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By Sharon Begley
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Scores of obstacles confront a fetus struggling to grow from a mere fertilized egg into a sentient, conscious human being. There are fingers to mold from featureless blobs, brains to craft from undifferentiated protoplasm. One of the higher hurdles looms at the eighth week. That's when the diaphragm, separating the abdomen and chest, should close. But for unknown reasons, in about one of 2,500fetuses it remains open. As a result the stomach, intestines, spleen and part of the liver can spill into the chest, leaving the lungs with no room to grow. About 75 percent of such babies die--often right in the delivery room-unable to gasp even the tiniest breath. Now, at least for those fetuses in which the hernia has been detected by ultrasound, there is hope. Last week in The New England Journal of Medicine, a team of physic fans led by Dr. Michael Harrison of the University of California, San Francisco, reported that in two life-threatening cases, they had reached into the womb itself to repair the defect.
These triumphs represent the first successful major surgery on a fetus. With other such operations in the offing, says UCSF's N. Scott Adzick, "fetal therapy is here to stay." It has been slow in coming. For years obstetricians have given transfusions to anemic fetuses, steroids to those with underdeveloped lungs and other medications to those with abnormal metabolisms. But doctors wanted to do more, and none more badly than Harrison. So he experimented on hundreds of fetal sheep and rhesus monkeys, perfecting his surgical techniques. Finally, in 1981, he and his colleagues treated a 30-week-old fetus with a blocked urinary tract, which can damage kidneys and lungs, by passing a needle through its mother's abdomen and shunting urine out of the fetus's bladder. The baby was born healthy. Other physicians copied the technique, and scores of shunts have since been done on fetal organs.
In 1982 Harrison for the first time operated on a fetus directly, rather than through its mother. The surgery, to unblock a urinary tract, worked again. But the baby's lungs and kidneys were so damaged that he died within hours of birth. Since then, Harrison and his team have reported four more such operations. All were technical successes, but in half the cases the fetus had suffered so much damage from the blockage that, despite the surgery, it could not live. That showed how crucial it is to identify fetuses whom surgery has a chance of helping.
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By the mid-1980s the UCSF team was ready to try repairing hernias of the diaphragm. None of their first six patients lived. Then, last year, Harrison and his team operated on a 24-week fetus with the defect. The surgeons made a small incision in the womb of his mother, Beth Schultz of Michigan, and lifted aside the fetus's left arm (diagram). They opened the baby's chest and pushed the abdominal organs into their proper place. The surgeons then closed the diaphragm with a patch of GoreTex, water proof material commonly used in parkas. They also made an incision in the abdomen, to enlarge it enough to accommodate the returned organs, and patched it with more Gore-Tex. The operation took 54 minutes. Seven weeks later, Blake was born. He spent three weeks on a respirator, but at eight months, he is home and thriving. A girl who had the same defect was operated on this March; now six weeks old, she is also developing normally.
'The mom': Technical difficulties aside, fetal surgery is plagued by a perceived conflict between maternal and fetal rights. Some physicians and ethicists argue that it is wrong to endanger a woman--through general anesthesia and major surgery--in order to benefit a fetus, especially if the benefits are far from assured. As Harrison says, to save the baby, "We have to put at risk an innocent bystander--the mom." And bioethicists worry that courts may require women to submit to such surgery. Partly for that reason, the UCSF team emphasizes that the mothers understand the risks, consent to them, and are not harmed by the procedure. In the six cases where the fetus with the defective diaphragm died, all four of the mothers who tried to conceive again delivered healthy babies.
Although heroic medicine usually carries a stiff price tag, this operation may not. At $15 721, it costs less than the intensive care given babies born with a herniated diaphragm--most of whom die anyway. Insurance companies, however, view the procedure as "experimental" and will not pay for it. This isn't a cure-all. In some babies, the damage is so great that even if the defect is corrected the newborn doesn't stand a chance at life. In others, the hernia is so mild that, says Adzick, "it should be treated after birth, with the operation reserved for worse cases." Still, while the procedure will never be routine (only the UCSF team knows how to perform it), it may pave the way for other in utero surgery. The UCSF surgeons are already eying the possibility of operating on fetal lung tumors, for instance. Medicine cannot reduce the hurdles to a healthy birth, but it can help at least some fetuses over them.
PHOTO (COLOR): Thriving: Baby Blake with his father
During the first major operation on a fetus still in its mother's uterus, physicians treated a 24-week-old with a defective diaphragm, a condition that is almost always fatal. Seven weeks later, a healthy baby was born.
1. Doctors open up the uterus and life aside the fetus's left arm. The fetus is continuously monitored; amniotic fluid has been drained and preserved.
2. Surgeons cut into the fetus, whose abdominal organs have spilled into the chest. The lungs have little room to grow.
3. Surgeons move the abdominal organs into their proper place, giving the lungs room to develop.
4. They close the diaphragm with a Gore-Tex patch and fill the chest cavity with a saline solution.
5. They enlarge the fetus's abdomen, so its organs fit, with more Gore-Tex. The amniotic fluid is returned.
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