When ultrasound scans are abnormal, this Singaporean foetal surgeon helps parents through hard decisions

There may be few people who understand the power of words like Dr June Tan, whose calming presence belies a heavy responsibility. While her advice is doled out with great care and compassion, it can turn an expectant parent’s life on its head. 
After speaking with this senior consultant at the Department of Maternal Fetal Medicine at KK Women’s and Children’s Hospital (KKH), a couple or woman could decide to terminate their pregnancy. 
One woman, Dr Tan recalled, had to make this painful decision twice.
“In each pregnancy, the baby was affected with a genetic condition – a different type of genetic condition (each time), unrelated to the family history. It was just by chance. So it was very hard for her to accept, and also very hard for her to continue with a third pregnancy,” she said. 
“Thankfully, although the third pregnancy was difficult, in a sense that it was filled with a lot of uncertainties, the pregnancy was okay and a healthy baby girl was delivered.” 
FROM ULTRASOUND TO SURGERY 
Pregnant women are strongly encouraged to undergo at least three ultrasound scans, one during each trimester, said Dr Tan, who performs and interprets these scans. She noted that many scans come back “normal”. 
But when an ultrasound detects “structural abnormalities” in the baby or produces “unusual findings”, she helps expectant parents through the decision process of how they would like to continue with the pregnancy. 
In some cases, foetal surgery is an option.
As one of KKH’s three foetal surgeons, Dr Tan performs about one to two surgeries every three to four months. The 56-year-old was posted to KKH, coincidentally where she was born, for her first year as a general doctor after medical school more than 30 years ago and has remained at the hospital since. 
Her posting to the maternity ward cemented her decision to specialise in obstetrics – a subspecialty that covers pregnancy, childbirth and the postpartum period, under the medical speciality of obstetrics and gynaecology (O&G). Generally, O&G training takes six to eight years after medical school, followed by two to three years to train as a foetal medicine specialist, and another two to three years to specialise in foetal surgery, she said.
Women hope to have “a very uneventful pregnancy and delivery” but for a small proportion, their unborn baby may have a foetal condition, Dr Tan told CNA Women.
“In some cases, we can do either medical or surgical therapy to improve the long-term effects on the baby.”
GIVING PARENTS INFORMATION TO MAKE DECISIONS
One of the “more common” abnormalities is a condition that occurs when there is fluid in the baby’s chest outside the lungs. 
Known as foetal hydrothorax, it can be detected as early as during the 20-week ultrasound scan, said Dr Tan, who sees such cases once every two to three months on average. 
After detecting the condition, doctors sometimes spend one to two weeks monitoring the situation, she added. There is no need for surgery if the fluid in the space around the baby’s lungs “remains stable, doesn’t worsen, and the baby continues to grow”.
But if the condition worsens, a procedure is performed where a needle, under ultrasound guidance, is used to drain the fluid, allowing the baby’s lungs to expand and develop properly during the pregnancy.
Some parents worry that the needle would injure the baby’s nerves. But Dr Tan assures them that the chance of that happening is “very, very low”.
The main risk, she said, is “premature rupture of the membrane, leading to leakage of amniotic fluid”. With that comes an increased risk of miscarriage or premature labour, where “the baby is delivered at a very early stage of the pregnancy”.
Nonetheless, expectant parents might feel overwhelmed by the information and need a short break during the consultation to think about what other questions they would like to ask, ultimately so they can decide whether to go through with surgery. 
Time is of the essence in many cases as well, she noted. 
“Because the child is already affected by this condition, we may need to do these surgeries on a semi-urgent basis. Sometimes, within a few days, the parents need to decide whether to go ahead with the surgery.”
PREPARING PARENTS FOR “ALL EVENTUALITIES”
Expectant parents also need to be prepared for the possibility – and disappointment – that a surgery might not happen as scheduled for various reasons. 
In one case, a surgery involving foetal blood transfusion had to be called off, despite having assembled and trained nurses for the procedure and prepared blood from a donor. The team was unable to proceed to give blood to the foetus because the “position of the blood vessel was not suitable”, Dr Tan recalled. 
