Lifeline in the womb: How surgeons are saving babies even before they are born

medium118889269The joy of expecting twins turned to panic for 28-year-old Mumbai resident Prajakta Yadav* after an ultrasound revealed severe Twin-to-Twin Transfusion Syndrome (TTTS). Blood was being shunted from one twin to the other through abnormal blood vessel connections in the shared placenta. The donor twin had become dangerously anaemic and could die soon. The other had a 40% chance of death or severe neurological disability. The fetal medicine team at Mumbai’s Jaslok decided to save at least one child with a procedure called Radio frequency Ablation (RFA), which was performed in the womb at 23 weeks. Prajakta delivered a healthy baby girl weighing 3kg at 37 weeks. Now one, the child is growing well without any complications.While fetal surgeries are not new, Dr Neelam Suri, senior consultant in obstetrics and gynaecology at Indraprastha Apollo Hospitals, says improved tests and imaging have made it possible for doctors to treat a variety of ailments in the womb itself. “For one, prenatal testing has come a long way in detecting such anomalies with high-resolution ultrasound and fetal MRI. Innovations in miniature surgical instruments, regenerative medicine (to restore function in damaged organs and tissues) and 3D planning (using 3D imaging to create detailed fetus model) have together expanded fetal care possibilities,” says Dr Suri.It has opened up “a remarkable frontier in maternal medicine, offering hope in situations that once seemed hopeless”, says Dr Shilpa Agrawal, an obstetrician and gynaecologist specializing in maternal and fetal medicine at Jaslok Hospital who treated Prajakta. “In cases like this, where TTTS poses grave risk to both babies, advanced procedures like RFA selectively seal blood vessels in the affected twin’s umbilical cord, giving the healthier twin a chance to thrive.” medium118888809Better chances for mother, childWhile open fetal surgery (where the fetus is removed from the womb, operated upon and placed back) has not been performed in India so far, minimally invasive fetoscopic techniques have greatly reduced risks for both mother and unborn child. Two years ago, specialists at New Delhi’s All India Institute of Medical Sciences (AIIMS) performed a complex balloon dilation procedure on the “grape-sized” heart of a 28-week-old fetus in just 90 seconds. The fetus had a closed main valve due to reduced blood flow which, if untreated, would have led to aortic atresia at birth — a rare condition where blood flow from the left ventricle to the body is interrupted.Many other advanced interventions treat rare conditions affecting the unborn baby (see box). Dr Vandana Bansal, director, department of fetal medicine, at Mumbai’s Wadia Group of Hospitals, has seen around 300 fetal intervention cases at the hospital in the last year alone. “Complex procedures like intrauterine transfusion (IUT) treat severe fetal anaemia caused by Rh isoimmunization (when mother’s blood is incompatible with baby’s) by transfusing blood directly to the fetus,” she says, recalling a rare case of IUT involving triplets where the Rh-negative mother had developed antibodies against the Rh-positive blood of the fetuses. In a pregnancy where each fetus has its own placenta, it’s too crowded to access each umbilical cord. And IUT in a single session is time-consuming, raising risks of preterm labour, she says. But Dr Bansal and her team proceeded with IUT for the triplets in a single session to restore red blood cell count and prevent fluid build-up. “A real-time ultrasound showed their umbilical cords. A fine needle was inserted through the mother’s abdomen into the umbilical vein of each fetus, and donor blood was slowly transfused with ultrasound monitoring,” she says. The triplets were delivered at 34 weeks. Postnatally, all three got intensive phototherapy and intravenous immunoglobulin to manage newborn jaundice. They were discharged within four days. ShowQuotesTiny incision, max resultsDr Reema Bhatt, head of fetal medicine and perinatology at Amrita Hospital, Faridabad, says new-age prenatal screenings enable early detection of spina bifida (neural tube defect), corrective procedures for which include a tiny incision using a camera or through temporary uterine opening to repair the fetal spine. “There’s also non-invasive fetal therapy that involves giving drugs to the fetus through the placenta,” says Dr Bansal.While genetic disorders like Down syndrome and Spinal Muscular Atrophy (SMA) can be identified prenatally, most treatments happen after birth. A groundbreaking case in the US reported by the New England Journal of Medicine last month details the first successful in-utero treatment of SMA using gene-targeting drug risdiplam, taken by the mother from 32 weeks. The child, now almost three, shows no signs of SMA. The field of fetal surgery continues to advance, with ongoing research focused on enhancing procedural safety and efficacy. *Name changed on request