Fetal Surgery: Huge Strides in Care for the Tiniest Patients

The Fetal Care Center is one of the few centers in the world where specialists can operate on the fetus in utero, before birth.

Dr. Josh Copel with a patient.

Yale Medicine's Joshua Copel, MD, performs an ultrasound on a pregnant patient.

Credit: Robert A. Lisak

4 fast facts about fetal surgery
  • Fetal surgery has been used to remove tumors, repair holes in the diaphragm and lungs and correct obstructed bladders.
  • For fetuses with spina bifida—a birth defect of the spine affecting 1 out of 1000 babies—surgery before birth has been shown to have superior outcomes to surgery shortly after birth.
  • The average size of organs operated on in fetal surgery is 1/2 inch.
  • Fetal surgery is an option in less than one tenth of one percent of pregnancies.

It’s the news no expecting parent wants to hear: Their developing baby may have a serious birth defect. Just one generation ago, parents faced with this reality would have stark choices—choose to terminate the pregnancy or treat the abnormality after birth, knowing that in many cases their child’s condition would grow worse as he or she grew up.

Then, in the early 1980s, medical science—led in part by physicians at Yale—offered families a third alternative: operate on the fetus in utero, before birth. Of course, operating on a fetus without harming either the developing child or the mother remains one of medicine’s greatest challenges. Yale offers one of the few centers in the world where such procedures are done.

“We are known for being one of the first places in the country to offer fetal ultrasound and means of fetal diagnosis and treatment,” says Joshua Copel, MD, professor of obstetrics, gynecology and reproductive sciences and of pediatrics at Yale School of Medicine and associate chief medical officer of Yale Medicine. “Every day is exciting, every baby referred to us presents new challenges.”

'Needles, Not Scalpels'

Until the 1990s, fetal surgery was such a risky proposition that it was only done if the defect—most often a lung malformation or a problem with the diaphragm—was likely to cause death if not treated before birth. Even now, with terrific advancements in surgical technology, our doctors stress safety at every turn. “A lot of what we do involves needles, not scalpels,” says Dr. Copel.

Fetal surgery at the Fetal Care Center—a joint effort between Yale Medicine and Yale New Haven Children's Hospital—falls into two categories. “Open surgery” is when doctors open the uterus—as might be done in Caesarean section—and lift the fetus out of the womb so that it can more readily be operated upon. Endoscopic surgery is a procedure in which tiny incisions are made in the mother's abdomen, and doctors operate using specialized instruments that are threaded into these minute openings.

Both open and endoscopic surgeries carry risks for mother and fetus; Yale doctors approach each case individually, determining the specific needs of every family and homing in on their unique wishes.

Ethical Questions

For some families, maternal-fetal surgery, like stem-cell research, touches on sensitive ethical and religious questions. As such, Yale takes great care to spend the time understanding the unique wants and needs of every patient family.

Yale Medicine's Maternal-Fetal Medicine is comprised of a diverse group of specialists who help expectant parents decide what’s right for them. We have maternal-fetal medicine specialists, bioethicists, pediatric surgeons, operating room teams, anesthesiologists and neonatal specialists.

“Once a week, the prenatal diagnosis team meets with the pediatric team to discuss the cases of babies who are due to be born in the next few weeks,” Dr. Copel says. “It includes specialists from obstetrics/gynecology, pediatrics, cardiologists, neonatal intensive care, radiologists and other professionals. Together, we can make a specific treatment plan for each and every baby.

“The most important thing is to just be there for the family, to be genuinely present,” Dr. Copel says. “Being there, listening to parents, trying to help.”