Fetal surgery

Overview

Fetal surgery involves performing procedures on a developing fetus while it is still in the uterus. This type of surgery is typically undertaken to correct potentially fatal birth defects and treat conditions such as spina bifida (myelomeningocele), significantly improving the baby’s condition after birth. Since some defects can worsen as the fetus grows, fetal surgery aims to address these issues before delivery.

Also known as in-utero or prenatal surgery, fetal surgery may sometimes be referred to as “fetal intervention” for less complex or invasive procedures. Fetal surgeons carry out these interventions to preserve the fetus or enhance outcomes after birth.

Reasons for undergoing the procedure

Fetal surgery can be used as an early intervention to treat life-threatening birth defects and, in certain situations, to improve outcomes before the baby is born. Certain birth abnormalities cause a risk to the developing fetus. For instance, the fetus’s heart may be compressed by a significant lung deformity. Death and heart failure may result from this.

Certain medical conditions are not considered an immediate fatal but can lead to impairments that develop after delivery. Following birth, surgeons frequently treat these conditions. However, prenatal care can enhance long-term results.

Fetal surgery is still a relatively new and a developing specialty. Treatments for these disorders in highly specialized medical facilities with fetal surgery specialists consist of:

• Bipolar cord coagulation for TRAP sequence
• Ex-utero intrapartum treatment (EXIT)
• Fetal cardiac intervention
• Fetal vesicoamniotic shunt (VAS) and fetal cystoscopy for bladder obstruction
• Fetoscopic endoluminal tracheal occlusion (FETO) for severe CDH
• Fetoscopic laser ablation for TTTS and TAPS
• In utero open or fetoscopic repair of myelomeningocele, the most severe form of spina bifida
• Intrauterine blood transfusion
• Open fetal surgery for SCT resection
• Open fetal surgery to remove CCAM of the lung
• Radiofrequency ablation for fetal tumors
• Serial amnioinfusions for bilateral renal agenesis and complex renal diseases
• Shunt placements

Risk

The healthcare provider should go over any potential risks associated with the procedure, including those to you and the unborn child.

The possible risk for the mother includes:

• Adverse drug reactions, such as hypotension and shallow or overly slow breathing (respiratory depression).
• Loss of blood, which could indicate a need for a blood transfusion.
• Uterine scar reopening or thinning, which increases the risk of getting pregnant again in the future.
• Having a C-section performed to deliver any future or present pregnancies.

The possible risk for the fetus includes:

• The possibility that surgery will result in premature labor.
• Placental abruption, which may hinder the fetus’s ability to absorb nutrition.
• The potential for problems from choreoamniotic membrane separation.
• Chorioamnionitis, a rare amniotic fluid infection.

Procedure

When operating on a fetus inside your uterus, fetal surgeons use a number of techniques. Their approach will be determined by the state of the fetus and your overall health. Some of them are:

• Open surgery: You will be under general anesthesia for the open surgery. To access your uterus, a surgeon must first make an incision in your abdomen. The fetus is then reached by an incision made in your uterus. During the procedure, they maintain the fetus inside your uterus. After that, your uterus and abdomen are closed, allowing the pregnancy to continue to the closest point of term.
• Fetoscopic surgery: In fetoscopic surgery, surgeons make small “keyhole” incisions in the abdomen to access the uterus, using a minimally invasive approach. They insert a fetoscope—a small camera mounted on a long, flexible fiber-optic tube—into the uterus to address conditions such as twin-to-twin transfusion syndrome or diaphragmatic hernia. Through the fetoscope, they use long, thin instruments to perform the necessary treatments. For conditions like myelomeningocele, a form of spina bifida, the surgeon first makes an incision in the abdomen to expose the uterus. Then, they create two to three small incisions in the uterus to insert the fetoscope and other surgical tools.
• Surgical delivery: During a surgical delivery, specific fetal procedures may be performed by the surgical team. To prepare for the procedure, you’ll be given medication to relax your uterus and placed under general anesthesia. The surgeon will then partially deliver the fetus by making an incision in your uterus. Once the fetus is stabilized, the surgeons will cut the umbilical cord and separate it from the placenta. These procedures can address issues such as clearing an obstruction in the airway or removing a large tumor that might threaten the newborn’s breathing or circulation.

Before the procedure

The healthcare team that is caring for you and the fetus regularly monitors you if you are carrying a child that has a congenital condition. In addition to determining a prognosis, they will inform you precisely which condition affects the fetus. Then, in collaboration with you and your family, they will choose the most appropriate treatment plan.

Certain minimally invasive procedures can be performed by fetal surgeons as early as 16 weeks of pregnancy. Depending on the fetus’s condition. The best window of opportunity for more involved treatments is between 22 and 26 weeks of development.

During the procedure

Surgery performed by fetal surgeons differs based on the condition being treated. Fetal surgeons visualize the fetus through fetoscopy and ultrasound before guiding surgical instruments through tiny holes for minor treatments. Open surgery involves greater complexity. The amniotic environment must be preserved during surgery; thus surgeons must exercise caution. To keep the amniotic fluid from leaking, they utilize specialty staplers and ongoing infusions.

After the procedure

Based on your procedure, you may need to stay in the hospital for a few hours or a few days. The fetus and you will be under constant observation by your healthcare team. In certain cases, even if your pregnancy goes to term, you will still need to have a scheduled C-section. Some infants require extensive care after delivery.

Outcome

Healthcare providers often only recommend fetal surgery when it is necessary to save the fetus. This early intervention, carried out on a selected infants by fetal surgery specialists, can provide better outcomes than surgery after delivery. This suggests that, compared to what would have happened if they had undergone surgery after birth, children with spina bifida, for instance, may be far less impaired as they age. Spina bifida at an early stage can lessen the damage it causes because the condition worsens as the fetus develops.

Treatment for hydrocephalus is less likely to be required in infants born with corrected spina bifida. They are also more likely to be able to walk and have control over their bowel and bladder.

If your fetus is diagnosed with a life-threatening condition and you’ve been told there are no options for saving them, fetal surgery might still offer possibilities. This field is continually advancing, with new techniques and treatments for congenital conditions being explored by fetal surgeons. Reach out to a hospital specializing in fetal surgery for a personalized consultation to discuss your treatment options.