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LSCS for Hydrocephalus

YES
Dr Kumkum Mathur
Research Officer, Regional Centre for Clinical Research in Human Reproduction, Indian Council of Medical Research Seth GS Medical College & KEM Hospital

Women (and their babies) are not dying because of diseases we cannot treat They are dying because societies have yet to make the decision that their lives are worth saving Mahmoud Fathalla - 1997

Points to Discuss
Changing trends Safety of LSCS Evidence in the literature Skill and training of obstetricians today Rights of the unborn child Fetal pain Regressive belief that India is under developed and SOME babies are dispensable

Fetal Hydrocephalus
It is an abnormal build up of

cerebrospinal fluid (CSF) in the ventricles of the brain Incidence is 0.3-2.5/ 1000 live births Also quoted as 1 in 2000 live births May be isolated or associated with congenital malformation syndromes

Hydrocephalus: Management
Early diagnosis is the mainstay

Antenatal monitoring and management


Mild, progressive and severe types

Planned safe delivery in

consultation with pediatric surgeon Intensive postnatal care


Medical and surgical

management

With timely treatment, many children with hydrocephalus go on to lead normal lives

Fate of the Baby


Hangs in the balance To live or die ? What is our duty? Can we justify murder of a viable fetus NO The baby deserves to be delivered by LSCS

Not written in stone


Logic dictates that certain malformations that produce sufficient enlargement of fetal structures are at probable risk for dystocia of labor and may benefit from abdominal delivery

Hazards of Vaginal Delivery


Disproportion and its ensuing problems
Obstructed labor and rupture uterus More common with mild degrees of

hydrocephalus which are not detected antenatally

Maternal injury Fetal injury Cephalocentesis Destructive operations

LSCS : the preferred choice in hydrocephalus


LSCS is the preferred choice LSCS is very safe LSCS is a planned, certain, safe option No trauma to mother or baby Less contamination hence less postnatal

sepsis Sensitive Humane approach No medicolegal issues

Why LSCS ?
No compression of head, therefore no compression of brain Delivery of baby in controlled manner No maternal injury by difficult vaginal delivery of large fetal head No need to resort to last minute panic and cephalocentesis

Elimination of exposure to and contamination by vaginal flora (important for postnatal shunt)

Destructive operations
To be condemned Only have a place in

books, history and archives No place for mutilating insensitive practices in modern obstetrics

Besides their distasteful messiness, the

main argument against these operations is that, in inexperienced hands, they are liable to be even more dangerous than Cesarean section

Intrapartum cephalocentesis
Akin to destructive

surgery Fraught with dangers Associated with high fetal morbidity and mortality Medicolegal and informed consent issues Cannot be recommended for fetus with a favorable prognosis

Evidence from literature


No recent studies from the developed world

All studies are retrospective


Normal developmental outcome with treatment Hydro Combined Chiari Aqueductal Dandy II Stenosis Walker cephalus type 48% 66% 40% 29%

Chervenak FA Am J Obstet Gynevol 1985

Evidence from literature


Williams Textbook of Obstetrics 2 studies Mentioned Recommends abdominal delivery
Am J Obstet Gynecol. 1985 Apr 1;151(7):933-42. The management of fetal

hydrocephalus. Chervenak FA, Berkowitz RL, Tortora M, Hobbins JC.

Large series of 53 consecutive documented cases of fetal hydrocephalus


Am J Obstet Gynecol. 2001 Sep;185(3):734-6. The role of cephalocentesis in modern obstetrics. Chasen ST, Chervenak FA, McCullough LB.

Recommendation : cepalocentesis use be limited to fetuses with severe associated anomalies ,which they concede is not always possible; all others to be delivered abdominally

Indian Data
Arch Gynecol Obstet. 2011 May;283(5):929-33. Epub 2010 Dec 31.
Destructive operations--a vanishing art in modern obstetrics: 25 year experience at a tertiary care center in India. Sikka P, Chopra S, Kalpdev A, Jain V, Dhaliwal L.

Dept of Gynaecology and Obstetrics, PGIMER, Chandigarh 160012, India.

In 85,952 deliveries over 25 years The total number of destructive operations performed was 230 (0.26%). Advise individualized approach to each case of obstructed labor. Choose from available options to deliver the mother by the safest route without

causing morbidity and mortality.

The numbers game


Incidence of hydrocephalus Incidence of cephalocentesis Number of cases performed in recent
Decreased dramatically

0.05% of all pregnancies

literature

Most obstetricians will see less than 1 case per year Stick to the tried and true rather than struggling with something you are not familiar with

Very very few

Cry of terror

Did anyone ask this

baby if he or she chose to die ?

"There is no foot so small that it cannot leave an imprint on this world"

Right to life

Rights of the unborn & newborn

Do not inflict pain


Give benefit of advances in medicine

especially pediatric surgery to this baby ALSO

LSCS for Hydrocephalus


YES

YES

YES
We too deserve to live

Points Discussed
Changing trends Safety of LSCS Evidence in the literature Skill and training of obstetricians today Rights of the unborn child Fetal pain Regressive belief that India is under developed and SOME babies are dispensable

destruction

Success stories.

http://www.hydroassoc.org http://www.hydrowoman.com