| Level I |
| Definition: Fetal therapies with low maternal and/or fetal risk |
| Personnel: Fetal therapy center team, supported by institutional infrastructure |
| Maternal care level: At least level III |
| NICU care level: At least level III |
| Examples of procedures: Fetal blood sampling, uncomplicated IUT ++, fetal shunt placement, radiofrequency or interstitial laser ablation, fetal antiarrhythmic treatment***. |
| Additional consideration: Mechanism in place to evaluate case complexity prior to interventions and transfer care to a higher level fetal therapy center if required. |
| Level II |
| Definition: Fetal therapies with low or high maternal risk, but low neonatal risks |
| Personnel: Fetal therapy center team supported by institutional infrastructure |
| Maternal care level: At least level III |
| NICU care level: At least level III |
| Pediatric surgery care level: Level 1 for all conditions where a fetal intervention is offered |
| Examples of procedures: All procedures performed at level I centers, with the addition of complicated IUTs++, fetoscopic laser ablation for TTTS, ultrasound guided cord or vascular occlusions, fetoscopic amniotic band resection, fetal cardiac interventions*, uncomplicated EXIT procedure** |
| Level III |
| Definition: All fetal therapies, irrespective of their risk level |
| Personnel: Fetal therapy center team, supported by institutional infrastructure |
| Maternal care level: At least level III |
| NICU care level: Level IV |
| Pediatric surgery: Level 1 for all conditions |
| Examples of procedures: All procedures performed by level I and II centers irrespective of the level of fetal compromise or procedural challenge, plus FETO balloon placement and retrieval, complex multi-disciplinary fetoscopic procedures, open fetal surgery, 24/7 availability of EXIT |
Legend: TTTS= twin-twin transfusion syndrome, FETO= fetoscopic tracheal occlusion, EXIT= ex-utero intrapartum treatment, IUT = intrauterine transfusion
++
complicated IUTs refer to procedures < 20 weeks gestation, in the presence of a compromised or hydropic fetus or with a large maternal BMI
**
uncomplicated EXIT refers to procedures that can be scheduled electively, well in advance and where all required resources are available
*
only to be undertaken if the disease specific pediatric care services are present ideally at that institution or else by remote virtual consultation
***
maternal Digoxin, Sotalol, Flecainide or Amiodarone treatment should be undertaken with input from and neonatal follow-up with fetal/pediatric cardiology.