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INTRODUCTION

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Over the past several decades, invasive fetal therapy has evolved from an appealing concept to a dedicated field of medicine that bridges the disciplines of obstetrics, pediatrics, anesthesiology, and surgery. Since description of the first case of fetal therapy by Liley in 1963 involving transfusion of a hydropic fetus affected by Rhesus alloimmunization, advances in prenatal diagnosis and surgical innovation have resulted in breakthroughs in the management of congenital anomalies or conditions historically considered to be lethal or severely life-limiting.1 The advent of prenatal ultrasonography and video fetoscopy, the refinement of needle-based procedural techniques, and innovations in anesthesia and surgical practices have each been critical to the arrival of modern fetal therapy.

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The first published guidelines establishing suitable candidacy for fetal therapy were promoted by the group that would later become the International Fetal Medicine and Surgery Society (IFMSS)2,3 (Box 28-1). These recommendations, which remain relevant to this day, require a certain and severe fetal diagnosis amenable to prenatal intervention, a multidisciplinary approach to care, and an intent that maternal risk be minimized with all fetal therapy undertakings.

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Box 28-1 INTERNATIONAL FETAL MEDICINE AND SURGERY SOCIETY GUIDELINES FOR CONSIDERING FETAL THERAPY (AS SUMMARIZED BY CHESCHEIR)2,3

  1. The disorder must be of a significant nature and should be a simple structural defect that interferes with organ development whose alleviation might allow for fetal development to proceed normally.

  2. The diagnosis must be complete and accurate, such that patients whose fetus is so severely affected that intervention is futile as well as those whose fetus is so mildly affected that postnatal treatment would be effected are equally excluded; the defect should be isolated, with a normal karyotype and absent other anomalies.

  3. The fetus should be a singleton without concomitant anomalies according to Level II ultrasonographic examination and amniocentesis for karyotype, amniotic fluid alpha fetoprotein, and viral cultures.

  4. An animal model for the disorder and intervention should exist.

  5. There should be access to a Level III high-risk obstetrics unit, an intensive care unit, and bioethical and psychosocial counseling.

  6. A multidisciplinary team, including a perinatal obstetrician experienced in fetal diagnosis and intrauterine transfusion, an ultrasonographer experienced in the diagnosis of fetal anomalies, and a pediatric surgeon and neonatologist who will manage the infant after birth, should concur on the plan for innovative treatment and obtain the approval of an institutional review board.

  7. The family should be fully counseled about risks and benefits and should agree to treatment, including long-term follow-up to determine efficacy.

  8. Maternal risks should be minor and acceptable.

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As is the case with all medical innovation, a major challenge is to ensure that fetal therapies are both ethically justifiable and scientifically validated prior to acceptance as standard of care.4 Scientific validation is a particular challenge with invasive fetal therapy, as the overall rarity of conditions that might be suitable for fetal therapy has limited the production of ...

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