Embryatrics: Transfusions in the Womb

A new medical specialty is developing. Not yet officially recognized, it is embryatrics: the treatment of the baby still in the womb. Conceived little more than a year ago in Auckland, New Zealand, it is now being practiced on four continents in the hope of saving fetuses endangered by Rh incompatibility. And if its pioneers’ hopes are fulfilled, embryatrics will eventually be extended to the treatment and prevention of other handicapping or fatal conditions.

Ever since the days of Hippocrates the womb has been regarded as a privileged sanctuary in which the fetus was protected against most kinds of harm. Any disturbance promised a premature birth, and doctors did not dare to attempt direct treatment of the unborn. But the more they learned about anemia from Rh incompatibility and the more certain they became of saving nine babies out of ten who are threatened by this disease, the more frustrated they became about the tenth.

Analyzing the Waters. The first breakthrough was a diagnostic technique involving the insertion of a hypodermic needle through the walls of the mother’s abdomen and uterus, into the amniotic sac (bag of waters). Fluid withdrawn through the needle showed the extent to which the baby’s Rh-positive cells were being destroyed by antibody from the Rh-negative mother. If the damage was moderate, obstetricians delivered the baby prematurely and gave it transfusions of Rh-negative blood. But if the fluid showed severe damage when the fetus was still too premature for delivery, the obstetrician could only sit back and wait for a malign nature to take its course.

New Zealand-born Dr. A. William Liley applied simple, practical reasoning to the problem. Anything he did, he figured, must be for the better—”You couldn’t possibly do any harm to the baby, because it couldn’t be worse off than it already was.” And if it was all right to push a hypodermic needle into the bag of waters, why not keep going and push it into the fetus’ abdomen? At National Women’s Hospital in Auckland, he did just that. Through the bore of the heavy-gauge needle, he then inserted a thin plastic tube. And through this he injected red cells, Rh-negative like the mother’s, to replace the baby’s own Rh-positive cells, which were being destroyed. A fetus can absorb blood cells directly from its abdominal cavity.

Into an Artery. Dr. Liley’s bold invasion of the womb failed in his first three tries because the babies had already been too severely damaged. His fourth attempt succeeded, and a live baby—now 16 months old and developing normally—was delivered. Dr. Liley has since had 13 successes in 18 cases. He is now at Manhattan’s Columbia Presbyterian Medical Center on a research grant from the U.S. Public Health Service.

Also at Columbia, Dr. Karlis Adamsons Jr. decided that as valuable as the Liley technique may be, it is still too little and too late in too many cases. What the fetus may need, he reasoned, is a massive, virtually total exchange transfusion. But how to give it? In one case, Dr. Adamsons boldly cut through the mother’s abdominal wall and enough of the uterus to expose the fetus’ abdomen and one leg. He cut into the fetus’ groin and put a plastic catheter in the femoral artery. Through this tube he withdrew much of the baby’s blood and replaced it with donor blood. Astonishingly, this radical surgery did not kill the fetus. But when the mother later went into labor, the baby was too premature to survive.

Dr. Adamsons has since tried another approach. He has cut into the uterus and into the fetus’ peritoneal cavity, and there he has implanted an extremely fine catheter that can be left in place. All six fetuses operated on in this way continued to develop for a month or more; Dr. Adamsons and his colleagues are confident that eventually a way will be found to help the mothers carry them until they can survive normally.

Back in Auckland during Dr. Liley’s absence, Surgeon Graham C. Liggins has found a way to insert a catheter through the bore of a hypodermic needle, then anchor it in the peritoneum in such a way that no matter how much the fetus squirms, the catheter will not pull out. Thus it can be left in place for repeated transfusions.

After Ten Failures. Rh sensitization is a more frequent cause of childlessness in countries where tropical anemias are treated by transfusions that may be mismatched, which explains the keen interest in embryatrics in South America. But there are so many cases in North America that it is being tried in at least two medical centers in New York City, and at others in Rochester, N.Y., Boston, Denver, Los Angeles, San Francisco and Winnipeg. About half of the hundred or more babies treated have been saved. Last month the University of California’s Dr. Jimmie Alf Westberg flew to Phoenix and supervised a Liley-style transfusion. The 40-year-old mother had lost ten babies to Rh incompatibility. Her latest pregnancy will have a chance of success.