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IN UTERO SURGERY

Doctors are currently experimenting with two surgical operations that can be performed on babies while they are still in the womb. The more common and straightforward is a blood transfusion for a foetus still in the womb. This could be valuable where there are Rh antibodies in a mother's blood and the foetus is severely anaemic. But only very few foetal blood transfusions have so far been performed. Charles Rodeck, an obstetrician at King's College Hospital, claims: 'We are getting around sixty to seventy per cent survival rates so far, but we are getting better all the time.' There is an optimum chance of success if the transfusion takes place as early as possible in the hope of preventing further complications. This has normally meant about twenty to twenty-two weeks, though, says Rodeck: T am very keen to start even sooner. You could even begin at eighteen weeks.' Past operations suggest that the baby still has to be delivered at about thirty-two weeks, which is early, and that it may well require a further complete transfusion soon after delivery.

The procedure still has many unknowns. If transfusing starts at eighteen to twenty weeks, another four or five transfusions may have to be performed before the baby is born. Does that increase or decrease the risks? Does it lead to further interventions and complications? How much blood should a twenty-week-old foetus be given? How often? What is the ideal delivery date? What is the best method of doing it? At present there are no certain answers. The other experimental form of foetal surgery is intended to help babies with severely blocked urinary tracts which can cause a build-up of urine in the bladder. This, in turn, can irreparably damage the kidney well before birth. Blocked urinary tracts can sometimes be detected under very close ultrasound inspection but are more likely to be noticed because of general signs such as that the foetus is too small for dates. The operation entails inserting a catheter - a very fine tube - into the foetus through the mother's abdomen to bypasss the blockage and allow the bladder to empty into the amniotic fluid at it normally would. After the baby is born more permanent surgery can be performed to clear the blockage. Several babies with catheters have been successfully delivered.

In utero surgery raises difficult ethical, possibly even legal, issues. Who is the patient - the women or the foetus? To begin with, it is not an entirely new question. For years doctors alone have had the right to balance the relative safety of the mother and baby in deciding whether a pregnancy should continue or be terminated. Legally speaking, a foetus of twenty to twenty-two weeks is not considered a viable human being. If, however, an operation could save its life, viability could become a very flexible concept, and decisions about abortion could become even more fraught than they already are. How could the viability be weighed against the possible hazards to the mother, and against her rights? The development of medical techniques such as in utero surgery impinges directly on a woman's rights over the control of her own body. Her own needs are intermingled with those of the foetus, her partner and her role as mother.

The obstetrician and the in utero surgeon have strong interests in the development, deployment and success of the new techniques which promise to increase their roles in ante-natal care. This increases the likelihood of even more intensive research, more tests and screening techniques and more penetration of technology into pregnancy with a by no means certain improvement in the statistics of successful pregnancies. As with other developments in the medicalisation of ante-natal care, our appreciation of the possible potential of in utero surgery must therefore be balanced by deep concern over its likely role in taking even more aspects of pregnancy out of our hands.

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Women's Health




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In utero surgery

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