FETAL SURGERY – The newest speciality in Medicine
A majority of surgeries performed in the world today are those done on people after they are born. Even paediatric surgeons perform on neonates once they are born – until now! Fetal surgery, a branch of paediatric surgery, can very well be called the newest speciality in medicine with the first fetal surgery performed only in 1981.
However, advances in ultrasonography and prenatal imaging have made it possible to diagnose congenital birth defects, much before birth. So, what would otherwise be known only after birth, or many a time months or years later, is now being detected in-utero? The obvious questions that then arise are – “What do we do about the problem that we know exists?” “Can we correct it in the womb?”, “Is there an advantage of operating before birth ?”, “Are these changes transient (For eg Dilatations of the kidneys- Hydronephrosis)?”, “Will they improve as the fetus develops?”
Anything new often meets with resistance and this applies to foetal surgery too. Here are a few things about this new field of medicine that you should know!
Initially, undertaking fetal surgery threw up important ethical issues. Firstly, about whether it is ethically correct to conduct an operation on the pregnant woman which is of no physical benefit to her. It was argued that this may be against the Hippocratic oath which says ‘first do no harm’.
But, over the years, since the 1960s when fetal surgery was first performed in humans, the field has evolved, changed and improved dramatically. Many antenatally diagnosed conditions and their natural intrauterine progress have been studied in detail. This has enabled fetal medicine teams to understand which anomalies need to be corrected before birth and which can wait for postnatal management.
The science of Tocolyis or uterine relaxation (another prerequisite for Fetal Surgery) has also improved with the development and usage of safer tocolytic agents such as nifedipine and magnesium sulphate among many others.
Importantly, several scientific trials comparing the pros and cons of antenatal surgery versus postnatal repair have conclusively established the benefits of fetal surgery in selected conditions. For eg. The MOMS trial (Management of Meningomyelocele study) which published its first results in February 2011 in The New England Journal of Medicine, concluded that operating and correcting spina bifida cases in-utero provided obvious benefits such as a decreased incidence of associated hydrocephalus, probable reduction of neurological deficit, and the potential of improved urodynamics.
Another fascinating aspect of operating on foetuses is that the operation leaves no scars!
Fetal surgery is no longer experimental
Today in the United States if a meningomyelocele case is detected before birth, fetal surgery is offered as a legitimate treatment option to the parents and the fetus is transferred in-utero to one of the centres where fetal surgery is performed. The number of centres performing Fetal Surgery in the USA is 59 and the number worldwide is higher and continues to increase. Though a couple of centres in India have performed less-invasive fetal interventions, open fetal operations are yet to be done.
This new exciting field of Fetal Medicine and Fetal Surgery is rapidly evolving. Stringent criteria are being defined for Fetal intervention and surgery. Fetoscopy and fetoscopic procedures are also making fetal interventions less invasive. Research is progressing on newer areas such as Fetal stem cell therapy and Fetal gene therapy. Some of these developments have the potential of revolutionising medical science.