Principles of Fetal Surgery

Fetal therapy (in utero therapy) is a type of special therapy which aims to prevent or correct congenital anomalies in fetus, and prevents their severe consequences on later fetal development. It includes the use of in utero human fetal stem cell transplantation, fetal gene therapy and gene-editing technology as a new treatment for fetal genetic disorders. It started with open fetal surgery and then significantly advancing with innovations, toward minimally invasive fetal procedures, which are undoubtedly the future of fetal surgery, with the goal of providing the best possible fetal outcome, while minimizing the morbidity and mortality to the mother. The goal of fetal treatments is to decrease both fetal and maternal risks and prevent premature rupture of membranes. Fetal ultrasound and MRI are crucial for successful fetal interventions. Moreover, multidisciplinary fetal teams, including fetal surgeon, ultrasonographer, perinatologist, and anesthesiologist, are essential for optimum care to both mother and fetus. Finally, any new modality of fetal therapy must be thoroughly evaluated in animal models before clinical practice. In this chapter, we discuss the basic principles of fetal surgery, milestones of fetal surgery, specific fetal anomalies that are amenable for fetal surgery, successful fetal surgery criteria and future of fetal surgery

Fetal-Maternal Surgery for Spina Bifida in a HIV-Infected Mother

Introduction: In select cases, in utero surgery for myelomeningocele (MMC) leads to better outcomes than postnatal repair. However, maternal HIV infection constitutes a formal exclusion criterion due to the potential of vertical HIV transmission. Encouraged by a previous case of a successful fetal spina bifida repair in a Hepatitis Bs antigen-positive woman, a plan was devised allowing for fetal surgery. Case report: In utero MMC repair was performed although the mother was HIV-infected. To minimize the risk of in utero HIV transmission, the mother was treated by highly active antiretroviral therapy throughout gestation as well as intravenous zi-dovudine administration during maternal-fetal surgery. The mother tolerated all procedures very well without any sequelae. The currently 20 month-old toddler is HIV negative and has significantly benefitted from fetal surgery. Discussion/conclusion: This case shows that maternal HIV is not a priori a diagnosis that excludes fetal surgery. Rather, it might be a surrogate for moving towards personalized medicine and away from applying too rigorous exclusion criteria in the selection of candidates for maternal-fetal surgery. Keywords: HIV; Maternal-fetal surgery; Myelomeningocele; Post-exposure prophylaxis; Zidovudin

Global Policy and Practice for Intrauterine Fetal Resuscitation During Fetal Surgery for Open Spina Bifida Repair

IMPORTANCE: Globally accepted recommendations suggest that a woman should be between 19 weeks and 25 weeks plus 6 days of pregnancy to be considered eligible for fetal closure of open spina bifida. A fetus requiring emergency delivery during surgery is therefore potentially considered viable and thus eligible for resuscitation. There is little evidence, however, to support how this scenario is addressed in clinical practice. OBJECTIVE: To explore current policy and practice for fetal resuscitation during fetal surgery for open spina bifida in centers undertaking fetal surgery. DESIGN, SETTING, AND PARTICIPANTS: An online survey was designed to identify current policies and practices in place to support fetal surgery for open spina bifida, exploring experiences and management of emergency fetal delivery and fetal death during surgery. The survey was emailed to 47 fetal surgery centers in 11 countries where fetal spina bifida repair is currently performed. These centers were identified through the literature, the International Society for Prenatal Diagnosis center repository, and an internet search. Centers were contacted between January 15 and May 31, 2021. Individuals volunteered participation through choosing to complete the survey. MAIN OUTCOMES AND MEASURES: The survey comprised 33 questions of mixed multiple choice, option selection, and open-ended formats. Questions explored policy and practice supporting fetal and neonatal resuscitation during fetal surgery for open spina bifida. RESULTS: esponses were obtained from 28 of 47 centers (60%) in 11 countries. Twenty cases of fetal resuscitation during fetal surgery during the last 5 years were reported across 10 centers. Four cases of emergency delivery during fetal surgery after maternal and/or fetal complications during the last 5 years were reported across 3 centers. Fewer than half the 28 centers (n = 12 [43%]) had policies in place to support practice in the event of either imminent fetal death (during or after fetal surgery) or the need for emergency fetal delivery during fetal surgery. Twenty of 24 centers (83%) reported preoperative parental counseling on the potential need for fetal resuscitation prior to fetal surgery. The gestational age at which centers would attempt neonatal resuscitation after emergency delivery varied from 22 weeks and 0 days to more than 28 weeks. CONCLUSIONS: In this global survey study of 28 fetal surgical centers, there was no standard practice about how fetal resuscitation or subsequent neonatal resuscitation was managed during open spina bifida repair. Further collaboration between professionals and parents is required to ensure sharing of information to support knowledge development in this area

