The St. Louis Fetal Care Institute is one of the few places in the country that performs fetal surgery, or surgery in the womb.
These open, and minimally invasive procedures can save the lives of babies with various diagnoses before they are born.
The St. Louis Fetal Care Institute Scientific and Ethical Review Board—made up of a pediatric surgeon, neonatologist, maternal fetal medicine specialist, ethicist, and labor and delivery nurse—reviews most cases prior to surgery. The Board meets to discuss the case, weigh the benefits and the risks, and assure that the decisions made are medically and ethically sound.
Open Fetal Surgery
In open fetal surgery, the mother is placed under general anesthesia and given an epidural to help with pain control. The fetus is also given medications as needed for pain control and to prevent movement.
During the surgery, the surgeon makes a 10-inch incision into the mother’s abdomen and a 4 to 5-inch incision into the uterus using a special device that helps control bleeding and membrane separation. Warmed fluids are continuously infused into the uterus to keep the amniotic fluid level safe for the mother and baby. The surgery is performed on the baby while still in the womb, and then the uterus is closed.
After open surgery, we require our mothers to stay in the hospital for 4 to 5 days or until any complications are ruled out. We then ask our mothers to remain on modified bed rest to decrease the risk of preterm delivery for the rest of the pregnancy (no heavy lifting, only light activity).
If a mother is from out of town, we ask that she remain in St. Louis for two weeks following fetal surgery with a dedicated caregiver. Medications are also used for the remainder of the pregnancy to help decrease the chance of any preterm labor. Although many mothers can carry the pregnancy to term, most deliver their babies early, at an average of 34 to 35 weeks.
Because the uterine incision for open fetal surgery does not heal as well as that for a cesarean section, our open fetal surgery mothers cannot labor in the current and future pregnancies. All future deliveries should be by cesarean section.
Open Fetal Surgery may be used for several conditions:
Minimally Invasive Fetoscopic Surgery
In minimally invasive fetoscopic surgery, the surgeon makes a pencil-tip-sized incision and inserts a small telescope called a fetoscope into the uterus. The fetoscope allows for a telescopic view into the uterus.
Ultrasound technology helps guide the fetoscope throughout the uterus.
Fetoscopic surgery is much less invasive than open fetal surgery, thus decreasing the risk of preterm labor. Mothers are given anesthesia during the procedure to help with pain control and anxiety. The fetus is also given medication to decrease movement and prevent pain.
Following surgery, our mothers typically remain in the hospital overnight until any surgical complications are ruled out. We then ask our mothers to remain on modified bed rest for the rest of the pregnancy to decrease the risk of preterm delivery (no heavy lifting, only light activity). If a mother is from out of town, we ask that she remain in St. Louis for one week following fetal surgery with a dedicated caregiver. Medications are also used for the remainder of the pregnancy to help decrease the chances of any preterm labor. Many mothers can carry the pregnancy to term, but some deliver their babies early, depending on the baby’s condition.
Because the uterine incision for fetoscopic surgery is very small, it heals well. Mothers can labor in the current and future pregnancies, and can plan on a vaginal delivery. Based on current research, we do not think that fetoscopic surgery will affect future pregnancies.
Fetoscopic surgery may be performed for several conditions:
- Laser ablation of placental vessels for twin-twin transfusion syndrome, where the surgeon uses a laser, inserted into the uterus through the fetoscope, to eliminate communicating blood vessels in the placenta between twin fetuses.
- Laser ablation of lesions, where the surgeon uses a laser inserted into the uterus through the fetoscope to eliminate the area causing complications, such as a posterior urethral valve in bladder outlet obstuction or amniotic band constricting a limb.
Needle-Based Ultrasound-Guided Procedures
In Needle-based ultrasound-guided procedures, the physician provides fetal intervention through ultrasound guidance and needle-based therapy. This is much less invasive than open or fetoscopic fetal surgery to the mother and baby, and usually does not require an overnight stay in the hospital.
However, we do require the mother to stay for several hours after the procedure to rule out any complications. Needle based therapy may be used for several conditions:
- Amnioreduction/ Amnioinfusion, where a needle is placed into the uterus and amniotic fluid is either removed due to polyhydramnios (too much amniotic fluid) or warmed fluid is infused due to oligohydramnios (too little amniotic fluid).
- Fetal transfusion or fetal blood sampling, where the surgeon places a needle into the baby’s umbilical cord to either provide donor blood to the baby or to remove fetal blood for sampling.
- Fetal shunt placement, where the surgeon places a small tube between the chest or bladder and the amniotic fluid to help drain excess fluid.
Procedure During Delivery
The Ex Utero Intrapartum Treatment Procedure (EXIT procedure) is performed when we anticipate that a baby will have an immediate, critical problem once separated from the mother at delivery. The purpose of an EXIT is to provide the necessary intervention to the baby before the umbilical cord is cut. This allows for a more stable transition from placental circulation to newborn circulation.
During an EXIT procedure, the mother is placed under general anesthesia. The delivery is started similar to a cesarean section, however a special device is used to open the uterus and prevent uterine bleeding at the same time. The baby’s head and arms are delivered. Monitors are placed on the baby and IV access is obtained. The baby remains attached to the placenta, which serves as life support, while the surgeon performs the necessary procedure to stabilize the baby.
In cases of airway obstruction, an EXIT procedure gives the surgeon time to clear the baby’s airway, secure a breathing tube, and provide adequate ventilation, before the baby is separated from the mother. When the baby is stable enough for delivery, the umbilical cord is cut and the newborn is transferred to the care of the neonatologist and the pediatric surgeon.
The St. Louis Fetal Care Institute performs EXIT procedures at SSM Health Cardinal Glennon Children’s Hospital and SSM Health St. Mary’s Hospital, depending on the individual patient’s circumstances. During an EXIT procedure, our pediatric surgery team, neonatal team and maternal team work together to assure the safety of both the mother and baby.
Similar to open fetal surgery, the mother cannot labor with future pregnancies and will require cesarean sections for all future deliveries. Mothers typically are hospitalized for three to four days after an EXIT procedure for recovery, similar to that of a cesarean delivery.
Conditions That May Require Fetal Surgery
Problems which cause hydrops (fetal heart failure) by compressing the heart:
Problems which cause hydrops by stealing blood flow:
Problems with the airway or lungs at birth:
- Congenital high airway obstruction syndrome
- Cervical teratoma
- Massive cystic hygroma
- Problems with small lungs (pulmonary hypoplasia)
- Pleural effusions
- Massive lung lesions
- Severe oligohydramnios
Problems which can cause irreversible organ or limb damage: