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Recent developments in fetal therapy
Published in Hung N. Winn, Frank A. Chervenak, Roberto Romero, Clinical Maternal-Fetal Medicine Online, 2021
The first invasive fetal intervention began in 1963 with Liley (4). It was a blind intrauterine intraperitoneal blood transfusion. The evolution of fetal surgery has progressed since then with historical surgeries and a countless number of animal experiments. Fetal surgery is now a clinical reality (3) validated by randomized trials for a number of fetal pathologies but remains investigational for many others. The concept of fetal surgery is subjected to skepticism due to lack of clinical evidence, ethical issues, and public perception (5). Clinical trials are ethically challenging and difficult to organize and finance. This, however, should be no excuse to address all pertaining relevant issues appropriately (6).
Fetal surgery
Published in Mark Davenport, James D. Geiger, Nigel J. Hall, Steven S. Rothenberg, Operative Pediatric Surgery, 2020
Emily A. Partridge, Alan W. Flake
Maternal–fetal surgery is a specialty born of clinical necessity; a congenital defect alters normal development and causes irreversible organ damage before birth, leading to prenatal or neonatal death. Observations of fetuses with congenital anomalies and neonates with irreversible end-organ damage led to the compelling rationale that correction in utero might arrest progression of disease or even reverse the pathophysiology and restore normal development. Improvements in fetal imaging and serial clinical observation have allowed better definition of fetal pathophysiology, and better prediction of which fetuses might benefit from prenatal intervention. Because of the potential maternal risk, maternal–fetal surgery has historically been reserved for fetal disorders deemed to have a high probability of causing fetal or neonatal death. However, the success of the Management of Myelomeningocele Study (MOMS) in reducing the neurologic morbidity associated with myelomeningocele (MMC) has expanded the potential application of maternal–fetal surgery to non-lethal conditions.
Treatments and trials for the fetal patient: imposing the burdens of enthusiasm?
Published in Dagmar Schmitz, Angus Clarke, Wybo Dondorp, The Fetus as a Patient, 2018
As is made clear throughout this volume, the relationship between mother and fetus is complex. One can hardly talk of ‘fetal surgery’ when the mother is so inevitably and intimately involved in the surgery too: of course it has to be ‘maternalfetal surgery’ (Lyerly & Mahowald, 2001). The approach of McCullough and Chervenak (2008) is to attempt to evade the debate about the moral status of the embryo by claiming that we can have obligations to be beneficent towards the fetus without any assumption that the fetus has rights. However, this position cannot be sustained if the two sets of interests conflict (Brown, 2008; Lyerly et al., 2008). McCullough and Chervenak in fact ascribe greater weight to the interests of the mother than the fetus and only attend seriously to the interests of the fetus if the mother has already demonstrated her commitment to the fetus/ pregnancy (Rodrigues et al., 2013).
Fetal Mediastinal Fibrosarcoma. Report of Two Cases
Published in Fetal and Pediatric Pathology, 2022
Murat Cagan, Selma Yildirim, Gulenay Gencosmanoglu Turkmen, Ozgur Ozyuncu, Zuhal Akcoren, Ozgur Deren, Safak Gucer
CF tends to be locally aggressive with a low metastatic rate reported as 10%, and has a distinctly more favorable prognosis as compared to the adult fibrosarcoma [3,18]. Approximately 7% of cases occur in the retroperitoneum, which is associated with an increased risk of metastasis and a lower survival rate. Lesions located in the extremities have been reported to be associated with lower recurrence rates [8]. In infantile fibrosarcoma, wide local excision is the recommended treatment, with adjuvant chemotherapy (CT) or radiotherapy infrequently required. Neoadjuvant CT may be life-saving without increasing morbidity especially in non-resectable infantile fibrosarcomas. VA (vincristine and dactinomycin) CT is recommended primarily in neoadjuvant CT by the International Society of Pediatric Oncology due to higher treatment response and the lower toxicity [18]. The average duration of treatment is 3–8 months and aims to shrink the tumor to allow definitive surgery to be performed. In this situation, open fetal surgery or CT for fetal tumor does not seem to be a wise move, as the potential risks outweigh the potential benefits. To our knowledge, there is no case of fetal surgery or fetal neoadjuvant CT for the treatment of fetal fibrosarcoma.
Restrictions on Abortion, Social Justice and the Ethics of Research in Maternal-Fetal Therapy Trials
Published in The American Journal of Bioethics, 2022
Anne D. Lyerly, Alaia Verite, Mary Faith Marshall
That these pressing concerns are not raised in Hendricks et al.’s framework reflects a second problem, extending from the two-patient model, one that has historically challenged the field: a failure to fully attend to the interests and status of pregnant persons as ends in and of themselves. This tendency manifests both as a failure to take seriously reproductive autonomy as a priority and as a failure to routinely collect immediate or long-term outcomes for pregnant persons who participate in trials. In a recent meta-analysis, nearly a quarter of published reports were excluded for failing to report the presence or absence of maternal outcomes in open and fetoscopic procedures (Sacco et al. 2019). Moreover, they note, few studies have assessed the psychosocial impact of such procedures on pregnant persons and families, even as such benefits could redress the ethical concerns about the risk-benefit imbalance for pregnant persons that emerge in the two-patient model. We and others have previously recommended use of the term “maternal-fetal surgery” to emphasize that surgery on the fetus necessarily involves surgery on a pregnant person—a term reflected in the paper’s references but only once in the paper itself.
Multidisciplinary Ethics Review for Liminal Cases in Maternal-Fetal Surgery: A Model
Published in The American Journal of Bioethics, 2022
Kirsten A. Riggan, Abigail Rousseau, Siobhan Pittock, Mauro Schenone, Leal Segura, Lindsay Warner, Megan A. Allyse
As members of the fetal surgery advisory board at a large tertiary care center, we read with great interest Hendriks’ et al. (2022) target article proposing a new ethical framework for fetal therapies. As highlighted in the article, and reflective of our own experience and research (Michie and Allyse 2019), the pregnant patient’s decision to undergo maternal-fetal surgery (MFS) is not only informed by a clinical calculus of immediate medical benefits but also psychosocial benefits for the family, including impact on siblings, financial burden, and increased autonomy for an affected child. We appreciate the efforts of Hendriks et al. to incorporate evidence-based, psychosocial benefits into their proposed framework, and we applaud their suggestion that IRBs take an expansive view of maternal-fetal risks and benefits beyond categorical thresholds.