In what can be described as one of the most challenging surgical fetes, doctors from Amrita Institute of Medical Sciences (AIMS), Kochi have successfully done fetoscopic valve ablation on a 22-week old foetus.
The Fetal Medicine Department at AIMS decided upon an emergency intervention on the premature foetus as ultrasonography detected that the posterior urethral valves in the baby were choking urine flow, with the potential for renal failure.
The obstruction to urine flow produced by the posterior urethral valves resulted in high pressure in the bladder and kidneys. This produced oligohydramnios—a condition characterised by a deficiency of amniotic fluid, doctors said.
A fetoscope was passed through the mother’s abdomen into the uterus under local anaesthesia and ultrasound guidance. It was then pushed through the abdominal wall of the foetus into the bladder.
After visualising the obstructing valve, surgeons introduced a laser fibre through the fetoscope, and the valves were ablated.
Pregnancy continued and the baby was delivered at a later date.
“Fetoscopic valve ablation is not being done in many places in the world. We were probably the first ones to do this at this gestational age,” says Dr Mohan K Abraham, Professor and HOD, Paediatric and Fetal Surgery, AIMS.
The outcome is good for the kidneys and the lungs of the baby, he adds.
According to Dr Mohan, had the intervention not been attempted, it would have led to morbidities like chronic renal failure in the baby, warranting a kidney transplantation later in life.
Fetoscopic valve ablation is not always a totally safe and risk-free procedure. Any foetal intervention, as is well known, can result in premature delivery and the baby can have problems related to prematurity.
A few months ago, the same experts from the fetal medicine department of AIMS carried out an ex-uterine intrapartum therapy (EXIT procedure) on a foetus.
The baby had a 5mm thick septum in the trachea. This caused an accumulation of fluids in the tracheal tree, causing its dilatation, and the over-distention of the lungs. The abnormality was picked up in the antenatal ultrasound.
“A usual delivery by caesarean or vagina would have resulted in the death of the baby since breathing would have been impossible,” says Dr Vivek Krishnan, Professor, Fetal Medicine, AIMS.
LSCS was done with tocolytic administration to keep the uterus relaxed and prevent placental separation. The baby’s head was delivered with the body still inside the uterus. Tracheostomy was done and the baby’s umbilical cord was clamped after that. Blood flow through the umbilical cord allowed the baby to be perfused during the time of tracheostomy and till the lung fluids were sucked out and ventilation established. Once ventilation was established, the baby was removed from the uterus and put on a ventilator.
Currently, EXIT procedure is done in many places. It is resorted to when the airway of the baby is compromised. AIMS specialists did another case about 4 years back.
The outcome of EXIT procedures is good, since there is no issue of prematurity or upper segment scar in the uterus.
The lives of many babies can be saved through timely surgical intervention at the foetal stage. However, the public is not very aware of the fact that a baby can be operated upon in the uterus and the pathology corrected before permanent organ damage occurs, according to foetal surgeons.
Fetal surgery is an upcoming specialty and still in its nascent stages in India.
Because of low awareness about the specialty, the number of cases is small. In India, AIMS is the only centre equipped to do endoscopic as well as open foetal surgery, says Dr Mohan.
Foetal surgery is usually teamwork. Apart from the Fetal Medicine Department, which monitors the patient antenatally and during the time of the procedure and paediatric surgeons who do the procedure, gynecologists take care of the patient after the procedure, neonatologists look after the baby once it is born and anaesthetist administers anaesthesia to the mother.