Management of Fetal hydrocephalus

Management of Fetal

hydrocephalus

Aboubakr Elnashar Benha university Hospital, Egypt

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(A) Normal atrium of lateral ventricle: <10 mm

(B) Ventriculomegaly: Mild: 10-15 mm

(C) Severe: >15 mm

Diagnosis

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(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

Normal

Biventricular hydrocephalus

Triventricular hydrocephalus

Ventriculomegaly

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Ventriculomegaly, also known as hydrocephalus, occurs when cerebrospinal fluid collects intracranially, resulting in enlargement of the ventricular system.

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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.

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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)

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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

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.

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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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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

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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}.

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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

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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.

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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.

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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.

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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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