The womb is a metaphor for safety and security, an enveloping space that protects something in an extraordinarily vulnerable state.

But in pregnancy the nurturing vessel can also serve as a barrier of sorts when things go wrong, locking out physicians from treating potentially crippling or life- threatening fetal anomalies.

That’s become less and less the case in recent years, thanks to new techniques in fetal surgery and maternal-fetal medicine that allow for intervention in utero or in real time during the birthing process.

Families in the Sacramento region and beyond will now be able to benefit from those advancements close to home. As part of growth in its pediatric specialties, UC Davis Health System is building the first comprehensive multidisciplinary fetal diagnosis and therapy center in inland Northern California.

The UC Davis Fetal Care and Treatment Center is currently the region’s only to offer on-site fetal surgery as an option to help save infants at their earliest stages and give them the best opportunity for high quality of life. The service, provided at only a handful of hospitals around the nation, is made possible by the arrival of three of the country’s top authorities and technicians on fetal surgical intervention:

  • Diana Farmer, an internationally renowned fetal and neonatal surgeon, the first woman in the world to perform open fetal surgery, and a principal investigator on the landmark clinical trial of fetal surgery for spina bifida. Farmer is surgeon-in-chief of UC Davis Children’s Hospital and chairs the Department of Surgery at UC Davis;
  • Shinjiro Hirose, nationally recognized for his expertise as former lead pediatric and fetal surgeon at UC San Francisco; and
  • David Schrimmer, a perinatologist/obstetrician and renowned expert on twins and multiple fetuses, who successfully delivered the first set of healthy, surviving sextuplets in California.

Their combined leadership in fetal diagnostics and intervention rounds out the roster of the new UC Davis center, which will also offer nonsurgical therapy and tap the university’s nationally ranked expertise in related specialties such as neonatology, gynecology and pediatric orthopaedics, urology, neurology/neurosurgery and endocrinology.

“We are establishing a world-class center to serve the needs of the children in the Sacramento region, the Central Valley and beyond,” said Hirose, the center’s chief. “We want to give young families in these fast-growing areas the highest level of care close to home, without the additional stress and expense of distant travel in circumstances that are already challenging.”

New hope for expecting parents

Many families among us face those challenging circumstances at some point in time. As many as 10 to 15 percent of confirmed pregnancies nationwide are lost at various points, and for every 1,000 babies born, six will die in their first year, with birth defects, preterm birth and maternal complications of pregnancy among leading causes.

The U.S. birth rate for twins – often a source of obstetric complications – grew 76 percent between 1980 and 2009 to a level around 3 percent, due at least in part to increased use of fertility drugs and treatments.

Fetal surgery can offer hope of correcting or minimizing a variety of life-threatening or potentially disabling conditions affecting the fetus, helping to both facilitate delivery of a healthy child and protect the health of the mother.

For certain conditions it now represents the standard of care – for example in myelomeningocele, the most serious form of spina bifida that can limit a child’s future mobility, learning ability and bowel/bladder function. Surgery is also standard for twin-to-twin transfusion syndrome, a condition in which blood flow between twins becomes abnormal. Benefits for both conditions have been proven in randomized clinical trials.

For other conditions, prenatal surgery represents a new and powerful option for physicians and parents to consider as they seek to balance potential impacts to the mother’s health against those of the new child.

Completing a team

Completion of the UC Davis fetal care team began with the arrival of Farmer, a member of the Institute of Medicine of the National Academies – one of the highest honors in medicine – and a fellow of the prestigious Royal College of Surgeons of England. In the late 1990s Farmer was the first woman in the world to perform open fetal surgery.

Farmer is known for skilled surgical treatment of congenital anomalies and cancer, airway and intestinal surgeries in newborns, as well as for a body of research that includes more than 200 peer-reviewed articles and a landmark study to evaluate the safety and efficacy of fetal spina bifida surgery. She is currently researching a novel stem cell therapy for repairing damaged neural tissue in patients with the condition (see below).

Farmer joined UC Davis from UC San Francisco – site of the world’s first open fetal surgery – where she served as chief of pediatric surgery and surgeon-in-chief of the UCSF Benioff Children’s Hospital. She recruited Hirose last year to serve as chief of the newly established UC Davis Division of Pediatric General, Thoracic and Fetal Surgery, with a joint appointment as director of pediatric surgery at Shriners Hospitals for Children – Northern California.

