Fetal Surgery: Coming to a Center Near You?

Abstract

consent process that accompanies these procedures. Maternal–fetal surgery when properly performed by trained individuals in well-structured centers typically proceeds without the mother requiring admission to an intensive care unit. Nevertheless, familiarity with critical care considerations for the obstetric patient is helpful. Even in the best centers, significant maternal complications may arise at subsequent pregnancies, especially following open fetal surgery. On the other hand, the fetus is at risk for procedurerelated complications, preterm delivery, and the morbidity associated with the underlying anomaly. These and other factors should be discussed in a nondirected manner during the informed consent process. This is an area in which the intensivist should actively participate. Newborns who have undergone fetal surgery have had the natural history of their anomalies altered. The physiologic consequences of these alterations may or may not be predictable, challenges for which the neonatologist should be prepared. Fetuses that undergo procedures, especially shortly before birth, may manifest physiologic changes not typical of the average newborn. For example, drainage of large intrathoracic, cervical, or sacrococcygeal cystic lesions just before delivery may result in significant fluid shifts that need to be accounted for during the early newborn period. Expanding fetal surgical indications and a wide variety of interventions present new challenges for the neonatologist and other practitioners in the intensive care setting. A larger number of centers perform percutaneous procedures in utero. Although the vast majority of these are diagnostic and do not typically affect the well-being of the mother or fetus, increasing numbers of percutaneous therapeutic procedures are also being performed at many centers. Fetoscopic procedures require a higher skill set and special The intrigue and mystique of fetal surgery have moved from the realm of science fiction to medical reality. Since the initial attempts at fetal surgery in the 1960s, extensive preclinical studies coupled with advances in imaging technology and surgical instrumentation have resulted in a rapidly growing field. No longer is the womb a barrier to addressing some anomalies that plague newborn infants. Initially developed by perinatologists using needle-based interventions, fetal surgery has expanded to involve fetal/pediatric surgeons performing operations through a partially opened uterus. Minimal access surgery has also found its way into the fetal realm with fetoscopic interventions, which permit endoscopic visualization of the fetus and placenta. With markedly improved optics in recent years, fetoscopy has undergone a resurgence, especially for placenta-based procedures. However, limitations in instrumentation haverestricted its use for correction of structural anomalies (at least for now). Fetal surgical procedures affect the mother and fetus. The mother is typically an innocent bystander who assumes a significant amount of risk with minimal or no direct medical benefit. Many mothers would be willing to do whatever they can for the benefit of their fetus or baby, even putting themselves at undue risk. Understanding the expected benefit of the fetal intervention and the possible risks to the mother is therefore a critical part of the informed