Fetal surgery

## Contents

* 1 Open fetal surgery
* 1.1 Technique
* 1.2 Safety and complications
* 1.3 Indications
* 2 Minimally invasive fetal surgery
* 3 History
* 4 See also
* 5 References
* 6 Further reading

### Open fetal surgery

#### Technique

Tocolytics are generally given to prevent labor;[1] however, these should not be given if the risk is higher for the fetus inside the womb than if delivered, such as may be the case in intrauterine infection, unexplained vaginal bleeding and fetal distress.[1] An H2 antagonist is usually given for anaesthesia the evening before and the morning of the operation, and an antacid is usually given before induction to reduce the risk of acid aspiration.[1] Rapid sequence induction is often used for sedation and intubation.[1]

Open fetal surgery is similar in many respects to a normal cesarean section performed under general anesthesia, except that the fetus remains dependent on the placenta and is returned to the uterus. A hysterotomy is performed on the pregnant woman, and once the uterus is open and the fetus is exposed, the fetal surgery begins. Typically, this surgery consists of an interim procedure intended to allow the fetus to remain in utero until it has matured enough to survive delivery and neonatal surgical procedures.

Upon completion of the fetal surgery, the fetus is put back inside the uterus and the uterus and abdominal wall are closed up. Before the last stitch is made in the uterine wall, the amniotic fluid is replaced. The mother remains in the hospital for 3–7 days for monitoring. Often babies who have been operated on in this manner are born pre-term.

#### Safety and complications

The main priority is maternal safety, avoiding preterm labor and achieving the aims of the surgery.[1] The risk of premature labor is increased by concomitant risk factors such as multiple gestation, a history of maternal smoking, and very young or old maternal age.[1] Risks of fetal surgery, specifically prenatal spina bifida repair, include premature rupture of membranes, uterine rupture in future pregnancies, premature birth and intraspinal inclusion cysts or a tethered cord in the fetus or newborn baby.[2]

Open fetal surgery has proven to be reasonably safe for the mother.[1] For the fetus, safety and effectiveness are variable, and depend on the specific procedure, the reasons for the procedure, and the gestational age and condition of the fetus. The overall perinatal mortality after open surgery has been estimated to be approximately 6%, according to a study in the United States 2003.[3]

All future pregnancies for the mother require cesarean delivery because of the hysterotomy.[1] Fetal surgery is not thought to decrease maternal fertility.[1]

#### Indications

Neural tube defects (NTD), which begin to become observable at the 28th day of pregnancy, occur when the embryonic neural tube fails to close properly, the developing brain and spinal cord are openly exposed to amniotic fluid. After birth, exposure of the spinal cord to the outside environment (myelomeningocele or spina bifida) is associated with several morbidities including weakness or sensory deficits in the lower extremities, bladder dysfunction, fluid buildup in the brain and Type 2 Chiari malformations (herniation of the cerebellar vermis and medulla from the brain into the spinal canal.[2] Prenatal repair of spina bifida is available in specialty centers. Fetuses treated with prenatal fetal repair have significantly improved outcomes compared to children whose defects are repaired shortly after birth.[4] Specifically, fetal repair reduces the rate of hydrocephalus, ventriculoperitoneal shunt dependence, and Chiari malformation. Prenatal repair also shows improved motor skills at 30 months and improved mobility, neuropsychological function, and independent functioning between the ages of 5 and 10.[5][2]

Other conditions that potentially are treated by open fetal surgery include :

* Congenital diaphragmatic hernia (if indicated at all, it is now more likely to be treated by endoscopic fetal surgery)
* Congenital cystic adenomatoid malformation
* Congenital heart disease
* Pulmonary sequestration
* Sacrococcygeal teratoma

### Minimally invasive fetal surgery

Minimally-invasive fetoscopic surgery has proven to be useful for some fetal conditions.

