Fetal surgery

Fetal surgery also known as antenatal surgery, prenatal surgery, is a growing branch of maternal-fetal medicine that covers any of a broad range of surgical techniques that are used to treat congenital abnormalities in fetuses who are still in the pregnant uterus. There are three main types: open fetal surgery, which involves completely opening the uterus to operate on the fetus; minimally invasive fetoscopic surgery, which uses small incisions and is guided by fetoscopy and sonography; and percutaneous fetal therapy, which involves placing a catheter under continuous ultrasound guidance.

Fetal intervention is relatively new. Advancing technologies allow earlier and more accurate diagnosis of diseases and congenital problems in a fetus.

Fetal surgery draws principally from the fields of surgery, obstetrics and gynecology, and pediatrics- especially the subspecialties of neonatology (care of newborns, especially high-risk ones), maternal-fetal medicine (care of high-risk pregnancies), and pediatric surgery. It often involves training in obstetrics, pediatrics, and mastery of both invasive and non-invasive surgery, which require several years of residency and at least one fellowship (usually lasting more than one year each), to become proficient. It is possible in the U.S. to become trained in this approach whether one started in obstetrics, pediatrics, or surgery. Because of the very high risk and high complexity of these cases, they are usually performed at Level I trauma centers in large cities, at academic medical centers which provide the full spectrum of maternal and newborn care. This includes a high level neonatal intensive care unit, suitable operating theaters and equipment, and access to many surgeons and physicians, nurse specialists, therapists, and a social work and counseling team. The cases can be referred from multiple levels of hospitals from many miles, sometimes across state and provincial lines. In continents other than North America and Europe, these centers are not as numerous, though the techniques are spreading.

Most congenital conditions either do not require, or are not treatable through, fetal intervention. Those which are involve anatomical problems, for which in utero treatment is both feasible and can significantly improve the fetus’s continuing development and survival. Addressing anticipated concerns prior to birth increases the probability of a healthy baby, with few long-term health problems related to the treated condition.

Fetal intervention involves risk to fetus and pregnant patient alike. In addition to the general risks associated with any surgery, there is also a risk that scarring of the uterus will lead to difficulties with future pregnancies. This risk is higher than for a typical Cesarean section, for several reasons:

• the incision is usually a classical vertical one, with a greater risk of complications in subsequent pregnancies;
• the longer duration of the surgery, while the fetal intervention is performed;
• a second surgery is required days or weeks later – a Caesarean section to deliver the baby, which brings its own set of risks.