for select fetal tumors.
Cordocentesis involves guiding a needle through mother’s abdomen into the uterus to the baby’s umbilical cord. This direct access to the baby allows our maternal fetal medicine specialists the ability to sample the baby’s blood, give a blood transfusion, or administer special medication.
During the Procedure
During shunt placement, a tiny skin incision is made on the maternal abdomen. A special trocar is inserted through the abdomen and into the uterus using ultrasound guidance. The device is then inserted through the trocar and into the fetus and a tiny shunt (drainage tube) is deployed. Once maternal and fetal well-being is assured, the mother may be discharged and followed closely as an outpatient.
Local anesthesia is the preferred choice for an RFA procedure. After anesthesia has been achieved, a special needle electrode is guided by ultrasound into the uterus to the affected fetal area. Energy is transferred through the needle until blood is no longer flowing to the area. Recovery is similar to the shunt placement.
Fetoscopic surgery is a technique that uses a small camera or scope to examine the fetus and perform procedures inside the womb during a pregnancy.
Fetoscopic surgery is performed most commonly for twin-twin transfusion syndrome. It can also be used for treating twin-reversed arterial perfusion syndrome (TRAP), amniotic band syndrome, and fetal endoscopic tracheal occlusion (FETO).
The Michigan Medicine's Diagnosis & Treatment Center offers families a full team of maternal fetal medicine specialists as well as fetal and pediatric surgeons working seamlessly together to ensure the safety of mother and babies during these complex procedures.
During the procedure
Fetoscopy is performed in an operating room (OR) with special equipment for the safety of you and your baby, including special monitors that allow us to closely monitor mother and baby throughout the procedure.
Fetoscopic surgery is a minimally invasive technique using a very small telescope along with ultrasound guidance. Maternal epidural anesthesia is used with light sedation to keep mother comfortable.
A small skin incision is made in the maternal abdominal wall and a trocar (a small metal tube) is inserted through the abdomen and uterus using ultrasound guidance. A small telescope is then placed through the trocar. The fetal team can view the area on a large screen. The babies are continuously monitored with ultrasound.
In some procedures, such as with twin-to-twin transfusion syndrome (TTTS), a laser is used to coagulate abnormal blood vessels that are causing fetal problems. This is known as fetoscopic laser photocoagulation. The maternal-fetal medicine doctors and the fetal surgeons work together mapping the connecting vessels on the placenta before using the laser to seal them.
At the end of the procedure, the telescope and trocar are removed. The mother is given medication to prevent preterm labor, and she and her babies are closely monitored in the hospital.
Since each mother and each pregnancy is unique, the hospital stay and follow-up monitoring schedule is adjusted accordingly. Once maternal and fetal well-being is assured, the mother may be discharged home and followed closely as an outpatient. The pregnancy is typically allowed to progress to term and delivery normally does not require Cesarean delivery.
The EXIT (Ex Utero Intrapartum Treatment) Procedure is a highly-modified Cesarean delivery which requires an experienced multidisciplinary team. The goal is to partially deliver the baby, but maintain placental support to be able to perform surgery before the baby is completely delivered.
Instead of stopping blood flow and separating the placenta from the uterus as you would in a traditional C-section, an EXIT procedure allows continued oxygenation between mother and baby. This maintains the circulation of blood, nutrients, and oxygen to the baby so that the surgical team has time to secure the airway and perform all necessary treatments
An EXIT procedure may be used for conditions including, but not limited to:
The Michigan Medicine's Fetal Diagnosis & Treatment Center offers families a full team of maternal fetal medicine specialists as well as pediatric and fetal surgeons working seamlessly to ensure the safety of mother and child during these complex procedures. As one of only a handful of medical centers in the nation in which a comprehensive birth center is located within a world-class children’s hospital, we are uniquely positioned to manage any further interventions that may become necessary during, or immediately following, the birth of your child. We offer immediate access to the region’s most sophisticated newborn intensive care units (NICU) and around-the-clock access to a full pediatric surgery team.
During the procedure
An EXIT procedure is performed in an operating room (OR) with special equipment for the safety of you and your baby, including special monitors that allow us to closely monitor mother and baby throughout the procedure.
The mother will be given a general anesthetic to relax her uterus and maintain blood flow to the placenta during the operation. The uterus is opened with a special stapling device to prevent bleeding, but the incision is similar to a standard C-section that allows for possible future vaginal deliveries.The baby receives anesthesia via the placenta, as well as additional anesthesia delivered by a shot.
There are two primary reasons for an EXIT procedure:
- EXIT to airway: the surgeon will attempt to secure an airway for the baby by placing a breathing tube in the trachea. If a breathing tube cannot be placed, the surgeon will perform a tracheostomy to create an airway.
