Recognizing that every life is precious, nurses at Texas hospitals have recently participated in the care of babies undergoing rare surgeries that have given the youngsters a chance for normal lives.
A fetal intervention team at Texas Children’s Fetal Center in Houston performed an open procedure to remove a tumor on a 24.5-week gestation fetus, and a multidisciplinary team separated conjoined twins at CHRISTUS Santa Rosa Children’s Hospital in San Antonio.
“Fetal surgery is reserved for pregnancies that are not going to make it otherwise,” says Karen Moise, RN, fetal intervention coordinator at Texas Children’s. Macie Hope McCartney fell into that category.
Chad and Keri McCartney of Laredo took their four children, ages 18 months to 13 years of age, to watch an ultrasound and learn if they would soon have a new brother or sister. The technician picked up on a serious abnormality — a tumor the size of a grapefruit.
McCartney’s obstetrician in San Antonio had never treated a patient with a sacrococcygeal teratoma, a tumor at the base of the tailbone. He was at a loss about what to do and left the parents with little hope. In search of a second opinion, Keri learned about Texas Children’s Hospital’s fetal program. She called and started crying when Moise knew how to pronounce her child’s disorder.
“She realized, if I could pronounce it, it meant we had seen it before,” Moise says.
Moise immediately brought her in for an evaluation. Little Macie Hope was going into heart failure due to the vascular teratoma, which was robbing her blood supply.
Texas Children’s performed a fetal MRI and two echocardiograms, 48 hours apart. The second echo indicated worsening heart failure. The multidisciplinary fetal intervention team, which includes a chaplain and ethicist, met with the parents and laid out the options.
The team hoped surgery could buy the child a couple of more weeks in utero while she recovered from heart failure. Risks involved premature membrane rupture, bleeding, infection, and the possible loss of the uterus.
The parents decided to move forward.
The surgery was complicated and lasted 3.5 hours. Five physicians scrubbed: two pediatric surgeons, an obstetrician, a maternal-fetal medicine specialist, and a cardiologist. The mom received deep general anesthesia and an epidural, all to try to keep the uterus as relaxed as possible.
The placenta was on the anterior surface, requiring surgeons to access the back side of the uterus, putting the mother at high risk for future pregnancies.
“Because the type of incision and the lesion was so large, we had to take the uterus out of her belly, lay it over, and make a horizontal skin incision on the back side,” Moise says.
With the fetus out of the uterus, two pediatric surgeons removed the majority of the lesion and replaced the fetus within about 20 minutes. Throughout the surgery, the team infused warm normal saline into the field to help maintain the fetus’s temperature. The room was kept at 98 degrees. The cardiologist performed real-time echocardiograms to monitor Macie’s heart. The physicians drew blood and administered resuscitory drugs and blood through the umbilical cord.
“We were operating on a very fragile fetus who was already in heart failure,” Moise says.
A neonatal support team stood by in case the baby was born early.
The surgeons closed using a stapler device, similar to a serger sewing machine. It connects the amniotic sac to the wall of the uterus. When the surgery was over, the plastic staples came out, and the surgeon placed a thin layer of a glue to create a water-tight seal.
The procedure went smoothly, but then concerns switched to maintaining the pregnancy.
“You worry about the uterus contracting, so you want it quiet and still,” Moise says. “The uterus was not meant to have an incision put on it like that and not deliver.”
Nurses administered magnesium sulfate and indomethacin (indocin) and carefully monitored mom and baby. With repeat echocardiograms, the team watched for ductal constrictions. Nurses drew blood to check magnesium levels to avoid overdosing.
McCartney stayed in the hospital for three weeks. She went home. But uterine activity increased, so physicians readmitted her. She remained in the hospital until delivering 6-pound Macie by a planned C-section about 10 weeks after the fetal surgery and one day shy of 35 weeks gestation. The baby required no supportive therapy.
Eight days later, surgeons took Macie back to surgery to resect the remaining tumor. The procedure lasted eight hours, as physicians carefully removed all evidence of the mass.
“Every day, when I would watch Keri and Macie inside of her, I knew a miracle was in the works,” Moise says.
Macie is home now, a healthy little girl, thriving. “It’s amazing,” Moise says.
Sacrococcygeal teratomas occur in about one in every 35,000 to 40,000 live births. But only about 10% involve blood vessels. This was the first fetal sacrococcygeal teratoma removal performed at Texas Children’s. Moise estimates 12 fetal sacrococcygeal teratoma resections have been done worldwide, and six were successful. Of those six, only two of the children are neurologically intact.
The CHRISTUS team of seven physicians separated 9-month-old, male conjoined twins on June 6. The identical twins failed to separate during the first trimester of gestation and were born with a partial cranial joining.
Post-op, the twins were intubated for a period. Their heads were wrapped. The babies held their own bottles for feeding.
“All I did was play with them,” says Eloisa Reyna, LVN, an ICU nurse who cared for the boys. “They were smiling and loved the attention, especially the dominant one, the bigger guy. He was a joy to work with.”
Reyna and the other nurses watched for drainage, signs of infection, fevers, changes in vital signs, or respiratory congestion. The one-week ICU period progressed uneventfully.
Joining, which can take place anywhere on the body, occurs in about one in 200,000 live births. Cranial joining only happens in about 2% of those births. Since surgical separations became possible in 1952, 11 sets of twins with partial cranial joining have successfully been separated, with 12 of those children reportedly normal. This is the first time CHRISUS Santa Rosa has performed a separation of conjoined twins.