* Twin-twin transfusion syndrome – Laser Ablation of Vessels
* Spina bifida – Fetoscopic closure of the malformation. Prenatal repair of the spina bifida lesion through this approach has been purported to result in less complications to the mother,[6] whilst affording benefit to the baby.[7]

## History

Fetal surgical techniques were first developed at the University of California, San Francisco, in 1980 using animal models.[8]

On April 26, 1981, the first successful human open fetal surgery in the world was performed at University of California, San Francisco, under the direction of Dr. Michael Harrison.[9][10] The fetus in question had a congenital hydronephrosis, a blockage in the urinary tract that caused the kidney to dangerously extend. To correct this a vesicostomy was performed by placing a catheter in the fetus to allow the urine to be released normally. The blockage itself was removed surgically after birth.[10]

Further advances have been made in the years since this first operation. New techniques have allowed additional defects to be treated and for less invasive forms of fetal surgical intervention.

The first two percutaneous ultrasound-guided fetal balloon valvuloplasties, a type of fetal surgery for severe aortic valve obstruction in the heart, were reported in 1991.[11] Among the first dozen reported attempts at this repair in the 1990s, only two children survived long-term.[11] Dr. Oluyinka Olutoye, alongside Darrell Cass, from the Texas Children's Fetal Centre, removed a 23-week-old fetus from her mother's womb in order to perform surgery upon a spinal tumor she had. The girl was placed back in the womb after a five-hour surgery and was born without complications.[12]

In March 2020, a team of more than 20 specialists led by Mert Ozan Bahtiyar at Yale-New Haven Hospital performed the first open in-utero repair of myelomeningocele in Connecticut, during the early stages of the COVID-19 pandemic.[13][14]

## See also

* Fetoscopy
* EXIT procedure
* Maternal-fetal medicine, a discipline of high-risk obstetrics and gynecology; most fetal surgeons were previously trained in OB-GYN and maternal-fetal medicine before their fetal surgical training
* Neonatology and neonatal surgery, related to high risk OB-GYN and maternal-fetal medicine and fetal surgery, are branches of pediatrics and pediatric surgery that focus on the treatment of newborn infants (less than one month of age)
* Pediatric surgery, a related but distinct discipline of surgery and pediatrics, involving surgery on infants, toddlers, and children and adolescents
* MOMS Trial
* Spina bifida
* NAFTNet
* Samuel Armas

