Medicine And Surgery In Utero – Fetal Attraction
Thursday, 05 May 2016
Professor Alan Cameron, Consultant Obstetrician, Ian Donald Fetal Medicine Unit, Southern General Hospital, Glasgow.
Medico-Chirurgical Hall at 7.00 pm (preceded by a finger buffet from 6.30 pm)
Alan Cameron has been a consultant obstetrician in Glasgow for 22 years. He undertook his subspeciality training in Maternal Fetal Medicine at the University of Calgary, Alberta, Canada. After this he was appointed Lecturer in the Department of Obstetrics and Gynecology in Glasgow. He has retained an active research profile and was rewarded with an Honorary Professorship from the University of Glasgow.
His main research interests are in prenatal diagnosis and fetal therapy. He has been involved with the development of guidelines for referring obstetricians who consider that their patients require fetal evaluation and /or fetal therapy in the form of detailed prenatal ultrasound evaluation and where necessary the performance of in utero therapy. This therapy is performed using ultrasound guided intravascular fetal blood transfusions via either the umbilical or hepatic veins.
The Ian Donald Fetal Medicine Unit provides interventional fetal therapy for Scotland.
The President welcomed the company to the meeting. He noted that this was the 8thmeeting of the programme. One member indicated that they had been present at all eight. The president reminded audience of the forthcoming Cabaret Evening on 14th May at which there will be 14 varied acts.
Members were informed of the death of Dr George McDonald who was known to many. Having trained in Aberdeen, he moved to Glasgow Royal Infirmary where he established the Department of Haematology. A founder-member of the British Society for Haematology, he returned to his Aberdeen roots in retirement. (obituary: http://www.heraldscotland.com/opinion/14417979.George_McDonald/)
The President informed members they had a few hours remaining to make nominations to Council. The final meeting of the programme, the Annual Business Meeting and Presidential Address, would be held in the Suttie Building. This will allow refurbishment of the Hall by Aberdeen University. He welcomed the plans for new IT facilities and indicated that changes would be sensitive to the ambience of the hall.
He then invited Professor Alan Cameron to give the evening’s lecture “Fetal Attraction”. Professor Cameron is a Consultant Obstetrician in the Ian Donald Fetal Medicine Unit at the new Southern General Hospital in Glasgow.
Professor Cameron began his talk with a history of the Queen Mother’s Hospital in Glasgow showing the influence of Ian Donald after whom the Fetal Medicine Unit is named. He traced the development of ultrasound from the diasonograph of the 1950s and 60s. Technological advances had enabled the specialty of Fetal Medicine to develop. Professor Donald had worked in cooperation with industry and engineer and with Bertil Sunden in Sweden.
The talk continued chronologically with an outline of Prenatal Diagnosis, noting the progression from needling (amniocentesis) to ultrasound screening. He highlighted the significance of the nuchal translucency. With biochemical markers (CUB) they can achieve 80% detection of Down’s Syndrome in clinical practice. Further developed cell free fetal DNA with Non Invasive Pre-natal Diagnosis having been able to detect fetal and rhesus abnormalities since 2003. Non-invasive prenatal diagnosis of aneuploidy using next-generation DNA sequencing has been available since 2012. This has greater than 99% sensitivity and is essentially whole genome sequencing. It remains a screening tool rather than diagnostic, used after biochemistry and ultrasound. The commercial kit costs £3-400 in private clinics.
Moving on to specific fetal malformations, Professor Cameron indicated that the tests can identify fatal conditions, those with high mortality, those that require post-natal care and a small group suitable for fetal therapy. While good for many diagnoses, unfortunately cardiac anomalies are poorly detected. He talked about Gastroschisis and Fetal neck masses – amenable to ex-utero airway intervention while the infant stays on the placental circulation. He discussed Fetal Cardiology looking at size, position, structure and function. Next was Rhesus isoimmunisation, paying tribute to William Liley (1929-1983) and describing the detail of the technique using assessment of flow within the middle cerebral artery rather than amniocentesis. They carry out 30-40 intrauterine transfusions to a haematocrit of 40-45% per year with 94% reaching hospital discharge.
For Twin to Twin Transfusion Syndrome in monochorionic twins they can carry out placental laser ablation therapy. This has better survival and fewer neurological complications than alternative therapies. The technique uses 1-3 mm fetoscopes demonstrating the dependence on technological developments in this specialty.
Pig-tail fetal pleural catheters inserted under ultrasound control can treat heart failure in utero. Congenital Diaphragmatic Hernias, first described in 1754 can now be treated at fetoscopy by tracheal occlusion – an RCT is underway.
Finally Professor Cameron talked about the recognition and treatment of spina bifida which has a high incidence in Scotland. A team in Philadelphia have developed a technique for pre-natal in-utero surgery to close the back defect, avoiding premature labour.
He closed by showing pictures of members of the department through the years, some of whom were present in Aberdeen.
A lively question and answer session followed with discussion of sedation, with muscle relaxant only used for tracheal occlusion. Bladder shunting had been abandoned as many went on to need dialysis. Asked about developments in the next ten years, Professor Cameron indicated that even earlier diagnosis was likely with technological developments and a decrease in the need for diagnostic test (amniocentesis and Chorionic villous sampling.) A final question went into the ethics of the specialty, with most of their patients meeting the criteria of the Abortion Act. In a demanding specialty it is important for colleagues to be able to share their burdens and to have an appropriate manner with their patients.
The President thanked the speaker for a most enlightening talk which gave an insight into current and future practice.