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Advancements in fetal medicine lead to new program at Brown

By Scott Turner

The George Street Journal, September 15, 2000.


Twice this summer, three physicians from Hasbro Children's Hospital and Women & Infants Hospital performed a pioneering procedure on twin fetuses suffering from the often-fatal twin-to-twin transfusion syndrome.

Beginning this semester, the obstetrician-gynecologist and two pediatric surgeons who performed the procedure, the first of its kind in the Northeast, will apply their multidisciplinary approach to medical education through the School of Medicine's new Program in Fetal Medicine.

In twin-to-twin transfusion syndrome, blood from one fetus continually flows to the other, endangering the lives of both. It occurs in about 10 percent of identical twins sharing the same placenta.

A medical team performs a pioneering procedure on twin fetuses suffering from the often-fatal twin-to-twin transfusion syndrome. This photo was taken by Arlet Kurkchubasche, M.D., of the Fetal Treatment Program

For each operation performed this summer, a laser fiber was inserted through a very small telescope and into the uterus. The laser fiber was used to close all the blood vessels running from one twin to the other. As a result, the twins were separated, with each twin using only his side of the placenta. The first procedure was performed on 22-week-old fetuses; the second on 23-week-old fetuses. Neonatologists and others familiar with the diagnostic and surgical advances, particularly in miniaturization, assisted.
Fetal medicine is a new field. The Brown program was proposed and supported by a nucleus of fetal medicine specialists in obstetrics, gynecology, pediatrics and surgery.

Designed to encompass research, teaching and clinical work, the new program will build upon earlier fetal medicine initiatives by the faculty. For example, in 1997 they formed the Multidisciplinary Antenatal Diagnosis and Management Initiative (MADAM), which draws specialists for twice-a-month reviews of fetal-case management.

MADAM also acts as an advisory board for the Fetal Treatment Program, a collaboration developed in 1999 between the Providence faculty and physicians in Boston, and through which the pioneering surgery took place. Now, MADAM falls under Brown's new program.

The new program will provide a forum for the review of current cases; offer formal presentations for specialists, fellows, residents and medical students; collect data on fetal conditions; foster clinical research by young investigators, including medical students and residents; and establish a teleconferencing/telemedicine program to provide regional perinatal management.

By regrouping the knowledge and skills of the specialists involved, faculty hope the program will lay further groundwork for the Fetal Treatment Program.

"What you have here is a core of faculty that provide immediate access to fetal medicine for physicians, residents, fellows and students," said Thomas Tracy, M.D., professor of surgery and chief of pediatric surgery at Hasbro. "Because we're multidisciplinary, we think those who come to Brown will receive a much richer experience in fetal medicine than if they were elsewhere, where fetal medicine is more likely to be single-department based."

Moreover, "what separates the new program from the few others that exist is that it may be one of the first to include the teaching of medical students," said Francois Luks, M.D., co-organizer and a pediatric surgeon and associate professor.

The other two organizers of the Brown program are neonatologist Lewis Rubin, M.D., associate professor of pediatrics and maternal-fetal specialist Stephen Carr, M.D., associate professor of obstetrics and gynecology.

"Fetal medicine is a field that no one department can claim as its own discipline," said Luks, whose research into a miniaturized flexible scope enabled the transfusion-syndrome surgeries. "Because this program is now recognized at the pre-graduate level, it may pave the way for the establishment of a new specialty, which should be taught in more depth as more knowledge becomes available. In the near future, maybe some students will leave Brown's medical school as fetal specialists."

Donald R. Coustan, M.D., chairman of the Department of Obstetrics and Gynecology, said the new program is somewhat symbolic of the future of the medical school. "The program is multidisciplinary, encompassing contributions from three different departments. While departments aren't going to go away, a real opportunity has come when we can get beyond the borders of departments and bring expertise to bear on a particular problem. This is a great example."

'We're learning, not through baby steps, but fetal steps'
Although medical advances have made fetal surgery possible, anything new in medicine, particularly if it involves a fetus, is viewed hesitantly. When not treating an abnormality may lead to a better outcome, there are strong ethical and medical considerations against entering the fetus.
Lloyd Feit, M.D., is an assistant professor of pediatrics and a fetal cardiologist. He attends the twice-monthly fetal-case conferences. "More and more, you find out about prenatal malformations in advance and you want to know what you can do about them and to give parents an idea of what to expect," he said. "The more we know now, the more we will learn later. You have to start somewhere and in this case, we're learning, not through baby steps, but fetal steps."

What happened this summer to the two sets of fetal twins treated for twin-to-twin transfusion syndrome?

In the first case, the syndrome was resolved. But the smaller donor twin was too sick to recover, and died two weeks later. The remaining twin was born in August; both mother and child are fine. The boy, Stephen, was named for Stephen Carr, one of the physicians involved.

In the second case, the transfusion syndrome was also resolved. Identical boys were born in August. Unrelated to the surgery, one of the boys had his leg amputated based on a condition, linked possibly to the transfusion syndrome, that occurred during gestation. Mother and sons are fine.