Fetal Medicine

Birth of a disabled baby is distressing to the parents. And the baby has to live a life of difficulty. Can such birth be avoided?

Yes, sometimes.

Maternal Fetal Medicine (MFM), a relatively new discipline in medicine, makes this possible. MFM treats the fetus as an individual patient. It uses 3D and 4DUltrasound, MRI, CAT, blood tests and other tests to monitor fetal health, growth, and wellbeing and to diagnose fetal metabolic, chromosomal, and anatomic defects; and to assess if the fetal abnormality is amenable to medical or surgical treatment. However the advisability of fetal therapy as compared to postnatal therapy has to be critically assessed: the benefits of treatment should outweigh the risks if the fetal is left untreated, and the risks of the procedure itself to the fetus and to the mother.

With improved and safer methods now available to deliver nutrients, hormones, and substrates to the fetus, and to bypass certain blocked metabolic pathways, thirteen types of fetal malformations, such as Neural Tube Defects (NDT), Lung Prematurity and Maternal HIV infection can be medically treated. Several medical therapies are now in use; and research in fetal gene and stem cell therapy may soon offer early treatment for genetic disorders. For example, the first ‘in womb’ stem cell therapy trial to lessen the effects of the incurable ‘brittle bone’ disease – which can be fatal for babies born with multiple fractures, and can cause up to 15 bone fractures a year in the living – is scheduled to begin in January 2016.

Nine types of lesions, such as Obstructive Uropathy, Congenital diaphragmatic hernia, congenital heart disease - need surgical intervention. Open surgery on the fetus was first done in 1981 for obstructive uropathy by Dr. Michael Harrison at the University of California, San Francisco (UCSF). In the 30 years since then, several endoscopic procedures have evolved. But intrauterine fetal surgery is complex. And though a few of the procedures are now accepted as standard, questions remain about the safety and efficacy of fetal surgical corrections. Fetal surgery is thus still in the research and experiment domain.

If the fetal malformations are incompatible with life, such as severe chromosomal abnormalities and certain metabolic conditions and anatomic defects, especially of the brain and kidneys, then termination of pregnancy (MTP) may be an option.

Preterm delivery is an option in cases where the risk of continued gestation on the viability of fetus, or on fetal/maternal mortality/morbidity is greater - because of a maternal or fetal disorder - than the risk of preterm delivery.

Planned cesarean section is yet another option. It is done when a known medical problem would make labour dangerous for the mother or the baby.

Certain conditions increase the risk of chromosomal anomaly, eg maternal age above 35, previous offspring with chromosomal anomalies or other birth defects, previous Preterm birth, spontaneous abortions, high blood pressure and so on.

Such pregnancies are termed ‘High Risk Pregnancy’ and these should be under the care of a ‘High Risk Pregnancy’ expert obstetrician and MFM experts.

MFM has given rise to several ethical and moral issues. The autonomy of the woman and the moral status of the fetus are central to this debate. But more on it in another write up.

Dr (Prof) Sadhana Kala, Chairing a Session of Fetal Medicine, SCOPE Complex, New Delhi