UCSF Medical Center | Inside Surgery

UCSF was the birthplace of fetal surgery in 1981 and remains the world's most experienced center for in utero intervention. The fetal surgery team at UCSF Children's Hospital, under the direction of its founder, Michael Harrison, M.D., has concentrated on developing ways to minimize the risk of premature labor from the surgery while defining which babies are most likely to benefit from in utero intervention.

UCSF's pioneering work in the field has left an imprint throughout the world; most fetal treatment programs are staffed by specialists trained at UCSF. A recently launched interactive Web site — fetus.ucsfmedicalcenter.org — provides detailed information on fetal anomalies and options for correcting them before and after birth.

Congenital diaphragmatic hernia (CDH) was among the first birth anomalies to be corrected by UCSF fetal surgeons. In severe cases, the presence of the abdominal viscera in the pleural cavity can severely impair lung development. Temporarily occluding the fetal trachea stimulates lung development by blocking the exit of fluid that is normally produced in the fetal lung. The trapped fluid forces the lungs to expand, which in turn displaces the abdominal contents out of the chest.

In 2004, UCSF surgeons published in the New England Journal of Medicine the results of the first randomized trial of fetal endoscopic tracheal occlusion v. standard postnatal care. In this trial, where all treatment was provided in UCSF Children's Hospital's specialized CDH/Neonate Center, survival in both the prenatal and postnatal treatment groups was a record high 73 percent, compared to 37 percent in historic controls. Because these excellent survival rates showed no significant differences between the treatment arms, the trial was closed early.

UCSF has applied for a new National Institutes of Health (NIH) grant to assess whether a new occlusion procedure will show a clear advantage over high-level postnatal care for the most severely affected fetuses. Fetal surgery will be offered only in the most severe cases, based on the fetal lung/head ratio. The newly developed procedure eliminates the need for a maternal laparotomy when placing the tracheal balloon. The balloon will be removed prior to birth, allowing for a vaginal rather than Caesarean delivery, so women are spared extra trauma while still helping their fetuses.

Children who undergo surgery for congenital diaphragmatic hernia at UCSF Children's Hospital are regularly evaluated at a monthly specialized follow-up clinic, one of a few in the nation. Pediatric surgeon Kerilyn Nobuhara, M.D., oversees the multidisciplinary clinic staff of surgeons, neonatologists, developmental pediatricians, audiologists, and nutritionists, who are expert in treating the associated conditions that often affect these children.

Complications in the in utero development of twins occasionally threaten the life of one or both fetuses. Minimally invasive techniques are available at UCSF to treat these conditions. When one twin is fatally flawed and poses a health threat to the other, fetal surgeons use percutaneous radiofrequency ablation to stop blood flow through the umbilical cord to the anomalous twin. This minimally invasive procedure, which was developed at UCSF Children's Hospital, eliminates the risks to the mother and surviving fetus that are associated with open surgery.

UCSF also is part of a three-center, NIH-sponsored randomized controlled trial comparing two methods of treatment for twin-twin transfusion syndrome (TTTS). In this condition, which is a complication of shared-placenta twin pregnancies, abnormal vascular connections in the placenta cause one twin to transfuse the other. This in turn leads to a series of potentially fatal developmental problems in each baby. The clinical trial, nearing completion, compares laser ablation of the abnormal placental connections versus the more common treatment of reducing the volume of amniotic fluid.

UCSF Children's Hospital also is a regional referral center for treating conjoined twins, a condition that is typically diagnosed through the fetal treatment program. UCSF has a long history of separating conjoined twins in operations performed after birth. Thanks in part to expert computer modeling of the shared structures, UCSF recently completed the first successful separation of twins who had a cardiac defect and connection as well as shared liver, biliary tree and small intestine.

Following its pioneering laboratory work in the development of a fetal surgical procedure to correct this spinal deformity, UCSF Children's Hospital is spear-heading a three-year, NIH-funded clinical trial to establish the safety and efficacy of in utero correction of myelomeningocele. Also participating in the trial are Children's Hospital of Philadelphia, Vanderbilt University Medical Center and the Biostatistics Center at George Washington University. Participants are randomized to receive prenatal repair of this spinal defect before 25-weeks gestation or standard postnatal repair.

For more information about the UCSF Fetal Treatment Center, please call (800) RXFETUS or (800) 793-3887, email fetus@surgery.ucsf.edu or visit fetus.ucsfmedicalcenter.org.