Fetal Surgery

Fetal surgery refers to any surgical procedure performed on a developing fetus while it is still in the womb. It is also called prenatal surgery or in-utero surgery and is performed to treat life-threatening health problems or birth defects, such as spina bifida.

The goal of fetal surgery is to treat medical problems as early as possible to improve your child’s long-term health after birth.

It is performed to treat conditions such as:

• Amniotic band syndrome.
• Congenital airway obstructions.
• Congenital diaphragmatic hernia.
• Congenital lung disorders.
• Congenital tumors in the neck, mediastinum (chest cavity), pericardium (membrane surrounding the heart), or sacrococcyx (tailbone area).
• Lower urinary tract obstruction.
• Monochorionic twin complications.
• Myelomeningocele (spina bifida).

Because fetal surgery is a relatively new medical treatment performed only in limited cases, it isn’t very common. In fact, UPMC is one of the few centers in the U.S. that performs fetal surgery.

These procedures are done during pregnancy under general anesthesia and include:

• EXIT procedures — Performed through an incision in your uterus during a partial delivery of the fetus while the umbilical cord is still attached. After the procedure is complete, surgeons ensure your fetus’s condition is stable before fully delivering the baby, cutting the umbilical cord, and closing your incisions.
• Minimally invasive fetoscopic surgery — Performed through a small incision in your abdomen and uterus using a fetoscope, a flexible tube with a light and camera on the end. The camera transmits images of the surgical area to a screen, allowing the surgeon to see the surgical area and perform the procedure using special instruments inserted through the tube.
• Open surgery — Performed through an incision in your abdomen and uterus. The fetus remains inside your uterus during the procedure. After the procedure is complete, your uterus and abdomen are closed so your pregnancy can proceed.

What Is fetal surgery for spina bifida?

Spina bifida is a birth defect that occurs when the spinal column doesn’t close completely during development, leaving part of the spinal cord exposed. This exposure can cause damage, including inability to move the legs and loss of bladder or bowel control.

Spina bifida often gets worse as the fetus grows and develops. In some cases, fetal surgery can be performed between weeks 19 and 26 of pregnancy to repair the defect. Although the procedure comes with risks, repairing their condition early during fetal surgery may improve your child’s long-term quality of life.

Benefits of fetal surgery for spina bifida may include:

• Improved bladder and bowel control.
• Improved mobility in your child’s legs.
• Reduced need for mobility assistance devices, such as a wheelchair.
• Reduced risk of complications after birth.

Fetal surgery is an inpatient procedure. After you have been admitted to the hospital, you will be taken to a holding area where you will meet the anesthesiologist and your surgeon.

A maternal-fetal or pediatric anesthesiologist — a doctor who has experience and training in anesthesia for fetal surgery — will give you medications that make you sleep during the surgery and prevent you and your fetus from feeling any pain. At this time, you will be able to ask any questions about the procedure.

After your questions are answered, you will be taken into the operating room and given anesthesia to put you to sleep.

When you are asleep, the surgery will begin.

• Your surgeon will make an incision in your abdomen to reach your uterus.
• Your surgeon will make one or more incisions to reach the fetus inside your uterus.
• Your surgeon will perform the procedure on the fetus inside your uterus. Fetal surgery to treat spina bifida involves repairing areas where the spinal cord is exposed using sutures (stitches) or tissue grafts.
• If you are having an EXIT procedure, your surgeon will partially deliver the fetus to perform the procedure. Afterward, the baby will be fully delivered and the surgeon will cut the umbilical cord.
• Your surgeon will close the incision in your uterus using dissolvable sutures. Unless you have an EXIT procedure, the fetus will remain inside the womb and your pregnancy will continue.
• Your surgeon will close the incision in your abdomen using dissolvable sutures or skin glue.
• Your surgeon will place a bandage over your incision and make sure your condition and your fetus's condition are stable.

Fetal surgery may take several hours, depending on the type of procedure performed.

Your care team will take every precaution to make sure you and your baby are safe.

Risks of fetal surgery for you include:

• Blood loss.
• Scarring of your uterus, which increases risks during future pregnancies.
• Side effects from anesthesia.

