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Management of Fetal
hydrocephalus
Aboubakr Elnashar Benha university Hospital, Egypt
Aboubakr Elnashar
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(A) Normal atrium of lateral ventricle: <10 mm
(B) Ventriculomegaly: Mild: 10-15 mm
(C) Severe: >15 mm
Diagnosis
Aboubakr Elnashar
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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
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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.
Aboubakr Elnashar
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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
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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
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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}.
Aboubakr Elnashar
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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.
Aboubakr Elnashar
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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.
Aboubakr Elnashar
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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.
Aboubakr Elnashar
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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
Aboubakr Elnashar
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Thanks Aboubakr Elnashar