Research Summary: Surgery On The Smallest Patients

BACKGROUND: When birth defects are detected in a fetus during a prenatal check-up, doctors typically wait until the baby is born to operate, as most defects are correctable after birth. However, in a small subset of anomalies, waiting until after birth to do surgery would mean terrible physiologic consequences and long-term consequences for the child -- and likely death. Over the last 25 years, the field of fetal surgeries has emerged, where doctors are able to operate in utero and correct the defect and, according to fetal surgeon Hanmin Lee, M.D., of the University of California, San Francisco, "allow the child to be healthier or even survive an otherwise un-survival birth defect." He adds, "These are desperate circumstances in which almost all of these babies are not going to survive. So if we can get 50, 75, 80 percent survival, that is really wonderful." One example of this instance is the birth defect twin-twin transfusion syndrome. Dr. Lee says, "The chance of these twin babies surviving is less than 10 percent. By offering them therapy we can bump this right up to 80 to 90 percent."

RISKS: Dr. Lee says, "The pregnant uterus does not like to be poked and prodded." That's why there's about a 50-percent chance of premature delivery. He adds, "In certain circumstances, the fetal procedure will cause early delivery, and the consequences of premature labor can be potentially tremendous."

SPINA BIFIDA: Because of the risks and the fact that fetal surgeries have been hard to study in a clinical setting, they have been reserved to only circumstances where the babies will die or have horrible consequences of the birth defect if doctors waited to operate until after birth. But now, there is a trial underway on spina bifida sponsored by the National Institutes of Health. It's controversial because spina bifida patients typically survive after being treated post-natally. But doctors want to determine if treating them in utero will mean a better life for them.

EVOLVING TECHNOLOGIES: Twenty-five years ago, fetal surgeries were the equivalent of a cesarean section, where the uterus was opened up, the defect was fixed, and the doctors put the fetus back in, allowing the mom to serve as an intensive care unit until the baby was ready to be born. Now, because of advances in research, ultrasound, MRI, and minimally invasive surgical techniques, doctors are able to treat fetuses that were previously untreatable. Dr. Lee says: "Fast-forward many years, and we are now doing procedures through needles, through laparoscopic or fetoscopic instruments that are the size, in some instances, of relatively small needles, in other instances through instruments that are a size of a straw, and one that translates to is faster recovery times for mom, less trauma to both the mom and the fetus, and hopefully, decreased pre-term labor. And I think really the future holds things that I cannot even imagine, in terms of technological innovation that will us to do wonderful things that are not available to us right now."

BIRTH DEFECTS: Birth defects that are sometimes performed in utero include congenital diaphragmatic hernia, twin-twin transfusion syndrome, and hypoplastic left heart syndrome.

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