Dr Mohan Abraham is a noted pediatric surgeon at Amrita Institute of Medical Sciences in Kochi. He feels that advancements in fetal surgeries can help save many lives. In an interview with Gunjan Sharma, he talks about his recent cases and how fetal surgeries can save children from lifelong deformities and illness.

What are fetal surgeries?

The surgeries we perform on a fetus are fetal surgeries. There are times when the growing fetus may have some life-threatening health condition which, if corrected while it is still in the mother's womb, can save its life.

We can do open surgeries in which we take the fetus out of the womb, do the surgery and put it back in the womb. And we also perform many keyhole or laparoscopic surgeries.
 
What are the conditions where you need to do fetal surgeries?

Recently, we performed a surgery to create a hole in the urine passage so that the fetus can pass urine. It was a 22- week- old fetus, whose amniotic fluid was drying up. This fluid mainly consists of baby's urine. Reduction in the quantity of the fluid means that the fetus is not passing urine. This condition can cause kidney failure. We found that there was an obstruction in the urethra. We used a telescope and laser ablation to remove the obstruction.

We also performed a life-saving surgery in a case of twin pregnancy. One of the fetuses didn't have a heart and was using the other fetus’s heart to get blood. In such a case, the heart of one fetus is processing blood to both. There were high chances of heart failure of the baby.  So, in order to save the life of one baby, we needed to stop the blood flow to the baby without the heart.

Similarly, in another twin pregnancy, the blood vessels were interconnected. So most of the blood from the placenta flows to one baby and other baby does not get enough blood. Here one baby dies of heart failure due to too much blood and other baby dies of lack of blood flow. So with fetoscope and laser, we stop the blood flow between the two babies so that each baby gets its share of blood.

Then there are some tumours in the back of a growing fetus which can compress its heart or lungs. We can remove these tumours before they cause any risk to the life of the fetus.

Healing takes 24-48 hours. The small puncture in the amniotic sac heals on its own and the amniotic fluid takes 24-48 hours to become normal. In open surgeries, we replace the amniotic fluid with Ringer lactate solution before closing the uterus 

How safe are these surgeries?

It is a relatively new field. Only a few centers across the world are doing these surgeries. In 80 percent of the cases, the baby survives and grows inside the womb. There is a risk of premature delivery in most of the cases.

But then we choose to do these surgeries only in life-threatening conditions. So, if we are able to save a baby, it is worth it.
 
What is the kind of response you are getting from your patients?

More and more patients are opening up to fetal keyhole surgeries. There are a few conditions such as Myelo Meningocoele, in which the spinal cord is not fully formed. The child may suffer from paralysis of the lower limbs, accumulation of fluid in the brain, loss of control on urinary bladder after birth.

In open surgeries, we can take out the fetus, perform the surgery and put it back to grow in utero condition. But this involves risk to the mother and subsequent pregnancies will need caesarian section for delivery since open fetal surgery will result in small scar in the uterus which can rupture if planned caesarian is not done. So the risk to the mother and the risk of premature delivery should be weighed against the benefit to the baby before taking a decision to operate.
 
In the US, however, a few doctors have started correcting Myelo Meningocoele deformity using keyhole surgery. A large study in the US called Management of Myelomeningocele (MOM) study shows that surgery can reduce the risk of hydrocephalus (accumulation of water in the head) by 50 percent and increases the chances of a child walking without any support by 50 percent.
 
Are there special types of equipment for these surgeries?

We perform these surgeries in our pediatric operation theatre. The fetoscope is a very fine instrument with a diameter as small as 2mm. The telescope we pass through the foetoscope is even finer. 

What is the recovery time?

It takes 24-48 hours. The small puncture in the amniotic sac heals on its own and the amniotic fluid takes 24-48 hours to become normal. In open surgeries, we replace the amniotic fluid with Ringer lactate solution before closing the uterus.