In addition to his background in fetal surgery, Hirose is a nationally recognized children’s cancer surgeon and an expert in the development and use of minimally invasive surgery in children.

Schrimmer also joined UC Davis last year from UC San Diego, where he founded the fetal therapy and multiples program. He serves as chief of the new UC Davis Division of Maternal-Fetal Medicine in the Department of Obstetrics and Gynecology, offering fetal intervention for complications of multiple pregnancies as well as highly regarded nonsurgical care of mothers carrying fetuses with complex anomalies such as congenital diaphragmatic hernia.

Hirose and Schrimmer are among the creators and founding members of the University of California Fetal Therapy Consortium, a collaboration of the five fetal treatment programs at UC campuses in Davis, Irvine, Los Angeles, San Diego and San Francisco.

Breadth and depth

The three physicians have performed hundreds of surgeries and interventions between them and offer or are planning a wide range of on-site interventional capabilities and methods unique to inland Northern California, such as:

  • Open fetal surgery, which involves treating the fetus directly within the uterus via a Caesarian-like abdominal incision. The method is used for conditions such as spina bifida and for specific tumors before birth.
  • Less-invasive procedures such as fetoscopic or fetal image-guided surgery, which can avoid the large incision by using an endoscope and or sonogram to view the fetus during surgery and then a small incision to insert and manipulate instruments. For example, the team can employ an endoscope with a laser to treat twin-to-twin transfusion syndrome.
  • Ex utero intrapartum treatment procedure or EXIT, a surgical intervention at the time of birth that is most often used to relieve respiratory conditions such as airway compression or abnormal lung masses. The fetus is partially removed from the mother and undergoes surgery while still attached to the umbilical cord, which is then cut for completion of delivery.

“In many cases with these procedures you’re not just saving a life, but you’re ‘saving a lifetime,’” Farmer said. “Often these infants would face ongoing health challenges and limitations throughout their entire lives that many of us might only experience in advanced age.”

Support across the spectrum

Fetal surgery at UC Davis is also made possible by the existing level of skill, sophistication and technology at UC Davis Children’s Hospital, which ranges from highly trained neonatal nurses to nationally ranked pediatric subspecialists.

The fetal treatment center will involve high-touch coordination of care with these specialties and collaborations with surgeon-scientists such as Eric Kurzrock, chief of a pediatric urology program repeatedly ranked among the nation’s best. Together with partner Shriners Hospitals for Children – Northern California, UC Davis Children’s Hospital again rated among the U.S. top 50 in pediatric urology in U.S. News & World Report’s latest 2015–16 Best Hospitals analysis, as well as in pediatric orthopaedics.

UC Davis also achieved top-50 U.S. News rankings in neonatology; pediatric diabetes and endocrinology; pediatric neurology and neurosurgery; and gynecology. The rankings generally recognize hospitals that excel in treating patients with the most serious and challenging injuries and illnesses.

“The amalgamation of specialists across multiple disciplines and departments will allow us to optimize care for mothers and their unborn children – and that will continue after delivery with the care of these most vulnerable and needy patients,” Hirose said.

Fetal surgery research

Diana Farmer helped to pioneer in utero surgical treatment for spina bifida, and to prove that it can improve brain development otherwise threatened by the disabling congenital condition.

Now she and other UC Davis researchers hope that combining that in utero surgery with stem cell therapy may further improve motor function in spina bifida patients and allow them to walk independently.

Their study, supported by a $2 million grant from California’s stem cell agency, is one of several research efforts being tackled or planned by members of the new UC Davis Fetal Care and Treatment Center.

After investigating different stem cell types and the best way to deliver them in utero for the past six years, Farmer’s research team recently discovered a stem cell-based placental therapy that cures the paralysis of spina bifida in animal models.

A grant from the California Institute for Regenerative Medicine will allow Farmer and chief collaborator Aijun Wang, co-director of the UC Davis Surgical Bioengineering Laboratory, to optimize the stem cell product, validate effectiveness, determine optimal dosing and confirm preliminary safety in preparation for human clinical trials.

Other research topics in the fetal treatment center are expected to include:

  • Amniotic band syndrome
  • Gastrochisis
  • Sacrococcygeal teratoma
  • Congenital diaphragmatic hernia