الفهرس 
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Abstract
In this review, we highlighted several aspects of fetal therapy. We found that there is a wide range of controversy especially for surgical management, however the different lines of fetal therapy can be summarized as following:
(A) Medical therapy:
(1) Steroid therapy:
1- Corticosteroids usage in lung maturity induction:
- According to the gestational age:
* Early preterm fetus< 26 weeks gestation: There is no evidence from randomized controlled trials to support or refute the recommendation of administrating antenatal corticosteroids to women at risk of preterm birth <26 weeks’ gestation (evidence level: Ia).
* 26- 34 weeks gestation: There was a significant reduction in respiratory distress syndrome in preterm babies (evidence level: Ia).
* Late preterm fetus > 34 weeks gestation: there is no significant reduction in respiratory morbidities in babies born > 34 weeks gestation (evidence level: Ib).
- Single versus repeated courses of prenatal corticosteroid treatment:
* Usage of multiple courses of antenatal corticosteroids in women at risk of preterm birth does not offer significant benefits concerning the composite neonatal morbidity (evidence level: Ia).
* A small negative effect on fetal growth is found after usage of repeat antenatal steroids (evidence level: Ia).
2- Steroids usage in treatment of congenital adrenal hyperplasia:
Corticosteroids in the form of dexamethasone are used in pregnancies where there is a risk of congenital adrenal hyperplasia, also referred to as adreno-genital syndrome. Oral administration till term pregnancy is advised for prevention of virilisation of the female fetus (level III).
(2) folic acid therapy:
• For women in the reproductive age 400 microgram/ day of folic acid supplements is advised (evidence level: Ib).
• A reduction of some congenital abnormalities, mainly cardiovascular abnormalities, has been found after folic-acid-containing multivitamin supplementation (evidence level: Ia).
• There is no beneficial use of multivitamin containing folic acid supplementation during pregnancy on the mental performance of children (evidence level: Ia).
• Admini stration of folate late in pregnancy may develop asthma in young children (evidence level: III).
(3) Immunoglobulins for immune thrombocytopenia:
Intravenous administration of immunoglobulins to the pregnant woman for treatment of fetal or neonatal immune thrombocytopenia is effective in prevention of perinatal intra-cranial hemorrhage (evidence level: Ia).
Intravenous immunoglobulins alone or in combination with steroids or steroids followed by intravenous immunoglobulins are used for fetal or neonatal immune thrombocytopenia with about 100% success. No significant difference was found between these lines of treatments (evidence level: Ia).
(4) Anti-arrhythmic drugs:
• Fetal echocardiography is the main diagnostic tool for prenatal evaluation of fetal arrhythmias (evidence level: III).
• The prevalence of hydrops fetalis did not differ in fetal atrial flutter and supraventricular tachycardia with 1:1 conduction (evidence level: III).
• Digoxin is the drug treatment of choice as a first-line antiarrhythmic drug in non-hydropic fetuses. Transplacental digoxin can treat fetal atrial flutter and atrial flutter associated fetal heart failure and hydrops fetalis prior to delivery (evidence level: III).
• Maternal flecainide or sotalol is safe& effective to treat supraventricular tachycardia in hydropic fetuses. Anti-arrhythmic drug combination may be required as first line treatment (evidence level: III).
• The proper management remains unclear. Further trials are mandatory including long term follow up for the child and the mother.
(B) Stem cell therapy:
The human fetus early in gestation has a unique biology, affording it advantages as a donor recipient. It has a unique tolerance to foreign antigens and the ability to transport large cell volumes, leading to the assumption that it could be an ideal candidate for stem cell transplantation (evidence level: IV).
Stem cells transplantation in-utero can be considered to be an alternative to postnatal bone marrow transplantation. It has been performed for haemoglobinopathies, immunodeficiencies, storage diseases and osteogenesis imperfecta, but experience is still limited (evidence level: III).
(C) Gene therapy:
There is a good evidence that support the therapeutic uses of fetal gene therapy in some severe early-onset genetic disorders e.g.: Hemophilia (evidence level: IV).
More preclinical studies in small and large animal models must be done to define the most appropriate diseases to initiate clinical trials, the vector systems, the dosage, and the route and regime of administration to maximize safety and therapeutic efficacy (evidence level: IV).
(D) Fetal surgery:
When facing a fetal health problem, it is easiest to think of fetal intervention in terms of invasiveness. Open surgery is the most invasive and Fetal Image-Guided Surgery for Intervention or Therapy (FIGS-IT) is the least invasive. Another type, Fetal Endoscopic Surgery, falls in between.
Prenatal repair of myelomeningocele can decrease the need for postnatal intervention as shunting. It improves the mental development & the motor function but was associated with maternal and fetal risks (evidence level: Ib).
Prenatal bladder drainage can promote the survival rate perinatally in carefully selected fetuses for management of fetal lower urinary tract obstruction (evidence level: Ia).
For congenital diaphragmatic hernia, in-utero tracheal occlusion can improve the neonatal survival& lung growth compared with standard postnatal surgery with no differences in outcomes between subjects assigned to fetal endoscopic tracheal occlusion or open surgery (evidence level: Ib).
There is a good evidence that support fetal surgery in cystic adenomatoid malformation& sacrococcygeal teratoma (evidence level: III).
Percutaneous ultrasound-guided balloon valvuloplasty in human fetuses with severe aortic valve obstruction has a good evidence for improvement prenatal growth of the aortic and mitral valves after intervention. Hypoplasia of the left ventricle could be prevented and thus biventricular circulation preserved (evidence level: III).
Fetoscopic intervention can treat several congenital anomalies as amniotic bands, twin to twin transfusion syndrome& congenital diaphragmatic hernia by tracheal occlusion (evidence level: ш).
Endoscopic ablation of placental vessels is the preferred treatment for severe twin-to-twin transfusion syndrome with level I evidence and it may be the only chance to salvage the most severe forms of congenital diaphragmatic hernia (evidence level: Ib).
Whereas minimal access seems to solve the problem of preterm labour, all procedures remain invasive, and carry a risk to the mother and a substantial risk of preterm prelabour rupture of the membranes [PPROM] (evidence level: Ia).