Academic journal article Issues in Law & Medicine

The Perinatal Revolution

Academic journal article Issues in Law & Medicine

The Perinatal Revolution

Article excerpt

Introduction

Perhaps the final frontier of medicine is fetal diagnosis and therapy. With advancements in medical diagnosis and therapy we are now able to treat the "patient within the patient" - the fetus in utero. Clinicians, researchers and the public have become much more aware of the lasting impact of fetal life upon the rest of a persons life. As Choolani and Biswas have noted, with the unraveling of developmental origins of health and disease, we can begin to "recognize pivotal trends in the way we address fetal health and disease. No longer do we accept the limited choices of prenatal diagnosis - to continue the pregnancy, or not."1 Instead, medical pioneers are actively developing means and methods to treat the fetus in utero. These authors refer to this as the Third Alternative - the Perinatal Revolution the goal of which is to treat and possibly cure disease in the prenatal period, and thereby to improve human health across the lifespan.

History

The history of fetal surgery offers a fascinating glimpse into the beginnings of the perinatal revolution. Hippocrates (c. 460 BC - 370 BC) is stated to have first identified the fetal condition hydrops fetalis (where the fetus experiences heart failure in utero) around 400 BC. Vesalius (1514-1564) made observations of the fetus, as did Hieronymus Fabricius in his De formato foetu (On the formation of the fetus). However, studies of the fetus in animal models (guinea pig, rat, and cat) were not recorded until the 19th century. Starting in the 1930s, the development of fetal lamb, and later, primate models, allowed simulation of human fetal birth defects and studies of interventions to treat them. The development in the 20th century of advanced imaging techniques, especially ultrasound, enabled physicians to diagnose and follow the natural history of fetal structural abnormalities.

Treatment of the fetus in utero has been possible for obstetricians since the 1960s. Earlier, in 1932, Diamond et al. had described fetal anemia due to Rh sensitization of the fetus and newborn, and in the 1940s, Levine et al. linked fetal anemia to the presence of Rh antibodies.2,3 Subsequently the technique of exchange transfusion for treatment of Rh disease in the neonatal period was introduced, but fetal mortality remained at 30%. At this time, a new branch of medicine, perinatal medicine, became a reality through the contributions of obstetricians such as Professor Ian Donald in Glasgow and Dr. A. W. Liley in New Zealand. Bevis in England, Liley in New Zealand, and Freda in the U.S. analyzed amniotic fluid bilirubin to try to predict fetal death. Their research on the use of ultrasound and amniocentesis in Rh sensitization enabled doctors to treat the fetus as a patient.4 Other contributors to the development of perinatal medicine include Professor G.C. Liggins, who in the 1970s pioneered the administration of corticosteroids to mothers at risk for preterm delivery to prevent or decrease neonatal respiratory distress syndrome.

Fetal therapy would not have been possible without the development of diagnostic technology that could safely visualize the living fetus in utero from early to late stages of gestation. The ability to treat depends on the ability to diagnose, and the development and refinement of radiologic technology and techniques, in particular ultrasound and magnetic resonance imaging (MRI), have improved our ability to diagnose neonatal conditions presenting in utero. With the ability to see the fetus in real time came the ability to diagnose problems and to consider how best to help the affected fetus, to follow affected fetuses, and to monitor treated fetuses, over the course of pregnancy. This shifted the focus from the newborn, with a severe disorder that could not be corrected after birth, to the possibility of prenatal medical or surgical intervention that could help ameliorate the clinical manifestations of disease. Along with the availability of animal models described above, these diagnostic capabilities led to further research and clinical trials, and the realization that the fetus was, and is, a patient. …

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