MIRACLE BEFORE BIRTH
PROCEDURES DONE IN THE WOMB BOTH AMAZE AND RAISE MANY QUESTIONS
By Judy Foreman
The Boston Globe, August 2, 1999
`Closed' procedures are the
Although ``open'' fetal surgery is dramatic, doctors are increasingly
turning toward ``closed'' or minimally invasive procedures in
which thin instruments and a small TV camera are inserted through
tiny incisions; sometimes they use ultrasound to guide needles
to insert shunts.
At New England Medical Center, Wendy Andrasy, 33, a Weymouth
police officer, has already reaped the benefits of this approach.
When she was pregnant two and a half years ago, her fetus had
an enlarged bladder, a sign that something was obstructing the
flow of fetal urine into the amniotic fluid. This can cause kidney
damage as urine backs up; it can also sabotage lung development.
Fetal urine contains a growth factor that is ``essential for
lung development,'' says Dr. Diana Bianchi, chief of genetics
at the Floating Hospital for Children at New England Medical
Center. Normally, the fetus ``is inhaling its urine and that
is allowing this growth factor to get to the lungs.''
But Andrasy's fetus wasn't getting that growth factor. So when
she was 20 weeks pregnant, Dr. Sabrina Craigo, a perinatologist
at NEMC, slipped a tube through Andrasy's uterus, using ultrasound
guidance, and placed a drainage shunt with one end in the fetal
bladder and the other in the amniotic sac.
At the University of California in San Francisco, Dr. Michael
Harrison, director of the fetal treatment center and the undisputed
leader in fetal surgery, is pushing the envelope even further.
Harrison notes that 1 in 2,000 babies is born with a diaphragmatic
hernia, a hole in the diaphragm that allows the intestines and
sometimes the liver to poke up into the chest cavity. When this
happens, the lungs get so compressed they never develop, which
means that as soon as the baby is born, it dies.
The solution is counterintuitive: occlude the fetal windpipe.
Fetal lungs make fluid that pours into the airway and out of
the mouth; by blocking this outflow, the fluid, which spurs lung
growth, is pumped back into the lungs.
Harrison's team has perfected a way to close the fetal windpipe
endoscopically with a clip that is placed on the fetal trachea
during surgery and left there for the remainder of the pregnancy.
It is then removed during delivery by C-section so the baby can
breathe normally. The results on the first dozen patients, not
yet published, suggest that it works much of the time, he says.
At Children's Hospital in Boston, Dr. Rusty Jennings , director
of fetal diagnosis and treatment, is gearing up to do the trachea
procedure, as well surgery for spina bifida and other problems.
At a number of hospitals nationwide, including New England Medical
Center and Hasbro Children's Hospital in Providence, doctors
are working on ways to use endoscopes and lasers to treat yet
another fetal abnormality, the mixing of blood between identical
twins whose blood vessels join in the placenta. When this happens,
says Dr. Francois Luks, associate professor of surgery and pediatrics
at Brown University, one twin's heart tries to pump blood for
both, causing heart failure; the other twin often dies from anemia
because it gets too little blood.
As for Andrasy, her son was born two years ago. The surgery prevented
the child's death from underdeveloped lungs, but was not able
to prevent kidney damage -- in fact, he needs a kidney transplant.
But Andrasy, now pregnant again, was thrilled: ``He's wonderful.
They saved his life. He's funny. He's a great kid. He smiles
all the time.''