- EXIT to surgery: the procedure is similar for those babies with a mass inside the chest that would make breathing difficult after birth. A breathing tube would be secured in place and an injection of anesthesia would be given. The baby would then have an operation to remove the mass while still connected to the placenta.
Once the procedure is completed, the umbilical cord is cut and the baby is delivered. The mother is given medication to cause the uterus to contract, the placenta is removed, and the uterus and abdominal wall are closed.
The mother will be admitted to the Birth Center on the 9th floor of the hospital, and the baby is admitted to the Newborn Intensive Care Unit (NICU) on the 8th floor for further care. Recovery for the mother is similar to the recovery from a regular Cesarean delivery.
The EXIT-ECMO Procedure
This procedure is reserved for select babies with a very high-risk of lung or heart failure at birth because of an underlying problem. This technique uses a heart-lung bypass machine called extracorporeal membrane oxygenation (ECMO), to help provide a smooth transition from the womb.
During the EXIT-ECMO procedure, the airway is secured and a trial of ventilation is performed. If the infant is not exchanging oxygen adequately, ECMO cannulation (the placement of tubes into the carotid artery and jugular vein) is performed while the infant remains on placental support. Once the infant is stabilized on ECMO, the baby is delivered.
Open fetal surgery is performed during the second trimester of the pregnancy and requires a highly organized team of specialists to ensure maternal and fetal safety. It has been used to intervene and resect life-threatening tumors during mid-gestation. Over the last decade, it has been most often used to perform in utero repair of a myelomeningocele defect in select candidates.
During the procedure
Open fetal surgery is performed in an operating room with a dedicated and experienced multidisciplinary team and special equipment to ensure maternal and fetal the safety.
The mother will be given a general anesthetic to relax her uterus and maintain blood flow to the placenta during the operation. The uterus is opened with a special stapling device to prevent bleeding. Since a classical incision is made in the uterus, future pregnancies will need to be delivered with a cesarean section. The baby receives anesthesia via the placenta, as well as additional anesthesia delivered by a shot. During the procedure, the fetus is continuously monitored with fetal echocardiography. After surgery on the fetus, the uterus is closed using a special technique. After the procedure, the mother will be admitted to the Birth Center on the 9th floor of the hospital and cared for by a specialized team of obstetric nurses. Delivery will require a cesarean section.
Babies that need the procedures described above usually need to spend time in an intensive care unit after they are born. They will make that transition in one of two ways:
- For an EXIT procedure, a team from the Newborn ICU (NICU) is waiting to receive the baby in the Operating Room on the fourth floor of Mott Children's Hospital. After the umbilical cord is cut, the NICU team evaluates baby and secures intravenous lines, the breathing tube, and any other tubes (like ECMO tubes). Then the baby is moved by elevator upstairs to the NICU on our 8th floor. The Operating Room is a complex and sterile space, so a partner or other family member is not able to be in the room at the time of delivery. But typically one of our team members takes pictures of baby during the procedure and delivery.
- When it’s time to be born, babies that needed a Percutaneous Fetal Procedure, Fetoscopic Surgery, or Open Fetal Surgery are typically born in an operating room in the Von Voigtlander Women's Hospital, on the 9th floor of our Children's and Women's Hospital. Right after delivery baby moves through a door into the NEST, to meet the Newborn ICU team, ready to evaluate and stabilize.
NEST stands for Newborn Evaluation Stabilization and Treatment. The abbreviation NEST made us think of a home-like "nest" space, for a new baby needing extraordinary care. That image of a nest reminds us all that even though a baby in the NEST may need critical care right after birth, we can do that while including parents and family as part of baby’s team. After all, the arrival in the NEST is the next step in a family's life-long journey together. Usually mom’s partner or other close family member will follow baby from mom’s bedside to the NEST, and a NICU team member (the Parent Host) offers emotional support and explains what is happening.
The NEST is a four-bed section of our NICU, just one floor above the rest of the NICU and one floor below the Pediatric Cardio-thoracic Unit (PCTU). Because the Women's Hospital and the Children's Hospital share one building, any of the medical or surgical specialists of our world-class Children's Hospital can be ready to help with baby's care in the NEST. X-ray and ultrasound images are done at the bedside in the NEST. If emergency surgery is needed, it can be performed in the NEST.
Once stabilized in the NEST, and after some time for family bonding, most babies move to our NICU (8th floor), or babies with heart problems move to the PCTU (10th floor). Babies with the most severe heart problems are stabilized by our NICU team and within minutes are moved to our 11th floor Cardiac Catheterization and Hybrid Procedure suite for life-saving intervention, before they even reach the PCTU. Whatever the situation, the NEST is the gateway to comprehensive and family-centered care for a newborn with extra needs.