NEW YORK, January 23, 2001 - Three months after an unusual operation to seal a rupture in the fluid-filled sac protecting a pregnant woman's growing fetus, a healthy baby boy was delivered at NYU Medical Center. Bruce Young, M.D., Director of the Division of Maternal and Fetal Medicine and the Fetal Therapy Program, performed the reparative surgery, which has only been attempted by one other physician in the world.
The woman, who lives in New Jersey, had lost almost all of her amniotic fluid during the 17th week of pregnancy following a routine amniocentesis at another institution. During amniocentesis a needle is pushed through the abdomen and into the birth sac to remove a small amount of fluid to detect birth defects.
She was 20 weeks into her pregnancy when Dr. Young placed a tiny telescope through her uterus and used miniaturized instruments and biological glue to seal the rupture in the amniotic sac, which protects a growing fetus. Without the operation, the fetus would not have lived. The fluid in the birth sac is necessary for the lungs to develop.
Dr. Young, the Silverman Professor of Obstetrics and Gynecology at New York University School of Medicine, was among the nation's first doctors to perform intrauterine blood transfusions to the fetus during the late 1960s and subsequently, fetal bladder-shunt surgery.
"This is a remarkable kind of surgery that could potentially have an enormous impact because so many pregnancies are lost due to the premature rupture of the amniotic sac," said Charles Lockwood, M.D., the Stanley H. Kaplan Professor of Obstetrics and Gynecology and Chairman of the Department of Obstetrics and Gynecology at NYU School of Medicine, who became the pregnant woman's obstetrician and was part of the team of doctors who assisted in the operation to repair her amniotic sac.
The premature rupture of the amniotic sac surrounding a fetus is one of the primary causes of preterm delivery and is responsible for about 40% of preterm births. There are many reasons why the sac may tear, and in a small number of cases the tear is due to amniocentesis. According to the Centers for Disease Control and Prevention, the rate of miscarriage with amniocentesis is between one in 400 and one in 200. The procedure also carries an extremely low risk of uterine infection (less than one in 1,000), which can cause miscarriage.
The tiny puncture from an amniocentesis needle typically seals on its own, but it didn't seal in this case. Antibiotics are usually prescribed to prevent infections from developing in the amniotic sac when it is torn prematurely. Such infections threaten the life of the fetus.
Three weeks after the amniocentesis, the leaking hadn't stopped, and the woman and her husband were told by their doctors that the baby had no chance of surviving. By chance, the husband had a friend whose wife recently gave birth to twins with the aid of Dr. Jamie Grifo at NYU's program for In Vitro Fertilization, Reproductive Surgery and Infertility. Dr. Grifo referred the couple to Dr. Lockwood, who in turn sent them to see Dr. Young.
"I knew that I had to operate in order to give the fetus any chance of developing normally," said Dr. Young. "The woman is also diabetic, which further raises the risk of severe infection and subsequent sterility during pregnancy. So, with the leakage, her chances of having a full-term pregnancy were almost zero."
At the beginning of the one-hour operation, the fetal therapy team used ultrasound to guide a needle containing a salt solution into the uterus. The solution was used to outline the amniotic membrane. Then Dr. Young used a needle containing a small endoscope, a tiny hollow tube, with fiber optics and a miniaturized video camera attached to locate the region of the suspected tear. Dr. Ilan Timor, Professor of Obstetrics and Gynecology and Director of the Obstetrical and Gynecological Ultrasound Unit at NYU Medical Center, was also in the operating room to provide assistance.
"We had three TV monitors and two ultrasound screens, and a team of doctors and nurses assisting," says Dr. Young. "I had to locate the site of the rupture by scanning the inside of the uterus, but I was confident that the tear would be near the place the patient recalled as the site of amniocentesis three weeks earlier."
Dr. Young used a product called fibrin glue and mixed it with the pregnant woman's platelets to plug the holes in the membranes. Fibrin is a protein and platelets are a cellular component of blood. Both are necessary for blood clotting.
The day after the operation, the amniotic fluid index, a measure of the amount of fluid in the birth sac, was 8, which is normal, and no fluid was leaking from her vagina, said Dr. Young. Prior to the fetal surgery, the index was 0.8. "We were optimistic then that she had a good chance of continuing the pregnancy and giving birth to a healthy baby."
The woman gave birth at 32 weeks, when she developed severe hypertension and the baby had to be delivered. Fortunately, the pregnancy had proceeded long enough that the baby boy was healthy, even though he weighed only 2 pounds 12 ounces, and could breathe on his own in the neonatal intensive care unit. He spent three weeks in the unit, and he was a small, but normal newborn when his parents took him home.
The boy is now 10 months old.