BRIEF HISTORY OF FETAL SURGERY
Sir William Liley (1963) completed the first successful fetal surgery, which was transuterine fetal intraperitoneal red blood cell transfusion. This was performed for erythroblastosis fetalis, which at the time, without intervention, was a lethal malady. The field rapidly developed, to a large extent fueled by the work of Dr. Michael Harrison, an early pioneer in fetal surgery. In 1982, one of the first organized conferences on fetal intervention was held. Dr. Harrison summarized conclusions of the inaugural meeting, which would later become the International Fetal Medicine and Surgery Society (IFMSS) (Harrison, 1982). One key statement noted that "All case material, regardless of outcome, should be reported to a fetal-treatment registry, so that the benefits and liabilities of fetal therapy can be established as soon as possible." This ethos is as important today as it was three decades ago.
Fetal surgery has evolved during the past three decades from an innovative and ambitious concept to a regulated and leading field of medicine. Refinement of techniques for open surgeries, new technology, advances in minimally invasive image-guided percutaneous interventions, and development of feasible fetoscopic surgical procedures has fueled this evolution. In addition, protocols to control uterine contractions and preterm labor and to standardize care of neonates delivered preterm after surgery have been honed. Finally, specific fetal anesthesia considerations and intraoperative management algorithms contribute to improved fetal outcomes.
A fetal anomaly raises unique and complex issues for the pregnant woman and her family. The importance of a multidisciplinary team involved in the prenatal evaluation, surgical therapy, and postnatal care cannot be overemphasized. This team generally includes a maternal-fetal medicine specialist, pediatric surgeon, anesthesiologist skilled in maternal and fetal anesthesia, pediatric neurosurgeon, pediatric urologist, pediatric nephrologist, pediatric cardiologist, neonatologist, and bioethicist. The family should also have access to psychosocial support (Bliton, 2003).
Closed fetal therapies are procedures performed by inserting a needle or endoscopic trocar through the maternal abdominal and uterine wall without the need for hysterotomy. Most closed surgical procedures are performed under direct sonographic guidance and usually involve only one puncture, which typically measures 2.4 mm. This small puncture introduces a needle or trocar through which a shunt, balloon, or semirigid endoscope can be passed. Occasionally, closed fetal interventions are performed using a combination of sonographic and fetoscopic guidance.
In general, a policy should be adopted to administer fetal analgesics for any invasive procedures during which the fetus might experience pain. This is certainly true for 18- to 20-week or older gestations. Intramuscular or intravenous agents are delivered under sonographic or endoscopic guidance using an 22-gauge needle. We usually give vecuronium (0.2 mg/kg), atropine (20 μg/kg), and fentanyl (15 μg/kg) using estimated fetal weight to immobilize the fetus and to suppress the fetal stress response, which is bradycardia. For the mother, instrument insertion is usually done under local anesthesia, which is injected ...