Philosophy and Theology: Notes on Fetal Interventions

In the article, the author discusses the issues involving the ethics of fetal surgery. He cites the works of scholars Frank A. Chervenak and Laurence B. McCullough on the ethical questions on fetal surgery. The positions of such pro-abortion individuals as Peter Singer, Michael Tooley and David Boonin on the issue of fetal homicide are also cited

Fetal Surgery and Wrongful Death Actions on Behalf of the Unborn: An Argument for a Social Standard

Imagine a young couple in the not-too-distant-future who are eagerly awaiting the birth of their first child. During the eighteenth week of the pregnancy, the mother has an ultrasound performed to detect possible developmental problems with the child. To their dismay, the ultrasound reveals a malformation in the fetus. The defect will not be fatal, but if left untreated will cause the child severe breathing problems once born. The problem can be fixed with surgery after birth, but such a procedure will result in disfiguring facial scars. After thoroughly considering their options, which range from an abortion to carrying the pregnancy to a natural delivery, the couple decides to have a surgeon attempt to correct the defect while the fetus remains in the womb. If successful, this fetal surgery will fix the breathing problem without significant scarring. The woman is anesthetized, and the surgeon makes a small incision in her uterus to expose the fetus and attempts to correct the problem. Unfortunately, the surgery does not have the results intended. While in the recovery room, the woman begins to experience labor pains and eventually delivers a stillborn fetus. Distraught over their loss, the woman and her husband visit a lawyer with the intention of suing the hospital for the wrongful death of their unborn child. Whether their suit has any chance of success depends, in most states, on whether the fetus was of the age where it would have been able to survive outside of the womb. This Note will argue that the viability limitation on wrongful death recovery, which has been previously criticized as arbitrary and unjust, is particularly inappropriate in the fetal surgery context. While conceding that the viability standard is generally the most prudent approach when a fetal death results from another\u27s negligence, it argues that problems with allowing recovery for nonviable fetuses are not present when the cause of the death has been a negligent fetal surgery. This Note concludes that States should retain the viability standard as the general rule but should allow parents of non-viable fetuses to sue in wrongful death when the termination of the fetus has resulted from fetal surgery. Part II of this Note discusses the brief history and rapidly developing future of fetal surgery. Part III predicts how the current medical malpractice law would apply to fetal surgery, explaining that the recognition of a legal duty of care from the surgeon to the fetus would not mean that the surgeon would be liable every time a fetal surgery results in a miscarriage or stillbirth. Parts IV and V trace the evolution of the cause of action for wrongful death in Anglo- American law, both in general and as applied to the unborn. Part VI presents the reasons given by judges and scholars for adhering to the viability standard. Part VII offers a policy-based argument for a special standard in wrongful death cases involving fetal surgeries. Part VIII argues that the reasons presented in Part VI are either not applicable in the fetal surgery context or based on false premises altogether

Dilemmas in fetal medicine: premature application of technology or responding to womens choice?

Copyright @ 2006 The Author.It is argued that innovative health technologies (IHTs) may be changing the roles of both patients and health practitioners, and raising new issues, including ethical, legal and social dilemmas. This paper focuses on the innovative area of fetal medicine. All fetal treatment necessitates accessing the fetus through the pregnant woman's body, and non-surgical treatments have long been a part of pregnancy care. However, recent developments in this area, including the increasing routinisation of sophisticated antenatal ultrasound screening and the introduction of treatments including fetal surgery, may mark a shift in this specialty. The paper explores such shifts from the perspectives of medical and midwifery practitioners working in two Fetal Medicine Units. It examines the apparent effects of the orientation of fetal medicine on prevalent conceptualisations of the maternal-fetal relationship, and some of the consequences of this. It is argued that new forms of uncertainty, including complex risk and diagnostic information, and uncertain prognostic predictions set within the rhetoric of non-directive counselling and women's choice, are leading to unprecedented ethical dilemmas within this area. More widespread debate about such potential dilemmas needs to take place before, rather than following their introduction.This study is supported by the Wellcome Trust Biomedical Ethics programme and the ESRC Innovative Health Technologies Programme (grant number L218252042)

