Prenatal surgery–and the unborn child as patient


By Dave Andrusko

CHOP7In a story posted earlier today, NRL News Today wrote about the twice-fold misuse of medical technology. First, using prenatal screening techniques to “search out” unborn babies who are almost always aborted if a “flaw” like Down syndrome is discovered. Second, aborting babies who are mistakenly determined to have a disability, which is compounded the original wrong of a willingness to abort a child because of disability.

And then there is a beneficent use of medical technology—prenatal surgery to correct maladies that would kill the baby after birth or to greatly improve the child’s quality of life.

Josh Siegel offered an extensive overview yesterday at the

As you might expect, he uses the Children’s Hospital of Philadelphia as the linchpin of his story. Children’s has been at the forefront of prenatal surgery since the 1990s.

By Siegel’s account, the impetus for what was revolutionary surgery (the unborn child as a “patient”? Science fiction to skeptics) was “the frustration of caring for babies after birth and realizing it was too late,” according to Dr. Scott Adzick, CHOP’s chief of surgery. “We had to get to the baby earlier, while still inside mom.”

A major part of the calculus is determining which babies (or “fetuses”) could likely benefit and which had flaws not sufficiently severe to justify what Adzick called “big-time intervention.”

Siegel writes that in 1981 Dr. Michael Harrison “conducted the first open fetal surgery to correct a dangerously advanced urinary tract obstruction, a condition that likely would have turned fatal if treated after birth.” Today “surgeons can fix even nonfatal birth defects before birth, for defects such as spina bifida.” (As we’ve reported in NRL News Today, the child is much more likely to walk if her spina bifida is cured in utero.)

But while no longer experimental, such surgery remains rare. Children’s Hospital will evaluate 1,500 mothers carrying babies with severe birth defects but perform only 150 fetal surgery a year—5% to 10%.

Underscoring how grave the birth defects at issue are and how serious the surgery remains even now, “Additionally, the hospital reports that 20 percent of mothers who receive treatment at the center—including both those who pursued fetal surgery and those who didn’t—lose their babies.”

Safety is part of the reason—and a desire to treat a wider range of diseases in utero—that Adzick, Harrison, and other medical professionals are investigating the use of stem cell therapy. Such a therapy could be employed, for example, with babies with sickle cell anemia very early in gestation.

Adzick told Siegel, “His [Adzick’s colleague Alan Flake’s] concept is to give normal blood-forming stem cells to the fetus through a fetoscope into the umbilical cord.

“Those cells then engraft. The fetus does not recognize them as foreign, and, because it is preimmune, those cells proliferate and take over the missing function. [It] is an extraordinarily promising area of fetal therapy. It’s not like doing a big operation.”

The prospect of using of gene therapy, by contrast, is much further into the future. Dr. Adzick was enthusiastic about prospects, nonetheless.

“Cellular therapy before birth and gene therapy before birth would allow us to treat successfully thousands and thousands and thousands of patients,” Adzick said. “To treat what is expressed as disease after birth to treat before birth is the ultimate preventive therapy.”