>> TERATOMAS ARE MISCHIEF MAKERS FOR TWO BASIC REASONS —
ONE IS THE LOCATION AND THE SIZE; THE SIZE CAN COMPRESS ADJACENT
DEVELOPING ORGANS, THE AIRWAY IN THE NECK OR INTRA-ABDOMINAL
STRUCTURES FOR SACROCOCCYGEAL TERATOMAS THAT GROW
INTO THE ABDOMEN.
THEY CAN ALSO HAVE CONSEQUENCES IN TERMS OF THEIR BLOOD SUPPLY.
IF THEY'RE SOLID AND RICHLY SUPPLIED WITH BLOOD,
THAT TUMOR, THAT TERATOMA TUMOR, CAN STEAL BLOOD AWAY
FROM THE DEVELOPING FETUS AND PLACENTA AND CAUSE
CARDIOVASCULAR FAILURE.
>> THE SOLID PORTION OF THE TUMOR IS RELATIVELY
WELL VASCULARIZED.
>> SO WHAT IT IS COMPRISED OF IS A CIRCUIT,
AN ABNORMAL CIRCUIT OF BLOOD FLOW,
THAT FLOWS THROUGH THE TUMOR INSTEAD OF THROUGH THE PLACENTA
OR THROUGH THE FETUS'S TISSUES, AND WE CALL THAT
A "VASCULAR STEAL."
>> THE RICHLY VASCULAR TUMORS HAS BLOOD VESSELS THAT HAVE
MINIMAL RESISTANCE.
>> BECAUSE THE TERATOMA HAS LOWER RESISTANCE FOR BLOOD FLOW
THAN THE FETAL TISSUES DO, OR THE PLACENTA,
THEY WILL TEND TO STEAL MORE AND MORE BLOOD FLOW OTHER TIME.
>> THESE FINDINGS ARE IMPORTANT TO FOLLOW EXTREMELY CLOSELY BY
SERIAL SONOGRAPHY AND BY FETAL ECHOCARDIOGRAPHY.
>> THE FETAL ECHOCARDIOGRAMS THAT ARE PERFORMED IN AN ONGOING
WAY TELL US THE DEGREE OF HEART FAILURE OR HOW HARD
THE HEART IS WORKING.
>> HEART FAILURE IN THE FETUS EQUALS HYDROPS.
THE FINDINGS OF HYDROPS ARE STRAIGHTFORWARD TO SEE BY
MATERNAL-FETAL ULTRASOUND BECAUSE THERE IS AN ACCUMULATION
OF FLUID IN THE BODY CAVITIES OF THE FETUS.
>> FLUID AROUND THE LUNGS, FLUID AROUND THE HEART,
FLUID IN THE SKIN, AND OTHER ORGANS.
>> THAT FLUID CAN ACCUMULATE IN THE PLACENTA AS WELL WHICH HAS
MATERNAL HEALTH CONSEQUENCES, SUCH AS THE MATERNAL MIRROR
SYNDROME.
>> AND THAT'S THE SYNDROME WHERE THE MATERNAL PHYSIOLOGY
BEGINS TO LOOK LIKE THE FETAL PHYSIOLOGY.
>> THESE MOTHERS CAN BECOME INCREDIBLY SICK,
REQUIRE TRANSFER TO THE INTENSIVE CARE UNIT,
REQUIRE EVEN INTUBATION, BECAUSE THE FETAL PROBLEM HAS CAUSED
ISSUES WITH MATERNAL HEALTH.
>> SO REALLY THE ONLY TREATMENT IS DELIVERY OF THE BABY.
AND YOU'RE FORCED INTO THAT SITUATION NO MATTER WHAT
THE GESTATIONAL AGE IS.
>> THE MAIN WAY TO PREVENT FETAL HYDROPS FROM OCCURRING OR,
AT LEAST NOT TO BE SURPRISED BY THE FINDINGS,
IS TO MONITOR THE MATERNAL-FETAL UNIT EXTREMELY CLOSELY.
>> WE'VE FOLLOWED PATIENTS AS OFTEN AS THREE TIMES A WEEK WITH
COMPLETE IMAGING AND MEASURING OF CARDIAC OUTPUT AND OTHER
PARAMETERS JUST TO TRY TO DETECT THE ONSET OF HIGH OUTPUT
PHYSIOLOGY, OR HYDROPS, AS EARLY AS POSSIBLE.
IF IT LOOKS LIKE THE BABY IS GOING INTO HIGH OUTPUT HEART
FAILURE, WE CAN EITHER DELIVER THE BABY AT AN EARLIER
GESTATIONAL AGE TO ALLOW TREATMENT WITH THE BABY OUT
OF THE UTERUS OR, IN SOME RARE CASES,
WE ARE FORCED TO TRY TO DEAL WITH THE TUMOR BEFORE BIRTH
WITH FETAL SURGERY.
