Management of Fetal hydrocephalus

1. Management of Fetal hydrocephalus Aboubakr Elnashar Benha university Hospital, Egypt
Aboubakr Elnashar

2. (A) Normal atrium of lateral ventricle: <10 mm (B) Ventriculomegaly: Mild: 10-15 mm (C) Severe: >15 mm
Diagnosis
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3. (A)Normal: Bright echogenic choroid plexus (CP) entirely fills the lumen of the atrium, being closely apposed to both medial and lateral walls of the ventricle (arrowheads). (B)Ventriculomegaly: anterior displacement of the shrunken choroid plexus that appears clearly detached from the medial wall of the ventricle. FH, Frontal Horns of Lateral Ventricles; Ant, Anterior; Post, Posterior.
Aboubakr Elnashar

4. Normal
Biventricular
hydrocephalus
Triventricular
hydrocephalus
Ventriculomegaly
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5. Ventriculomegaly, also known as hydrocephalus, occurs when cerebrospinal fluid collects intracranially, resulting in enlargement of the ventricular system.
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6. Management
Depend on
1.gestational age at diagnosis
2.presence of other anomalies
3.results of the karyotype
4.infectious studies
5.views of the parents.
Aboubakr Elnashar

7. If the diagnosis is made prior to fetal viability: patient may consider pregnancy termination.
If the diagnosis is made after viability or the couple chooses to continue with the pregnancy: the following procedures can be performed (depending on the circumstances)
Aboubakr Elnashar

8. I. isolated or associated with other congenital anomalies.
Isolated ventriculomegaly is associated in 3% of cases with chromosomal anomalies.
If associated with other defects, this figure rises to 36%.
The most common associated anomaly (25- 30%), is spina bifida, followed by other defects (CNS, renal, GIT) in 7-15%
1.Fetal echocardiogram to check for cardiac anomalies
2.Amniocentesis to analyze the fetal karyotype
3.Maternal testing to check for recent or current infections
Aboubakr Elnashar

9. 4. Genetic counseling: X-linked recessive aqueductal stenosis carries a 1 in 4 risk of recurrence for future pregnancies and a 1 in 2 risk for male fetuses. Cerebellar agenesis with hydrocephalus is rare but may also be sex-linked and thus have a similar recurrence risk.
Aboubakr Elnashar

10. II. Degree of ventriculomegaly
Mild: > 10 mm cortical thickness + normal BPD Severe: < lOmm cortical thickness + abnormally increased BPD
Atrium of lateral ventricle: <10 mm Mild: 10-15 mm Severe: >15 mm
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11. Follow up
1.If it is an isolated and is mild to moderate, serial scans to follow the progression and/or regression. 2. Attempt to carry the pregnancy until fetal lung maturity
Aboubakr Elnashar

12. Timing of delivery 1. Associated with other defects or chromosomal abnormalities: couple should be counselled about termination of the pregnancy 2. No clear indication for preterm delivery if the hydrocephalus is rapidly progressive prior to fetal lung maturity {respiratory distress syndrome, which would delay shunt placement, could actually worsen the final outcome}. 3. If the hydrocephalus is rapidly progressing and delivery is necessary prior to lung maturity: corticosteroids {decrease the severity of RDS}.
Aboubakr Elnashar

13. Mode of delivery
1.CS: a. isolated disease and moderate to severe macrocephaly {facilitate the atraumatic delivery of the enlarged fetal head}. b. Macrocrania is present
Aboubakr Elnashar

14. 2. Vaginal delivery
a.vertex presentation and has only mild macrocephaly.
b.Associated anomalies that are either incompatible with life or associated with the severest forms of neurologic dysfunction e.g., alobar holoprosencephaly, hydrancephaly, or thanatophoric dysplasia with cloverleaf skull), cephalocentesis and subsequent vaginal delivery are an acceptable alternative to cesarean delivery.
Aboubakr Elnashar

15. Cephalocentesis prior to delivery –
This is a destructive procedure.
done to reduce the cranial size and potentially allow for vaginal delivery.
This is associated with significant fetal/neonatal morbidity and is indicated only in cases where the prognosis is thought to be extremely poor.
performed by passing a 14- to 18-gauge needle transabdominally or transvaginally under US guidance, and removing sufficient cerebrospinal fluid to allow overlapping of the cranial sutures.
Aboubakr Elnashar

16. Ventriculo-amniotic shunt
Placement of a tube between the fetal ventricular system and the amniotic cavity to potentially reduce pressure preliminary experiments on human fetuses are not encouraging.
Aboubakr Elnashar

17. Shunting after birth prognosis is usually improved when this occurs. outcome is better if performed before 6 months of age. If operative tt is not delayed, most cases of hydrocephalus are compatible with normal physical development and normal head size
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18. Thanks
Aboubakr Elnashar