Author: Hanah Gomberg
Editors: Tharindi Jayatilake and Anand Soma
Artist: Doris Tan
Fetal surgery is arguably one of the newest surgical specialties in the world today, only being developed in its most primitive form in 1965. Although it has been around for 55 years, there are still many misconceptions about what it is and if it is even worth it.
Fetal surgery is a prenatal procedure done in utero, meaning that surgeons perform surgery on a baby while it is still in the mother’s uterus. This can all be very daunting or surreal to most people, and the process begs several questions. How can fetal surgery better a child’s life? Are there any differences in neonatal outcomes to pediatric outcomes? Why is fetal surgery so life-changing to parents and children? What types of prenatal surgery are available at the moment and how do we do it? What do we hope to be able to do in the future?
Often, when parents are told that an unborn baby needs surgery and it needs to be done without delivering the child, it can sound like science fiction. However, there is a reason why fetal surgery has continued to develop throughout the years, because without it, there may be degenerative defects that only worsen as the child grows. Spina bifida is a great example of highly successful prenatal surgery. Often, when the child undergoes fetal surgery to repair spina bifida, it can be less invasive (through the use of a fetoscope), and the child has a higher chance of eventually being able to walk and live to their full potential. A study funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) in 2011 found that surgical intervention for spine malformation done before birth can improve mobility and reduce the risks for more serious complications later on in their lives. Contrastingly, when surgery is performed by a pediatrician the surgeon has to put in a shunt at the child’s spine to help drain the fluid and protect it from too much brain pressure, however, this shunt will have to be changed many times throughout their life and they are dramatically less likely to ever walk or lead a normal life.
Today, surgeons can treat over fourteen diseases that ten years ago would have either translated to a death sentence or a very poor quality of life. As for the methods that are used to cure these diseases, they need to be very precise because the children are very small and any mishaps can be detrimental to their quality of life and can hinder their development. For advanced cases of Congenital Diaphragmatic Hernia, Fetoscopic endoluminal tracheal occlusion is used as it is a highly non-invasive procedure that is catered especially for fetuses. In more severe cases of the aforementioned spina bifida, there needs to be a more radical approach that requires open repair of the myelomeningocele, in which the spine is exposed. Physicians nowadays can even treat tumors on fetuses through radiofrequency ablation, and they manage to do this in a way that does not hinder fetal development nor does it harm the mother.
Fetal surgery is undoubtedly the future of modern medicine and it will change the way surgery is done. Great scientific developments include: gene therapy for people that were born blind, cochlear implants for those born deaf, pace-makers for people with heart-damaging conditions, and even the insulin shot for diabetics. Today, clinicians are finding ways to not only diagnose genetic diseases in an intrauterine manner but also treat them in utero. With the progress thus far physicians can confirm that fetal application is showing promise in improving life quality for those with debilitating genetic disorders and prevention for early-onset genetic diseases such as cystic fibrosis and Duchenne muscular dystrophy. An outstanding example of great use of fetal neurosurgery to ensure the child would not be debilitated was a case in which physicians had to manage an: Intracranial Hemorrhage and Skull Fracture After Blunt Intrauterine Trauma. Even though this surgery was performed neonatally, physicians were only able to identify the trauma due to prenatal surgeons and machines that have been developed to aid in fetal surgery. As we put into consideration that a blunt trauma of this nature on a fetus could have caused a great number of intracranial pathologies such as hypoxic-ischemic injury, skull fractures, and intracranial hemorrhages, these types of equipment saved the child’s life. Today, the child is alive and in line with the developments of a child their age.
Science is ever-evolving and fetal surgery, like any branch of science, will develop insurmountably in the coming decades. For cardiothoracic fetal surgeries, there are a few studies involving how to treat right and left side regions in the fetus and how they differ. Infants with congenital heart diseases can be treated in utero in the coming decade as physicians have started research to better understand fetal hemodynamics since there is little to no literature about it and how cardiac diseases evolve in fetuses. Once the literature is developed and we have more knowledge surrounding the physiology of prenatal children, fetal surgeons will be able to perform balloon aortic procedures and pulmonary valvuloplasties to prevent postnatal ventricular malformations and to relieve valvar stenosis in fetuses. For fetuses with pulmonary abnormalities, procedures are being developed that would allow for better atrial septal communication.
Furthermore, the fetal field is not only based around surgery, nowadays bio-mechanics have been developing different tests to ensure that the fetus will be born healthy. The alpha-fetoprotein test for example followed by diagnostic testing (chorionic villus sampling or karyotyping by amniocentesis) can now be done to ensure that fetuses do not have chromosome disorders such as Down's syndrome, Edward's syndrome, or Patau's syndrome. Beyond diagnosing the infant, fetal therapy has been evolving to provide intrapartum interventions for prenatal anomalies. Lastly, recent discoveries into how genetic diseases work, how to design a vector that the body won’t reject, and minimally invasive techniques have allowed for fetal gene therapy to become a choice for parents in the near future. To lots of families nowadays abortions or having a child that is infected with Down syndrome or autism are the only choices. However, gene therapy for fetuses will allow for parents to have another (arguably easier) choice. How could this be possible? Well, recent research has proved that when fetuses are transferring genes that aid in their formation, STEM cells that grow very quickly are targeted by these genes and this is something that we cannot access after birth as the child has already developed enough. This implied that integrating vector systems into fetuses could be the answer to treating incurable genetic diseases. Throughout the animal testing, it was found that the fetal immune system does not respond to the inducted gene, therefore, allowing for us to induct tolerance to said diseases. Thus, this treatment can be repeated neonatally to correct the disease.
Overall, fetal surgery is the future of modern medicine because it can be insurmountably beneficial to a child’s life. The outcomes of fetal surgeries for many genetic abnormalities and degenerative diseases are dramatically better when they are done prenatally than when it is done neonatally. Although we have already made much progress, there is still a long and promising road ahead, in which we could potentially cure diseases before the children even suffered from them through the induction of immune tolerance.
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