Guest Editorial

Article Outline

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Because technology advanced, medicine has been able to apply therapies and interventions to smaller and smaller patients. We now stand on the threshold of treating our smallest patients yet, the fetus. With this capability comes great hope. Intervention early in development can prevent many of the irreversible, often deadly, sequela that occurs with congenital abnormalities. To treat congenital diaphragmatic hernia in utero can potentially prevent pulmonary sequela of hypoplasia and hypertension, which often results in death or significant morbidity. In utero decompression of posterior urethral valves can also save both lungs and kidneys, preventing death. At the same time, it also brings great challenges and great responsibility. The technical challenges are easily identified: small patient size, difficult access, and tool limitations. Medical challenges often include a poor understanding of pathophysiology and natural history of the disease process. The risks are doubled with 2 patients for whom risk benefit ratios must be evaluated. The responsibilities more than doubled. Families come into the process often desperate for help, willing to do anything to help their child. They can be easily swayed by “the experts.”

In this edition of the journal, the first 3 articles begin with an update on the current status of fetal therapy. The Warner, Altimier, Crombleholme article provides an overview of the field, reviews specific interventions, and approaches to specific diagnoses. The article by Franklin and Michelfelder focuses more specifically on fetal cardiovascular disease, a growing area of interest and intervention for both treatment and disease prevention. Finally, one of the most common fetal interventions is reviewed, twin to twin transfusion syndrome. Mason and Sidebottom offer insight into the underlying physiology, options for treatment, as well as information on short- and long-term outcomes. The effect on families is given specific consideration.

The next set of articles addresses how diagnoses are made and what can be done to verify certainty. The first question all families ask is, “Are you sure?” Bitters and Kline-Fath discuss the use of imaging techniques available for prenatal evaluation. They are our eyes into the womb. Peach and Hopkins provide an excellent discussion of common genetic testing that helps make and/or confirm the diagnosis. Included in both of these is an important discussion regarding limitations inherent in test results and risk with the procedures.

Besuner and Imhoff give an outline of how a fetal program is run. Emphasis is placed on collaboration and communication. Ensuring that information is in the hands of those caring for mother and baby at delivery is a major challenge. Care of the family (physical, emotional, and spiritual) is intrinsic to any fetal program.

Finally, the nature of this type of program means the patients are at high risk. As a result, not all will survive. Roush, Sullivan, Cooper, and McBride provide an overview of a perinatal hospice program. They examine the administrative components as well as emotional components to such a program.

In the end, we are left with hope, anxiety, and, most importantly, responsibility. We have a responsibility to ourselves to remain up to date on current options, with an understanding of their risks and benefits; a responsibility to families, providing medical care and emotional support; and, finally, a responsibility to our most vulnerable patients, which is to offer them a better outcome by continuing to evaluate new therapies and interventions carefully.