Advances in fetal therapy

Abstract

Key content Fetal medicine is a rapidly developing subspecialty. The mainstay of treatment for fetal alloimmune thrombocytopenia remains maternal immunoglobulin therapy. Stem cell transplantation and gene therapy have advanced over the last decade but must still be considered experimental. Laser coagulation is the best treatment for all stages of twin‐to‐twin transfusion syndrome presenting before 26 weeks of gestation. Fetoscopic endoluminal tracheal occlusion appears to improve prognosis in severe congenital diaphragmatic hernia. Learning objectives To gain an overview of the recent developments in fetal therapy. To understand the benefits and risks of different methods of fetal therapy. To appreciate the importance of high‐quality research in fetal medicine. Ethical issues With the option of fetal therapy, the value and implications of prenatal diagnosis have to be reviewed. The acceptability of fetal therapy to parents and to society should be investigated. The consideration of the mother and fetus as individual people presents an inherent difficulty in implementing randomised controlled trials in fetal medicine. Please cite this article as: Morris RK, Chan BC, Kilby MD. Advances in fetal therapy. The Obstetrician & Gynaecologist 2010;12:94–102.

Authors' reply

“…We thank Dr Bewley for her informative and insightful comments on our statement that ‘the fetus is an individual’ 1 . It has been debated in the past as to whether the popular view that the fetus is a patient or an individual has any ethical meaning 2 .…”

A new ethical framework to determine acceptable risks in fetal therapy trials

“…We argue that considering the societal value of fetal therapy studies is an important element of the assessment, because of the role of societal value (together with potential benefits for participants) in justifying the risks involved in conducting research 32, 33 . Although each study should be assessed separately, fetal therapies can offer significant societal value by aiming to improve health outcomes that cannot to the same degree be achieved postnatally (e.g., because irreversible damage has occurred in utero) 1, 2 . Societal value should be considered along with the risks and benefits to participants, high social value alone is not sufficient to justify a study.…”

“…For conditions that cause irreversible harm in utero, fetal interventions can provide unique treatment opportunities to minimize disease or organ damage prior to birth. [1][2][3] For example, fetal surgery for myelomeningocele results in more favorable long-term outcomes for affected children than postnatal repair. 4 Developing fetal therapies, however, requires testing their safety and efficacy in pregnant persons and their affected fetuses.…”

Careful language and research in pregnancy

“…Morris et al 1 claim ‘the consideration of the mother and fetus as individual people’ (my emphasis) impedes randomised trials in fetal medicine. If true, this would be a barrier to all obstetric research.…”