Risks of fetal surgery for your fetus include:

• Infection of the amniotic fluid.
• Placental abruption, which causes the placenta to separate from the wall of your uterus.
• Preterm labor.
• Separation of the two membranes around the fetus, called chorioamniotic membrane separation (CMS).

When general anesthesia is needed, there are important rules for eating and drinking that must be followed in the hours before the surgery. One business day before your surgery, you will receive a phone call from a nurse between the hours of 1 and 9 p.m. (Nurses do not make these calls on weekends or holidays.) Please have paper and a pen ready to write down these important instructions. The nurse will give you specific eating and drinking instructions.

Typical instructions include:

• After midnight the night before the surgery, do not consume any solid food or non-clear liquids. That includes milk, juices with pulp, coffee, and chewing gum or candy.
• Up to two hours before your scheduled arrival time, consume only clear liquids. Clear liquids include water, Pedialyte®, Kool-Aid®, and juices you can see through, such as apple or white grape juice. Milk is not a clear liquid.
• In the two hours before your scheduled arrival time, do not eat or drink anything.
• The nurse will review the list of medications you are taking and give you instructions for how to take your medications on the day of surgery, if needed. Your care team will let you know if you need to stop taking any medications in the days or weeks before your procedure.
• On the day of the procedure, be sure to bring your photo ID and health insurance card(s). Leave valuables such as cash and jewelry at home.
• Fetal surgery is an inpatient procedure, so you will need to stay overnight in the hospital to recover. Your doctor will let you know how long you can expect to stay in the hospital. You should bring toiletries, a robe, slippers, a cell phone and charger, medications, and a change of clothes.
• If you are having an EXIT procedure, you should plan to bring supplies for your newborn, including an infant car seat.
• You will need to arrange for someone to drive you home after you are discharged. If you had an EXIT procedure, your baby will need to go home in a rear-facing infant car seat.

After you have been registered for the surgery, a member of the anesthesia staff will meet with you to take your vital signs, weight, and medical history. You will be asked to sign a consent form before the anesthesia is given.

You will be taken to the operating room, where you will receive your anesthesia medications through an intravenous (IV) line. The medications will put you to sleep, so neither you nor your fetus will feel any discomfort during the procedure.

While you are asleep, both your and your fetus’s heart rate, blood pressure, temperature, and blood oxygen levels will be checked continuously. You might have a breathing tube placed while you are asleep. If a breathing tube is used, you may have a sore throat after the surgery.

To keep you asleep during the surgery, you might be given anesthetic medication by mask, through the IV, or both. When the surgery is over, the medications are stopped and you will begin to wake up.

After your procedure is complete, you will be monitored in the recovery area before being transferred to your hospital room. Your care team will continue to monitor you and your fetus during your hospital stay.

The most important role of a support person is to help you stay calm and relaxed before the surgery. Your support person could be your partner, another family member, or a friend. The best way to help you stay calm is for your support person to stay calm.

During the surgery, your support person should remain in the surgical family waiting area at all times in case the family needs to be reached.

Your doctor will give you instructions on how to care for yourself and your baby after you are discharged from the hospital.

You will need to keep your incision clean and dry after your procedure. Your doctor will let you know how often to change your bandages. You may also need to restrict your activity or have a planned C-section delivery, even if you are able to carry your baby to full term.

Your doctor will also give you instructions on how to manage pain and watch for signs of problems. You should be sure to attend all scheduled follow-up visits to make sure you and your fetus are healing as expected.

You should call your surgeon if you have:

• A fever of more than 100.0° F.
• Decreased fetal activity that lasts longer than a few hours.
• Difficulty breathing.
• Difficulty with walking or keeping your balance.
• New or increasing shortness of breath.
• Pain, redness, bleeding, drainage, or increased swelling at your incision site.
• Signs of pre-term labor.
• Severe pain that does not respond to medication.

If you have any specific questions about the surgery, you should discuss them with the surgeon before the surgery. You may call the Fetal Surgery team at UPMC Children’s and ask to speak with your surgeon or speak with them during the presurgical examination on the day of the surgery.

If you have any special needs or health issues you feel the doctor needs to know about, please call the Fetal Surgery team at UPMC Children’s before the surgery and ask to speak with a nurse. It is important to notify us in advance about any special needs you might have.