Service Description

Common fetal conditions (for example, minor malformations, late fetal growth restriction) are managed in local maternity hospital services, but complex and rare conditions (for example, major/multiple malformations, complications of monochorionic twins and severe early-onset fetal growth restriction and those secondary to maternal disorders, for example, alloimmunisation, where fetal red blood cells or platelets are destroyed by maternal antibodies transferred across the placenta) are managed in conjunction with specialist fetal medicine services.

Specialist fetal medicine services are provided from specialist centres; however, not all centres provide the full spectrum of fetal therapeutic interventions.

Cases are typically assessed and managed on an outpatient basis by the specialist multi-disciplinary team, often involving other specialist consultants and/or specialist services.

The fetal medicine services work to locally agreed clinical pathways of care with teams in local hospitals to provide care for patients with difficult or complex fetal disorders as near to their home as possible. Care is shared with local providers when the appropriate skills are available on a network basis. 

Outlined in the table below are the majority of conditions that require a specialist fetal medicine service diagnosis, management and/or intervention: 

Diagnosis and Management

Diagnosis and Management

Fetal anomalies

  • Fetal structural anomalies
  • Fetal surgical condition requiring in or ex-utero intervention
  • Fetal arteriovenous malformation ( AVM)
  • Fetal tumours
  • Fetal arrhythmias
  • Fetal hydrops

Fetal growth

  • Fetal growth restriction <32 weeks

Multiple pregnancy

  • Monochorionic twins complicated by twin-to-twin transfusion syndrome (TTTS), twin anaemia polycythemia sequence ( TAPS), selective intrauterine growth restriction (SIUGR) or discordant for fetal anomaly

·         Dichorionic twins complicated with growth discordance greater than 20% or discordant for fetal anomaly

  • Management of DCDA twin pregnancy where one is a molar pregnancy
  • Any higher-order multiple-pregnancy
Chromosomal/genetic anomalies
  • Raised risk of aneuploidy from combined screening or non-invasive prenatal testing (NIPT)
  • Family or previous pregnancy history of genetic condition

Placental anomalies

  • Imaging for placenta accreta spectrum
  • Placental tumours/chorioangioma
  • Molar pregnancy
  • Amniotic bands

Amniotic fluid anomalies

  • Severe polyhydramnios
  • Severe oligohydramnios
  • Spontaneous preterm premature rupture of membranes (PPROM)<24 weeks

Maternal disease affecting the fetus

  • Monitoring of the fetus in major maternal medical conditions such as early onset/severe pre-eclampsia, severe nephropathy, uncontrolled hyperthyroidism, myasthenia gravis, and other autoantibody conditions
  • Monitoring of fetus in alloimmune conditions such as
    • alloimmune red cell disease
    • alloimmune platelet disease (thrombocytopenia (NAIT))
  • Congenital infections
  • Teratogenic drug exposure

History

  • Surveillance of pregnancy previously affected by an adverse outcome related to a fetal medicine condition as listed
  • Surveillance of pregnancy where there is fetal risk due to previous or current maternal medical conditions

Interventions

Interventions

Invasive diagnostic procedures:

  • Amniocentesis
  • Chorionic villus sampling (CVS)
  • Fetal blood sampling

Fetal therapy procedures:

  • Laser treatment for Twin-to-Twin Transfusion Syndrome (TTTS)
  • Intrauterine blood transfusion
  • Fetoscopic endoluminal tracheal occlusion (FETO)
  • Feticide (selective, multifetal or singleton)

·         Selective reduction or multi-fetal reduction in dichorionic multiple pregnancies

  • Radiofrequency ablation or interstitial laser or bipolar cord coagulation in monochorionic multiple pregnancy
  • Fetal shunts/drainage of abnormal fluid accumulation in the fetus: e.g., pleural cavity, bladder.
  • Amniodrainage

Termination of pregnancy

·         Multifetal pregnancy reduction

·         Feticide (including selective termination in multiple pregnancy)

·         Cord occlusion in monochorionic twins

·         Intrafetal laser ablation or radiofrequency ablation in twin reversed arterial perfusion (TRAP) sequence