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>> WITH COMPLETE ABSENCE OF FLUID AROUND THE FETUS,
SONOGRAPHIC ASSESSMENT IS NOT AS PRECISE.
>> PART OF THE PROCEDURE MANY TIMES,
IS TO EXPAND THE AMNIOTIC SPACE AND THAT'S CALLED AN
AMNIOINFUSION WHERE WE ACTUALLY PUT FLUID INTO THE
AMNIOTIC SPACE TO CREATE ENOUGH OF A FLUID POCKET TO
ALLOW US TO DO THIS DEPLOYMENT OF THE SHUNT.
>> IF YOU PICTURED A COMPLETELY DEFLATED FOOTBALL
WITH YOUR KID INSIDE IT AND HIM TRYING TO STICK A NEEDLE
INTO THE FOOTBALL WITHOUT HITTING THE KID INSIDE.
>> BECAUSE THE BABY HAD HIS FISTS UP HERE BY HIS FACE,
THERE WAS A LITTLE SPOT OVER,
BETWEEN HIS HAND AND HIS FACE WHERE THEY COULD GET
THAT NEEDLE IN.
I THINK WHAT AMAZED ME MOST THROUGHOUT THE ENTIRE
PROCESS WAS THE AMAZING TEAMWORK THAT TOOK PLACE
BETWEEN THE ULTRASOUND TECHNICIAN AND THE PHYSICIAN,
WHETHER FOR A BLADDER TAP,
OR THE INFUSION, OR THE ACTUAL SHUNT PROCEDURE.
>> TO PLACE A SHUNT, WE DO THAT IN THE OPERATING ROOM.
>> IN UTERO SHUNTING IS PERFORMED AS AN OUTPATIENT
PROCEDURE IN THE SDU WHICH IS OUR SPECIAL DELIVERY UNIT.
MOMS WILL ARRIVE AND WILL BE PREPPED
FOR THE PROCEDURE, WILL RECEIVE ANESTHESIA SERVICES.
>> THE PATIENT GETS SEDATION AND IS COMFORTABLE THROUGH
THEIR IV.
WE USE LOCAL ANESTHESIAS SO THEY'RE NUMB AND THEY DON'T
FEEL THE PROCEDURE.
THE SEDATION THAT MOTHER GETS IS TRANSMITTED ACROSS
THE PLACENTA SO THE BABY DOES GET SOME OF THAT
SEDATION AS WELL.
WE NUMB THE SKIN AND WE MAKE A TINY FIVE MILLIMETER
INCISION THROUGH THE SKIN AND THEN WE DIRECT THIS
NEEDLE, THAT WILL EVENTUALLY BE USED FOR PASSING THE
SHUNT THROUGH THE MATERNAL ABDOMEN,
THROUGH THE WALL OF THE UTERUS,
AND INTO THE FLUID SPACE IMMEDIATELY NEXT TO THE
FETAL ABDOMEN.
ONCE THE TIP OF THE NEEDLE IS IN APPROPRIATE POSITION
BETWEEN THE *** BONE AND THE UMBILICAL CORD,
THEN IT HAS TO BE CAREFULLY INSERTED THROUGH THE FETAL
ABDOMEN AND INTO THE BLADDER.
ONCE IN THE BLADDER, THE BLADDER WILL START TO LEAK
FLUID AROUND THE NEEDLE SO YOU HAVE TO MOVE SWIFTLY,
BUT YOU HAVE TO MOVE VERY PRECISELY.
THE SHUNT HAS TO BE LOADED INTO THAT NEEDLE.
THE SHUNT ITSELF COMES IN THE DOUBLE PIGTAIL
CONFIGURATION.
>> SO THERE'S A CURLICUE END ON THE OUTSIDE OF THE
ABDOMINAL WALL AND ONE ON THE INSIDE OF THE BLADDER.
>> IT HAS TO CAREFULLY BE STRAIGHTENED OUT SO IT CAN
BE PASSED INTO THE NEEDLE.
>> IT'S A PLASTIC THAT HAS MEMORY AND SO IT WILL RECOIL
TO ITS ORIGINAL CONFIGURATION ONCE YOU'RE
OUTSIDE THE FETAL ABDOMEN.
YOU NOW HAVE TO AGAIN PULL THE SHEATH BACK A BIT,
TURN IT AT AN ANGLE AWAY FROM THE FETUS,
AND THEN PUSH THE OTHER PIGTAIL OUT INTO THE
AMNIOTIC SPACE.
SO THE HOPE IS THAT IT WILL LIE FLAT AGAINST THE FETAL
ABDOMEN.
>> AFTER THE SHUNT IS PLACED,
MOM COMES OUT TO HER ROOM ON THE SPECIAL DELIVERY UNIT
WHERE WE WATCH HER FOR, USUALLY,
ABOUT EIGHT HOURS.
SHE GETS ANTIBIOTICS BEFORE THE PROCEDURE.
SHE'LL GET AN ADDITIONAL DOSE OF ANTIBIOTICS AFTER
THE PROCEDURE.
>> WE USUALLY HAVE THEM RETURN FIVE TO SEVEN DAYS
AFTER THE SHUNT IS PLACED TO LOOK AT SHUNT PLACEMENT.
>> TO MAKE SURE THAT THE SHUNT IS FUNCTIONING,
TO MAKE SURE THAT THE BLADDER IS DECOMPRESSED,
MAKING SURE THAT THE AMNIOTIC FLUID VOLUME IS IN
THE NORMAL RANGE SO THAT THE KIDNEYS CAN DEVELOP AND THE
LUNGS CAN DEVELOP.
>> ONCE THE FAMILY HAS COME BACK FOR A POST-PROCEDURE
CHECK UP AND THERE ARE NO COMPLICATIONS,
WE START DISCHARGE PLANNING.