A prenatal surgeon performs surgical procedures on a fetus in the mother’s uterus. This field, also known as fetal surgery, addresses congenital anomalies before birth. The aim is to intervene early to save the fetus or significantly improve its long-term health outcomes. Prenatal surgery is a complex and evolving field, offering interventions for conditions that previously had limited treatment options.
The Role of a Prenatal Surgeon
Prenatal surgeons possess specialized training, holding board certifications in both general and pediatric surgery, with additional expertise in maternal-fetal medicine. Their educational path often includes an obstetrics and gynecology residency, followed by a fellowship in maternal-fetal medicine, and then specialized training in fetal surgery. This comprehensive background allows them to manage the health of both the pregnant parent and the developing fetus during these intricate procedures.
Prenatal surgeons work within a multidisciplinary team, collaborating with various specialists to provide comprehensive care. The team commonly includes maternal-fetal medicine specialists who oversee high-risk pregnancies, pediatric cardiologists who evaluate fetal heart conditions, and genetic counselors who support families with complex diagnoses. Other specialists like neonatologists, pediatric radiologists, and pediatric surgical subspecialists (e.g., neurosurgeons, orthopedists, urologists) also contribute to diagnosis, treatment, and postnatal care. This collaborative effort aims to diagnose and treat congenital anomalies in utero, improving the prognosis for the fetus and infant.
Fetal Conditions Requiring Intervention
Prenatal surgeons intervene for specific fetal conditions where early treatment can improve the child’s prognosis. One such condition is myelomeningocele, the most severe form of spina bifida, where the spinal cord and nerves are exposed through a defect in the spine. In-utero repair of myelomeningocele can reduce nerve damage and improve outcomes for the child after birth, including lessening the need for shunts for hydrocephalus. This repair is considered for singleton pregnancies with lesions between T1 and S1, and hindbrain herniation, before 26 weeks of gestation.
Twin-to-Twin Transfusion Syndrome (TTTS) occurs in monochorionic twin pregnancies when shared placental blood vessels cause an imbalance in blood flow. Untreated, severe TTTS can lead to high mortality for both twins. Fetoscopic laser ablation of connecting vessels, performed between 16 and 26 weeks, is a standard treatment. Congenital Diaphragmatic Hernia (CDH), a diaphragm defect allowing abdominal organs into the chest and hindering lung development, may also warrant prenatal intervention. For severe cases, fetoscopic endoluminal tracheal occlusion (FETO), which temporarily blocks the fetal trachea to promote lung growth, is an emerging treatment.
Other conditions benefiting from prenatal surgery include certain heart defects, sacrococcygeal teratoma (a tumor at the base of the tailbone), and lower urinary tract obstruction. For sacrococcygeal teratoma, intervention may be considered before 32 weeks if the tumor is large and causing complications like fetal hydrops. Lower urinary tract obstruction, which can lead to kidney and lung damage, may be treated with vesico-amniotic shunting to drain the fetal bladder.
Approaches to Fetal Surgery
Prenatal surgeons use several surgical techniques, each suited to different conditions. Open fetal surgery involves general anesthesia for the mother, with an incision in her abdomen to access the uterus. The uterus is then opened, and the fetus is partially or fully exposed to allow direct surgical repair of the anomaly. After repair, the uterus and abdomen are closed, and pregnancy continues, often with modified bed rest to reduce preterm labor risk. This approach is used for complex conditions like certain forms of spina bifida or large tumors.
Fetoscopic surgery is a minimally invasive alternative, using small incisions in the mother’s abdomen and uterus. A fetoscope, a thin instrument with a camera, is inserted through these incisions, allowing the surgeon to visualize the fetus and perform the procedure using long, narrow instruments. This method is used for conditions like twin-to-twin transfusion syndrome, where a laser ablates connecting blood vessels, or for some spina bifida repairs. Fetoscopic techniques aim to reduce maternal morbidity compared to open surgery.
The Ex Utero Intrapartum Treatment (EXIT) procedure is performed during delivery. In an EXIT procedure, the mother is under general anesthesia, and the uterus is opened to partially deliver the fetus while it remains connected to the placenta. During this brief period, surgeons can establish a secure airway or remove large masses that might obstruct breathing or circulation after birth. Once the necessary intervention is completed, the umbilical cord is cut, and the baby is fully delivered, similar to a caesarean section.
Navigating Prenatal Surgery
Families considering prenatal surgery begin with a comprehensive evaluation following a fetal diagnosis. This evaluation includes detailed imaging like high-resolution ultrasound, fetal echocardiography for heart conditions, and ultrafast fetal MRI to clarify the anomaly. Families receive counseling covering the diagnosis, treatment options, expected outcomes, and risks for both parent and fetus. This stage emphasizes transparency and supports informed decision-making.
Surgery preparation involves careful planning by the multidisciplinary team, including a review of the patient’s health and surgical considerations. The pregnant parent will have a hospital stay, with continuous monitoring and medications to relax the uterus and prevent preterm labor. The surgical team, comprising various specialists, works in coordination to manage the procedure.
After surgery, both parent and fetus are closely monitored. The parent’s recovery involves managing pain and preventing complications like preterm labor, often requiring reduced activity and specific medications. Fetal well-being is assessed through repeated ultrasounds and fetal echocardiograms to monitor the baby’s heart and overall condition. After discharge, families remain near the specialized center for ongoing prenatal care. Long-term follow-up care after birth ensures continued support and management of the child’s condition.