Similarly, there are instances when the foetus is not in the right position for surgery. And since foetal surgeons can’t control this, they can only reschedule surgery and “wait for the baby to be in a suitable position”.
Dr Tan also pointed to a case involving twin-twin transfusion syndrome – an abnormality in which blood flows unequally between twins who share a placenta. Such twins are called monochorionic twins. 
One of the treatments is foetal laser surgery. This involves passing a fetoscope (a small camera) through the amniotic sac of the “recipient” twin – the twin who receives more blood. A laser fibre is then used to “block off the blood vessel flow between the babies, allowing both to develop normally”.
In about 80 per cent of such surgeries, at least one twin “recovers from the procedure and continues to grow”. Most expectant mothers would also recover well, but remain under observation for a few days to a week post-surgery.
Even when surgery for twin-twin transfusion syndrome is successful, the condition might recur again, say, a few weeks or a couple of months later, and “the baby may need another surgery or be delivered prematurely,” she added. 
“As much as possible, we try to prepare the parents for all the eventualities.”
DRESS REHEARSALS FOR SURGERY
Doctors, too, need to be prepared. In a rare type of foetal surgery, which sees one or two such cases every year at KKH, plenty of dress rehearsals need to happen before the actual day.
This surgery is called the EXIT (ex-utero intrapartum treatment) procedure, and it’s done during the birth delivery itself over one to two hours.
The EXIT procedure is carried out when doctors identify foetuses with a potentially blocked airway. This includes babies with “a very large neck mass”, which could result in airway compression or some blockage to the trachea. 
“In these cases, it’s usually quite difficult to give the baby oxygen after it’s born. So what we do is a specialised caesarean section,” Dr Tan said. 
In the operating theatre, there will be about 20 healthcare professionals, including a foetal medicine specialist obstetrician who’s performing the caesarean section – most of the time, this is Dr Tan’s role. There is also an adult and paediatric anesthesiologist, a paediatric ear-nose-throat doctor and specialist nurses. 
“(When) we deliver the baby head and the shoulder, the baby is still on placental circulation and the mum’s still giving oxygen to the baby. And in that time, we take the opportunity to secure a lifeline airway (a tube that provides air) for the baby before we deliver the whole baby,” she said. 
“So we must do a dry run, even the day before the surgery, so that everyone knows what to do. Everybody needs to know their (role)… even who stands where. We need to plan.”
Occasionally, when well-prepared surgeries don’t go according to schedule, “yes, we feel personally (affected) if we’re not able to proceed with the surgery”, Dr Tan admitted. 
The team usually “rationalises” the outcome to bounce back from the setback. For example, when they were unable to conduct the foetal blood transfusion due to the unsuitable position of the blood vessel, they reasoned: “If we proceed with the surgery, we may do more harm than good; we may cause bleeding of the blood vessel.”
SATISFACTION AND PURPOSE 
Dr Tan recounted her deepening fascination with ultrasounds at the start of her career, as she realised the then-emerging technology could give expectant parents “a realistic expectation about the outcome of the pregnancy”. Scans could detect whether a child had features of Down Syndrome or a cleft lip, for example. 
Contrary to common assumption, she also found that the majority of parents were not in denial.
“Initially, it will take a little bit of time for (the news) to sink in, but quite soon after, most parents click into the mode of ‘what should we do’, finding solutions for the problem. I think that’s the resilience of parents,” she said. 
“For these cases, to be able to journey with them through this difficult period, helping them make decisions about what they want to do with a pregnancy, whether (they) do foetal surgery or not, that’s also very fulfilling for me.”
Years after Dr Tan’s patients are discharged, some also return to the hospital for regular gynaecological check-ups and take the chance to tell her about their child. They regale her with “regular” updates, like how their child, once suffering from a foetal abnormality, is now sitting for the Primary School Leaving Examination.
And simply seeing parents turn their child’s ordinary milestones into extraordinary events is, after more than three decades since deciding on her specialty, still the greatest satisfaction.
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