The making of fetal surgery

Fetal diagnosis prompts the question for fetal therapy in highly selected cases. Some conditions are suitable for in utero surgical intervention. This paper reviews historically important steps in the development of fetal surgery. The first invasive fetal intervention in 1963 was an intra-uterine blood transfusion. It took another 20 years to understand the pathophysiology of other candidate fetal conditions and to develop safe anaesthetic and surgical techniques before the team at the University of California at San Francisco performed its first urinary diversion through hysterotomy. This procedure would be abandoned as renal and pulmonary function could be just as effectively salvaged by ultrasound-guided insertion of a bladder shunt. Fetoscopy is another method for direct access to the feto-placental unit. It was historically used for fetal visualisation to guide biopsies or for vascular access but was also abandoned following the introduction of high-resolution ultrasound. Miniaturisation revived fetoscopy in the 1990s, since when it has been successfully used to operate on the placenta and umbilical cord. Today, it is also used in fetuses with congenital diaphragmatic hernia (CDH), in whom lung growth is triggered by percutaneous tracheal occlusion. It can also be used to diagnose and treat urinary obstruction. Many fetal interventions remain investigational but for a number of conditions randomised trials have established the role of in utero surgery, making fetal surgery a clinical reality in a number of fetal therapy programmes. The safety of fetal surgery is such that even non-lethal conditions, such as myelomeningocoele repair, are at this moment considered a potential indication. This, as well as fetal intervention for CDH, is currently being investigated in randomised trials. Copyright © 2010 John Wiley & Sons, Ltd.     

Fetal therapy: practical ethical considerations

Progress in prenatal diagnosis can lead to the diagnosis of severe fetal abnormalities for which natural history anticipates a fatal outcome or the development of severe disability despite optimal postnatal care. Intrauterine therapy can be offered in these selected cases. Prenatal diagnosis is the only field of medicine in which termination is an option in the management of severe diseases. Fetal therapy has therefore developed as an alternative to fatalist expectant prenatal management as well as to termination of pregnancy (TOP). There are few standards of fetal care that have gone beyond the stage of equipoise and even fewer have been established based on appropriate studies comparing pre- and postnatal care. Several ethical questions are being raised as fetal surgery develops, including basic Hippocratic principles of patients' autonomy and doctors' duty of competence moving the boundaries between experimental surgery, therapeutic innovation and standard care. In addition, the technical success of a fetal intervention can only rarely fully predict the postnatal outcome. Managing uncertainty regarding long-term morbidity and the possibility for fetal therapy to change the risk of perinatal death into that of severe handicap remains a critical factor affecting women's choice for TOP as an alternative to fetal therapy. Copyright © 2011 John Wiley & Sons, Ltd.     

Carbon dioxide emissions from transport and anemia influence on under-five mortality in Benin

Environmental Science and Pollution Research - This work is the first study about the joint effect (influence) of carbon dioxide emissions (CO2) from transport and anemia influence on under-five...     

Detection of advected, reacting redox fronts from self-potential measurements

We report on an experiment aimed at testing the use of self-potential measurements to monitor the motion and mixing of redox reactants advected through a well-controlled, laboratory-scale, artificial aquifer system. A rectangular, plastic tank was filled up with water-saturated sand and an array of unpolarizable electrodes was installed in the sand body. A nearly uniform, steady-state flow was established by tilting the tank and controlling the water level in reservoirs at both ends. Then, we simultaneously injected a known quantity of KMnO(4) and FeCl(2), respectively, into two separate compartments forming the upstream reservoir. We thus generated two abrupt fronts, one oxidizing and the other reducing, which subsequently travelled in parallel by advection through the sand body. The KMnO(4) and FeCl(2) solutions were in contact and reacted with each other in a region located along the median vertical plane parallel to the flow direction. During flow, the electrical potential differences between each electrode and a reference located in the downstream reservoir were recorded. In the unreacted FeCl(2) region the electric potential showed sudden variations successively occurring at increasing distances in the flow direction, associated with the passage of the FeCl(2) front. These signals essentially corresponded to the junction potential produced by the difference in ionic mobility of Fe(2+) and Cl(-). In the unreacted KMnO(4) region sharp signals, but with much smaller amplitudes, were also observed. Near the vertical median plane on the FeCl(2) side, we observed a second front associated with the spreading of the reaction zone. The shape and evolution of the reaction zone was largely controlled by the precipitation of Fe(OH)(3).     

Impact of peri-urban landscape on the organic and mineral contamination of pond waters and related risk assessment

Environmental Science and Pollution Research - Ponds are important for their ecological value and for the ecosystem services they provide to human societies, but they are strongly affected by human...