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Fetal Care
 

Open Fetal Surgery

 

Open fetal surgery is often performed in situations in which a baby will not survive without this level of intervention. The choice on whether to undergo open fetal surgery is a personal decision that is left up to the mother and her family. Fetal surgeries, like all surgical procedures, have an element of risk to the mother and her baby. That is why the procedure is performed only to correct life-threatening or devastating fetal conditions.

 

At the St. Louis Fetal Care Institute, our team will work with the family to discuss their options and possible outcomes. We want parents to have as much information as possible before making a decision. There is no wrong decision for a family to make. 

Common fetal health conditions that are sometimes treated by therapeutic fetal procedures include:

 Congenital Diaphragmatic Hernia (CDH): Occurs when an abnormal opening in the chest cavity allows internal organs such as the stomach, small intestine, spleen, liver and kidney to develop in the chest cavity instead of the abdomen. The displaced organs prevent the lungs from developing properly and most babies are both with respiratory distress. The severity of the disease can vary widely from immediate, severe distress to no clear effect at all.  

Treatment of CDH includes extensive fetal evaluation to determine the future severity of the disease. Usually a focused ultrasound, fetal MRI and fetal echocardiogram are required to assess the CDH severity. We have performed extensive research in the outcome of CDH babies. The Lung to Head Ratio (LHR), liver position, total lung volume and echocardiogram are the primary means by which we evaluate the risk. 

 Sacrococcygeal Teratomas (SCT): The most common type of tumors found in newborns, typically located between the coccyx and the sacrum, a bone at the end of the vertebral column. These tumors can actually become as large as the baby himself. When a tumor becomes enlarged, it puts tremendous strain on the heart as it works to circulate blood through the baby’s developing body and the tumor.

Treatment of SCT includes a resection – an open surgery in which the surgeon opens the uterus to expose and remove the baby's tumor from the fetal circulation path. The surgeon removes the tumor and seals the wound in the baby’s lower back. The surgeon then seals the uterus and returns the baby to the womb. This treatment requires several days of rest for the mother.

 Ex Utero Intrapartum Treatments (EXIT): This is an operation which is utilized for rare, life-threatening fetal anomalies like airway obstruction and severe congenital heart defects.  The concept of the operation is that while the mother supports the baby, fetal surgeons have more time to correct the life threatening problem in the baby.  When the baby’s problem is corrected or stabilized, then the umbililcal cord is cut and the baby is delivered.

To do this, the mother undergoes general anesthesia and has an incision in the lower abdomen and uterus just like a cesarean. The baby is then partially delivered through the opening in the uterus, but the baby remains connected to his mother through the umbilical cord attached to the placenta. This connection allows the baby to be supported by the mother while the fetal surgeons fix whatever problem is at hand.  After the baby has been treated, the umbilical cord is clamped. The baby is then delivered completely and separated from the mother.

Indications for an EXIT procedure: Any fetal anomaly which could cause life-threatening instability at birth.

  • Suspected congenital or iatrogenic airway obstruction: 
         - Cervical teratomas (tumors in the neck)
         - Lymphatic malformations (masses that result from an
           abnormal formation of lymphatic vessels)
         - Large goiters (thyroid glands)
         - Severe micrognathia (very small jaw)
         - Tracheal occlusion (obstructing the airway to create lung growth)

  • Large mediastinal or thoracic space-occupying masses:
         - Large cardiac masses (tumors on the heart)
         - Severe pericardial effusion with hydrops (excess fluid around the heart)
         - Massive congenital lung lesions (cystic and solid benign lung tumors such
           as CCAM or pulmonary sequestrations)
         - Severe congenital diaphragmatic hernia


  • Severe congenital heart defects:
         - Hypoplastic heart with restrictive atrial septum (underdeveloped heart
           affecting blood circulation)
         - Severe bradycardia (heart rate too slow)

 

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