If Kourtney Kardashian’s Instagram post last week marked the first time you’d ever seen the term “foetal surgery,” you’re not alone.
Procedures in which a doctor operates on an unborn foetus aren’t as recent a development as you might imagine, but they’re not particularly common, either.
Speculations arose that something had happened to Kardashian and the baby she is carrying when her husband Travis Barker, drummer for the band Blink 182, abruptly flew home from the group’s European tour to attend to an “urgent family matter,” leading to the postponement of several scheduled shows in Scotland and Ireland.
Four days later, Kardashian posted a black and white photograph of Barker’s hand holding hers on a hospital bed, an IV tube emerging from her taped wrist.
“I will be forever grateful to my incredible doctors for saving our baby’s life,” Kardashian wrote. “I wasn’t prepared for the fear of rushing into urgent fetal surgery. I don’t think anyone who hasn’t been through a similar situation can begin to understand.”
What is foetal surgery?
Foetal surgery is a term used to talk about “any procedure performed on foetuses prior to delivery,” Dr. Saul Snowise, foetal interventionist and the medical director of the Midwest Foetal Care Center, a collaboration between Allina Health and Children’s Minnesota, told HuffPost.
Some procedures are performed to “prevent foetal loss,” Snowise explained, while “others are meant to improve the long-term outcome for the newborn.”
An example of a lifesaving procedure is a foetal transfusion, in which donor blood is transfused into an umbilical vein. Foetal anemia, which has various causes, can be treated this way. Foetal transfusions, performed since the 1960s, are the earliest type of foetal surgery.
“The field rapidly evolved in the ’80s-’90s and there are now well-established foetal surgery programs across North America, Europe and Asia,” Snowise said.
A procedure to correct a neural tube defect, such as spina bifida, would be an example of a procedure aimed at improving the long-term outcome for the baby.
These procedures have become more common over the past decade, following the 2011 publication of a study in the New England Journal of Medicine showing a benefit to doing these repairs prenatally, as foetal surgery, rather than waiting to perform surgery on the baby after it is born.
What conditions can be treated?
Dr. Raphael Sun, co-director of the foetal surgery program at Oregon Health Sciences University, says that two of the most common conditions he treats with foetal surgery are twin-to-twin transfusion syndrome and neural tube defects such as spina bifida.
Twin-to-twin transfusion syndrome is a rare condition that occurs only in identical twins. When the twins are monochorionic and diamniotic (meaning they share one placenta but each have their own amniotic sac), they may “have unequal sharing of blood between the two foetuses,” Snowise said. This can threaten the entire pregnancy.
Surgeons like Snowise and Sun are able to use laser surgery to effectively create two functioning placentas from one, so that each twin has its own reliable source of blood. Twin-to-twin transfusion syndrome is not generally diagnosed or treated before 16 weeks of pregnancy.
Other instances where a foetus might need surgery include an accumulation of fluid in the chest or abdomen, which doctors are able to drain using a needle or sometimes by placing a shunt, “which is essentially a small tube that can divert and change fluid from one cavity to the other,” Sun explained.
Some conditions need to be treated right away in order to save the baby’s life, while other surgeries, such as those for spina bifida, are generally planned weeks in advance. Spina bifida or other neural tube defects aren’t generally treated before 24 weeks, Sun said. (At 24 weeks, it is possible for a baby to survive in a hospital NICU.)
“Foetal procedures range from minimally invasive needling procedures to complex maternal procedures requiring large incisions in the uterus,” Snowise said.
A procedure to drain fluid from the foetus’ lungs would be minimally invasive, involving the insertion of a needle. Slightly more invasive procedures include the placement of shunts or a foetal transfusion. “These procedures are done just with needles or small maternal incisions and are guided by ultrasound,” Snowise explained.
The kind of laser surgery to treat twin-to-twin transfusion syndrome is generally performed using “foetoscopy, or placing an operative scope into the uterine cavity,” Snowise said.
Procedures to correct neural tube defects or to remove tumours are the most invasive. “In these cases, a large maternal abdominal incision is made, the uterus is opened to expose the foetus, the tumour is removed or the lesion is repaired, and then the uterus is closed and the pregnancy continued,” he said.
Sun noted that in recent years, some surgeons are doing a more minimally invasive surgery to repair neural tube defects such as spina bifida, involving 2, 3 or 4 small incisions rather than one large one.
What are the risks?
Some of the risks from foetal surgery are the same as with any surgical procedure, such as bleeding and infection. “With minimally invasive procedures these are rare,” Snowise said.
The risks of more complex procedures can include blood clots or fluid collecting in the lungs of the mother.
“The major risk affecting both mother and foetus are the risks of preterm labor and preterm delivery,” Snowise said. The earlier a baby is born, the greater the risk of it not surviving or having other complications.
Which specialists perform foetal surgery?
Some foetal surgeons initially train as maternal foetal medicine specialists, or high-risk obstetricians. Others train first in paediatric surgery. Many large U.S. cities have a foetal surgery centre affiliated with their local children’s hospital, but these kinds of procedures are much less available in rural areas. Some patients have to travel long distances to reach a hospital where they can be treated.
Both surgeons emphasised that foetal surgery is a team effort. At the Midwest Foetal Care Centre, Snowise said, “our team consists of maternal-foetal medicine specialists, paediatric surgeons, paediatric cardiologists, paediatric neurosurgeons, neonatologists, clinical nurse coordinators, geneticists, and other specialty staff, all of whom have extra training in managing complex foetal cases.”
Sun concurred: “It’s special, and I think it’s really complex, and it takes an entire team to be able to execute this.”
“It’s really gratifying,” he continued. Foetal surgery “offers some mothers and foetuses a chance that would not have been otherwise available.”