>> BECAUSE HYDROPS IS UNIFORMLY LETHAL TO THE FETUS, IT'S ONE
INDICATION THAT WE FEEL COMFORTABLE OFFERING FETAL
SURGERY FOR.
>> WE ACTUALLY PARTIALLY DELIVER THE BABY,
TAKE A PORTION OF THE TUMOR OFF THAT WE CAN, SAFELY.
AND THEN PUT THE BABY BACK IN THE UTERUS AND TRY TO GET AS
MANY WEEKS AS WE CAN BEFORE THE MOM GOES INTO PRETERM DELIVERY
OR RUPTURES MEMBRANES OR SOME OTHER THING OCCURS THAT REQUIRES
US TO DELIVER THE BABY.
>> TERATOMAS CAN ALSO CAUSE TROUBLE JUST FROM THEIR SHEER
BULK AND SIZE.
>> IT'S A VOLUME, SPACE-OCCUPYING MASS
WITHIN THE UTERUS.
AND IT CAN GET SO BIG THAT IT FOOLS THE UTERUS INTO THINKING
IT'S TIME TO GO INTO LABOR AND DELIVER.
>> AND SO IF YOU HAVE A PATIENT WITH A VERY LARGE CYSTIC
TERATOMA THAT'S THREATENING PRETERM LABOR BECAUSE OF TUMOR
BULK, YOU MIGHT ACTUALLY CONSIDER DRAINING THE FLUID OUT
OF THE TUMOR.
>> SORT OF LIKE A FANCY AMNIOCENTESIS WHERE YOU REMOVE
FLUID FOR THE CYST TO DECREASE THE TUMOR SIZE.
>> ANOTHER MANIFESTATION OF TERATOMAS CAN BE POLYHYDRAMNIOS.
>> POLYHYDRAMNIOS IS JUST TOO MUCH AMNIOTIC FLUID.
>> FETUSES PRODUCE AMNIOTIC FLUID BY PEEING AND THEY REDUCE
AMNIOTIC FLUID BY SWALLOWING.
SO IF YOU INTERFERE WITH EITHER OF THOSE MECHANISMS,
IT IMPACTS AMNIOTIC FLUID QUANTITY.
>> AND TOO MUCH AMNIOTIC FLUID CAUSES THE UTERINE CAVITY
TO EXPAND TO GET MUCH BIGGER THAN IT SHOULD BE,
AND THE UTERUS CAN BE FOOLED INTO THINKING IT'S TIME TO GO
INTO LABOR.
>> SOMETIMES THIS CAN BE MANAGED IN THE SYMPTOMATIC MOTHER
WITH POLYHYDRAMNIOS WITH AMNIOREDUCTION.
>> TAKING OFF AMNIOTIC FLUID WITH A NEEDLE AND TRYING
TO REDUCE THE SIZE OF THE UTERUS AND THE LIKELIHOOD
OF PRETERM LABOR.
>> STARTING THE PATIENT ON MEDICATION THAT REDUCES BLOOD
FLOW TO THE BABY'S KIDNEYS, THAT LIMITS THE AMOUNT OF URINE THAT
THE BABY PRODUCES, AND MAKES MANAGEMENT OF THE POLYHYDRAMNIOS
EASIER SO THAT WE DON'T HAVE TO REPEATEDLY GO IN WITH NEEDLES
AND DRAW THE FLUID OFF.
>> ANOTHER ONE OF THE DETRIMENTAL MANIFESTATIONS
OF AN SCT OR ANY TERATOMA IS ITS POTENTIAL FOR RUPTURE.
>> WHICH IS ALMOST INVARIABLY FATAL.
THE FETUS BLEEDS TO DEATH.
>> AND THAT CAN OCCUR SPONTANEOUSLY BEFORE BIRTH.
>> AND THERE'S NO WAY TO PREDICT THAT EVENT.
>> OR IT CAN OCCUR AT THE TIME OF BIRTH AND THAT'S ONE OF THE
REAL RISKS ASSOCIATED WITH SCT THAT REQUIRES SPECIAL ATTENTION
AND CARE TO PREVENT.
>> SO EVEN WHEN THINGS ARE GOING GOOD, THE BABY IS DEVELOPING
GREAT, EVERYTHING SEEMS TO BE ON TRACK,
WE COULD STILL GET BLINDSIDED BY THESE TUMORS AND THAT'S WHY,
PERHAPS, WE ARE SO FOCUSED ON FOLLOWING THEM.