## References

1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Sutton LN (February 2008). "Fetal surgery for neural tube defects". Best Pract Res Clin Obstet Gynaecol 22 (1): 175–88. doi:10.1016/j.bpobgyn.2007.07.004. PMID 17714997.
2. ↑ 2.0 2.1 2.2 Iskandar, Bermans J.; Finnell, Richard H. (4 August 2022). "Spina Bifida". New England Journal of Medicine 387 (5): 444–450. doi:10.1056/NEJMra2116032.
3. ↑ Johnson, M. P.; Sutton, L. N.; Rintoul, N.; Crombleholme, T. M.; Flake, A. W.; Howell, L. J.; Hedrick, H. L.; Wilson, R. D. et al. (2003). "Fetal myelomeningocele repair: short-term clinical outcomes". American Journal of Obstetrics and Gynecology 189 (2): 482–487. doi:10.1067/S0002-9378(03)00295-3. PMID 14520222.
4. ↑ "A Randomized Trial of Prenatal versus Postnatal Repair of Myelomeningocele". New England Journal of Medicine 364 (11): 993–1004. 9 Feb 2011. doi:10.1056/NEJMoa1014379. PMID 21306277.
5. ↑ Houtrow, Amy J.; MacPherson, Cora; Jackson-Coty, Janet (5 April 2021). "Prenatal Repair and Physical Functioning Among Children With Myelomeningocele: A Secondary Analysis of a Randomized Clinical Trial". JAMA Pediatrics 175 (4): e205674. doi:10.1001/jamapediatrics.2020.5674.
6. ↑ Degenhardt J (2014). "Percutaneous minimal-access fetoscopic surgery for spina aperta. Part II: maternal management and outcome". Ultrasound Obstet Gynecol 44 (5): 525–531. doi:10.1002/uog.13389. PMID 24753062.
7. ↑ Verbeek, R. J; Heep, A; Maurits, N. M; Cremer, R; Hoving, E. W; Brouwer, O. F; Van Der Hoeven, J. H; Sival, D. A (2012). "Fetal endoscopic myelomeningocele closure preserves segmental neurological function". Developmental Medicine & Child Neurology 54 (1): 15–22. doi:10.1111/j.1469-8749.2011.04148.x. PMID 22126123.
8. ↑ Jancelewicz, Tim; Harrison, Michael R. (2009). "A history of fetal surgery". Clinics in Perinatology 36 (2): 227–236, vii. doi:10.1016/j.clp.2009.03.007. ISSN 1557-9840. PMID 19559317.
9. ↑ Science 80：Volume 4, issues 1–5. American Association for the Advancement of Science. 1983. p. ７２. https://books.google.com/books?id=1ss-AQAAIAAJ. Retrieved April 25, 2011.
10. ↑ 10.0 10.1 Russell, Sabin (May 5, 2005). "First fetal surgery survivor finally meets his doctor: 24 years ago, UCSF surgeon saved his life in mom's womb". San Francisco Chronicle. https://www.sfgate.com/health/article/SAN-FRANCISCO-First-fetal-surgery-survivor-2348923.php.
11. ↑ 11.0 11.1 Kohl, T.; Sharland, G.; Allan, L. D.; Gembruch, U.; Chaoui, R.; Lopes, L. M.; Zielinsky, P.; Huhta, J. et al. (2000-05-15). "World experience of percutaneous ultrasound-guided balloon valvuloplasty in human fetuses with severe aortic valve obstruction". The American Journal of Cardiology 85 (10): 1230–1233. doi:10.1016/s0002-9149(00)00733-5. ISSN 0002-9149. PMID 10802006.
12. ↑ "'Born twice': Baby removed for surgery, returned to womb". https://www.the-star.co.ke/news/2019-05-09-born-twice-baby-removed-returned-to-womb-for-surgery/.
13. ↑ "Undeterred by pandemic, YNHH team performs Connecticut's first fetal surgery to correct spina bifida". Yale Daily News. April 24, 2020. https://yaledailynews.com/blog/2020/04/24/undeterred-by-pandemic-ynhh-team-performs-connecticuts-first-fetal-surgery-to-correct-spina-bifida/.
14. ↑ "Yale New Haven Hospital team successfully performs surgery on unborn baby". New Haven Register. April 20, 2020. https://www.nhregister.com/news/article/Yale-New-Haven-Hospital-team-successfully-15191985.php.

## Further reading

* Sutton LN (February 2008). "Fetal surgery for neural tube defects". Best Pract Res Clin Obstet Gynaecol 22 (1): 175–88. doi:10.1016/j.bpobgyn.2007.07.004. PMID 17714997.

* v
* t
* e

Obstetrical surgery and other procedures (ICD-9-CM V3 72–75, ICD-10-PCS 1)

Diagnostic|

* Pregnancy test

* Leopold's maneuvers

* Cardiotocography
* Fetoscopy
* Fetal scalp blood testing
* Fetal scalp stimulation test

Sampling|

Fetal tissue
Chorionic villus sampling
Amniocentesis
Blood
Triple test
Quad test
Percutaneous umbilical cord blood sampling
Apt test
Kleihauer–Betke test
Lung maturity
Lecithin–sphingomyelin ratio
Lamellar body count
Fetal fibronectin test

Obstetric ultrasonography:|

* Nuchal scan
* Anomaly scan

Prenatal testing:|

* Fetal movement counting
* Contraction stress test
* Nonstress test
* Vibroacoustic stimulation
* Biophysical profile
* Amniotic fluid index
* Umbilical artery dopplers

Intervention|

* Fetal surgery
* Fetendo
* Podalic version
* External cephalic version
* Amnioinfusion

Delivery|

| Vaginal delivery|

| Induction|

* Artificial rupture of membranes
* Episiotomy
* Symphysiotomy
* Forceps in childbirth
* Ventouse in childbirth
* Odon device

|

Dystocia management|

* McRoberts maneuver
* Wood's screw maneuver
* Zavanelli maneuver

Third stage of labor|

* Manual placenta removal

Caesarean section|

* Elective
* On maternal request
* EXIT procedure
* Resuscitative hysterotomy

Postpartum hemorrhage|

* Hysterectomy
* B-Lynch suture

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