USF surgeon corrects problem in the womb

He is the first doctor to correct a rare disorder that can make a baby bleed to death in labor.

By LISA GREENE, Times Staff Writer
Published December 19, 2007

TAMPA -- A world-famous University of South Florida surgeon has become the first doctor to perform surgery inside the womb to correct a condition that can make the baby bleed to death during labor.

The baby girl was born 13 weeks early, five weeks after the surgery at Tampa General Hospital, and is now 9 months old and healthy. Her surgeon, Dr. Ruben Quintero, has published an account of the surgery in this month's issue of the Journal of Maternal-Fetal and Neonatal Medicine.

"Without him, she would not be here," said Elizabeth Guinea on Tuesday afternoon, as she held her daughter, Mia Bela Demier, on her lap.

The surgery won't be appropriate for every case of the rare disorder, called vasa previa, Quintero said Tuesday. But it gives pregnant women an alternative to a long hospital stay that could end in disaster.

Even at the hospital, if a woman goes into labor rather than getting a pre-term caesarean section, the baby may die.

"We're introducing a new potential concept," said Quintero, professor and director of the maternal-fetal medicine division at the University of South Florida College of Medicine. "Now that we know this is feasible, this can be put to the test."

Quintero said the technique needs further study, but he feels the surgery was a success and went without complications. Although he can't prove it, he thinks Guinea's early labor was unrelated to the surgery, since it happened five weeks later.

Guinea, 38, was diagnosed with vasa previa with a high-tech ultrasound when she was about four months pregnant. In this condition, fetal blood vessels attach abnormally to the placenta, so that they are unprotected by the umbilical cord and trail across the birth canal.

If mothers with the condition are diagnosed in time, they usually are hospitalized, and have a caesarean section about four weeks early to avoid labor. However, if the vessels rupture, even an emergency c-section may not be fast enough to save the baby.

Guinea had what's known as Type 2 vasa previa. In this case, the placenta is divided in two. The baby's umbilical cord connects to one part; the abnormal blood vessels connect the two parts.

Endoscopic laser used

To fix the problem, Quintero used an endoscopic laser -- a laser inserted into the uterus through a narrow tube -- to seal the abnormal blood vessels closed.

It's the same technique that he uses in the surgery he is best known for.

In that surgery, Quintero seals abnormal blood vessels in the placenta of twin fetuses who have what's called twin-to-twin transfusion syndrome. One fetus gets too few nutrients and the other gets too many. Usually, both die.

Quintero, 49, is widely known for developing the technique to identify the abnormal blood vessels that need to be sealed. Part of the procedure, still done by only a few surgeons, bears his name.

Guinea didn't know any of that when she was referred to Quintero. A Tampa mental health counselor, she didn't realize Quintero was so well-known until she went to Tampa General Hospital for her surgery. One nurse begged her to introduce Quintero; others kept asking Guinea where she was from.

It took a while for her to realize that they were asking because Quintero's patients come here from around the world.

Even so, it didn't take long for Guinea and her husband, financial manager Cris Demier, to decide to go ahead with the surgery.

"I don't think I would have been able to forgive myself if I did nothing and something happened to my baby," Guinea said. "That's what really did it for me."

Two things convinced them. Quintero has done hundreds of endoscopic laser surgeries on fetal twins. And Mia's umbilical cord was attached to the largest part of the placenta, so it would be able to provide enough nutrients even after the blood vessels connecting it to the second, smaller part had been shut.

Tampa General's ethics committee and research office approved the operation before it was done. Guinea's insurer wouldn't pay for the experimental surgery, but Quintero waived his fee. Tampa General also waived many costs. The couple paid about $7,000, about one-fourth the cost, Guinea said.

Although Quintero considers the surgery a success, it won't be done often. The condition occurs in one in every 2,000 to 5,000 births. It can be done only on Type 2 vasa previa.

Not the only option

What's more, the surgery is not the only option to save the baby, said both Quintero and a Texas fetal surgery expert. In many cases, doctors may feel trying to wait and deliver the baby early is less risky than a brand-new surgery that few can perform.

"Some would say it makes no sense in the absence of complications," said Dr. Anthony Johnson. "Others, such as the woman, would say, 'That's not acceptable to me.' "

Johnson, an obstetrician/gynecologist and associate professor at Baylor College of Medicine, also is chairman of the special interest group in fetal surgery for the national Society for Maternal-Fetal Medicine. He described Quintero as "truly a master," although he was not sure he would perform such a surgery himself.

The condition often isn't diagnosed until labor starts. Quintero hopes that news of the surgery will encourage more testing for the problem.

At her home Tuesday, Mia smiled and shook a rattle. She spent three months in the hospital, but now is doing fine, Guinea said.

Next week, she will celebrate her first Christmas.

Lisa Greene can be reached at greene@sptimes.com or (813) 226-3322.


Rare condition
Vasa previa is a rare condition in which the umbilical cord attaches to the placenta abnormally, leaving fetal blood vessels unprotected across the birth canal. If the vessels rupture during labor, the baby can quickly bleed to death. Doctors usually do caesarean sections about a month early to try to avoid labor.