In a world where uncertainty is almost certain, the womb is a sanctuary for the unborn. Yet, within this little haven, havoc happens sometimes.

The last thing that an expectant mother would want to hear is that there is something not quite right with the foetus. That itself is heart-wrenching, and while advances in science extend hope inward, within the womb, the journey is still fraught with uncertainty and trauma.

At 21 weeks in the womb, Samuel Alexander Armas was diagnosed with spina bifida and doctors said survival chances were low. Desperate but determined, his mother, Julie Armas consulted Dr Bruner from Vanderbilt University Medical Centre and little Samuel had his first dramatic surgery that startled the world.

As soon as Dr Joseph Bruner completed the operation, he felt the fragile tiny hand reaching through the incision to grasp his hand, and that was an emotional moment. He said his hand was frozen – with hope – almost instantly, that became framed as the “hand of hope” by photographers.

Overjoyed with tears, Samuel’s mother said, “The photo reminds us a pregnancy isn’t about disability or an illness, it’s about a little person.”

Pre-birth surgery saves complicated pregnancies, though high risks involved

Prenatal surgery is usually performed under circumstances in which the foetus is deemed to have poor chances of survival after birth.

In the US, there are only about 600 patients for pre-natal surgery each year as most of these operations are experimental and have high risk. Pre-birth surgery is typically done between 19 and 26 weeks.

Dr Erika Werner, of Johns Hopkins University, Gynaecology and Obstetrics, led the study evaluating the costs and effects on the health care system if doctors operated on babies while they were in the womb or after birth.

Their mathematical calculations predict that USD3,135,557 is saved for every 100 babies that received surgery before birth. The procedure, though promising, comes with risks for the mother, such as early birth, placental abruption, where the placenta detaches from the uterus, and complications in future pregnancies.

Doctors from Baylor College of Medicine and the Texas Children’s Hospital in Houston are now fine-tuning an experimental method of foetal operation to reverse the damage caused by this condition by operating on the foetus while still inside the uterus, but the uterus is outside the body.

Pre-natal intervention to treat cancer in the unborn

Baby born twice: It was a shock, for Margaret Boemer, at 16 weeks to learn of her daughter, LynLee’s rare birth defect. Photo credit: Paul Vincent Kuntz/CNN
Baby born twice: It was a shock, for Margaret Boemer, at 16 weeks to learn of her daughter, LynLee’s rare birth defect. Photo credit: Paul Vincent Kuntz/CNN

Prenatal surgery has been performed to remove tumours of the foetus while in the uterus. The incidence of zacrococcygeal teratoma (SCT), the most common tumour in newborns, especially girls, is one out of every 35,000 to 40,000 births.

These tumours at the base of the tailbone have the potential to grow very large. With early diagnosis, most SCT babies are delivered normally and the tumour is removed after birth. However, a small percentage of these tumours are large, hard, and full of blood vessels and may stress the foetal heart. The pre-birth surgical procedure destroys the blood vessels leading to the tumour, thereby preventing its growth.

"This is the most common tumour we see in a newborn," said Dr Darrell Cass, co-director of Texas Children's Foetal Centre and associate professor of surgery, paediatrics and obstetrics and gynaecology at Baylor College Medicine.

In the case of Boemer, the shock came at 16 weeks of the pregnancy. Obstructed by a large tumour feeding off the blood supply, the foetus became more ill each day.

Boemer was given the option of foetal surgery, though Dr Cass had warned her of the grim survival chances.

"LynLee didn't have much of a chance. At 23 weeks, the tumour was shutting her heart down and causing her to go into cardiac failure, so it was a choice of allowing the tumour to take over her body or giving her a chance at life,” explained Boemer.

The 5-hour surgery was performed by Cass and his partner surgeon Dr Oluyinka Olutoye at 23 weeks and five days of Boemer’s pregnancy. By then, the tumour had outgrown the foetus.

"The part on the foetus we do very, very quickly," said Cass. "It's only 20 minutes or so on the actual foetus." Most of the time is spent opening the uterus, which he described as "a big muscle lined with membranes."

Despite the trauma, the little fighter Lynlee Hope was born, weighing 2.4 kg.

“Foetal surgery is one of the few operations with a 200 percent risk of mortality,” said assisting surgeon, Dr Oluyinka Olutoye. "It was very difficult," Boemer said, and looking at the toddler’s smile, “It was worth every pain,” she added. MIMS

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