dolor fetal e implicaciones en medicina fetal

www.medicinafetalbarcelona.org/

Eduard Gratacós BCNatal - Centro de Medicina Maternofetal y Neonatología Barcelona,

Hospital Clinic y Hospital Sant Joan de Deu www.fetalmedicinebarcelona.org

DOLOR FETAL E IMPLICACIONES EN MEDICINA FETAL

Fetal Medicine & Therapy§ recent development!

§ high tech!

§ multidisciplinarity!

§ fetal surgery!

§ referral activity!

§ increasing importance!

§ high legal pressure

www.medicinafetalbarcelona.org/

Evolution of social demands in Fetal Medicine & Therapy: !the fetus as a patient

society of information

perception fetus as a person

capacity !Dx & Tx

DEMANDS

www.medicinafetalbarcelona.org/

Levels in Fetal Medicine!integration in public health

Advanced studies

Diagnosis1

2

3

US-guided fetal therapy

Endoscopic therapy & Fetal Surgery

Primary level

Tertiary Hospital!(1 in 300,000)

Fetal surgery Center!(1 in 15-20 million)

Levels in Fetal Medicine!integration in public health

www.medicinafetalbarcelona.org/

Complexity!Multidisciplinarity

Pregnancies

0.2%!(1 in >1,000)

5 % Advanced Fetal Medicine !Tertiary Center

Fetal surgery center!National or transnational level

Public Health System

100 %

Levels in Fetal Medicine!integration in public health

www.medicinafetalbarcelona.org/

Key Hole Surgery

FETAL SURGERY ≈ FETOSCOPY"!

• fetus ≠ smaller neonate!!

• uterus and mother not operable

www.fetalmedicinebarcelona.org/

FETAL THERAPY MUST BE NICE FOR PATIENTS NOT FOR DOCTORS ( “PIONEERS TIME” IS OVER)

Percutaneous Feto-Endoscopic Tracheal Occlusion!

Deprest J, Gratacos E, Nicolaides K. UOG 04

• increase airways pressure

• accelerated growth • first case: oct 01 • currently >500 !

TOTAL RCT international trial ongoing

LUNG DEFECTS

Bronchial atresia

Martinez et al. Fetal Diagn Ther 2013

www.medicinafetalbarcelona.org/

www.medicinafetalbarcelona.org/

Fetal surgery for spina bifida

www.medicinafetalbarcelona.org/

Desarrollo neurológico fetal 12s

20s

M: 28-30s

24s

www.medicinafetalbarcelona.org/

Fetal and neonatal pain

Anand KJ et al!Pre-term neonates exert hormonal responses to painful stimulus. !!Anand et al. - Fisk et al.!Premature fetus: hormonal + hemodynamic responses to invasive stimuli.!Can be blocked by analgesia.!Clear responses from 24 w!Conflicting data from 16 w

www.medicinafetalbarcelona.org/

www.medicinafetalbarcelona.org/

Dolor, desarrollo neurológico fetal y analgesia fetal

Experimental and clinical data (Anand et al): !Neonatal pain is associated with altered pain thresholds

www.medicinafetalbarcelona.org/

Terapia fetal !<22s: vencuronio !>22s: vencuronio fentanil atropina !Materna: !-Fetoscopia: Sedación materna Remifentanilo (Vandevelde et al 2005) !-Cirugía abierta: anestesia general (+ anestesia fetal)

www.medicinafetalbarcelona.org/

Eduard Gratacós BCNatal - Centro de Medicina Maternofetal y Neonatología Barcelona,

Hospital Clinic y Hospital Sant Joan de Deu www.fetalmedicinebarcelona.org

DOLOR FETAL E IMPLICACIONES EN MEDICINA FETAL