Fetal surgery for spina bifida

Open spina bifida is often diagnosed during pregnancy. In the last 20 years, fetal repair has been shown to have benefits to the neonate and child, and is now widely available, including within the UK. This article briefly examines the background, evidence, benefits and risks of fetal surgery for spina bifida

Fetal surgery for open spina bifida

Key content: Spina bifida is a congenital neurological condition with lifelong physical and mental effects. Open fetal repair of the spinal lesion has been shown to improve hindbrain herniation, ventriculoperitoneal shunting, independent mobility and bladder outcomes for the child and, despite an increased risk of prematurity, does not seem to increase the risk of neurodevelopmental impairment. Open fetal surgery is associated with maternal morbidity. Surgery at our institution is offered and performed according to internationally agreed criteria and protocols. Further evidence regarding long‐term outcomes, fetoscopic repair and alternative techniques is awaited. Learning objectives: To understand the clinical effects, potential prevention and prenatal diagnosis of spina bifida. To understand the rationale and evidence supporting the benefits and risks of fetal repair of open spina bifida. To understand the criteria defining those who are likely to benefit from fetal surgery. Ethical issues: The concept of the fetus as a patient, and issues surrounding fetal death or the need for resuscitation during fetal surgery. The associated maternal morbidity in a procedure performed solely for the benefit of the fetus/child. The financial implications of new surgical treatments

Amnion cells engineering: A new perspective in fetal membrane healing after intrauterine surgery?

In this study we aimed to set up an in vitro culture of the rabbit amnion in order to support in vivo fetal membrane healing capacity following fetoscopy. Fetal membranes were collected from a mid- gestational rabbit, and cultured on collagen support material for 14 days. 34 rabbits at 22 - 23 days gestational age ( GA) underwent fetoscopy. The entry site was randomly allocated to 4 closure technique study groups: group I, human amnion membrane ( n = 23); group II, collagen foil ( n = 16); group III, collagen plug ( n = 19), and group IV, collagen plug with cultured amnion cells ( n = 19). In all groups membrane access sites were additionally sealed with fibrin sealant, and the myometrium was closed with sutures. Fetal survival, amnion membrane integrity, and the presence of amniotic fluid were evaluated at 30 days GA. Cultures showed good survival in the collagen support material. Increased cellularity, survival and proliferations were observed. The amnion at the access site resealed in 58 - 64% of cases in groups II - IV, but none of the tested techniques was significantly better than the other. Histological examination indirectly revealed the anatomic repair of the membranes, since no entrapment of the membranes could be demonstrated in the myometrial wound. Copyright (c) 2006 S. Karger AG, Basel

Pregnancy related pharmacokinetics and antimicrobial prophylaxis during fetal surgery, cefazolin and clindamycin as examples

Antimicrobial prophylaxis during surgery aims to prevent post-operative site infections. For fetal surgery, this includes the fetal and amniotic compartments. Both are deep compartments as drug equilibrium with maternal blood is achieved relatively late. Despite prophylaxis, chorio-amnionitis or endometritis following ex utero intrapartum treatment or fetoscopy occur in 4.13% and 1.45% respectively of the interventions. This review summarizes the observations on two commonly administered antimicrobials (cefazolin, clindamycin) for surgical prophylaxis during pregnancy, with emphasis on the deep compartments. For both compounds, antimicrobial exposure is on target when we consider the maternal and fetal plasma compartment. In contrast, amniotic fluid concentrations-time profiles display a delayed and much more blunted pattern, behaving as deep compartment. For cefazolin, there are data that document further dilution in the setting of polyhydramnios. Along this deep compartment concept, there is some accumulation during repeated administration, modeled for cefazolin and observed for clindamycin. The relative underexposure to antimicrobials in amniotic fluid may be reflected in the pattern of maternal-fetal complications after fetal surgery, and suggest that antimicrobial prophylaxis practices for fetal surgery should be reconsidered. Further studies should be designed by a multidisciplinary team (fetal surgeons, clinical pharmacologists and microbiologists) to facilitate efficient evaluation of antimicrobial prophylaxis