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The combination of extraordinary advances in molecular genetics, prenatal genetic diagnosis,1 and the continuous technologic innovations in prenatal imaging2,3 now make it possible to diagnose prenatally virtually any condition with high levels of confidence. This capability has afforded the opportunity to consider prenatal treatment for an ever-expanding list of conditions that in years past depended on postdelivery assessments. In many instances, irreparable organ injury or even death occurred as a result of this delay. Fetal therapy holds significant promise to change the natural history and improve not only perinatal survival but long-term outcomes as well.4 Fetal therapy has expanded the conditions that may be considered for medical treatment, including congenital pulmonary airway malformations (CPAM),5,6 fetal arrhythmias,7 congenital adrenal hyperplasia,8 and even congenital diaphragmatic hernia.9-11 Possible indications for open fetal surgery have broadened to conditions such as myelomeningocele,12 sacrococcygeal teratoma,13,14 bladder outlet obstruction,15,16 and CPAM.6 But perhaps the most striking area of growth in fetal intervention is for conditions that may be treated by fetoscopic techniques,17 such as twin-twin transfusion syndrome,17-20 twin reversed arterial perfusion sequence,21,22 and congenital diaphragmatic hernia.9-11

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Fetal intervention is only possible with precise prenatal imaging, a complete understanding of the maternal history, selection criteria for the intervention, and techniques that are safe for both mother and baby. Recent advances in ultrasound imaging, especially 3-dimensional and 4-dimensional scanning capabilities, have dramatically improved the quality of ultrasound affording diagnostic precision and image-guided capabilities not previously available.3 Ultrasound imaging is complemented by the greater imaging capacity afforded by fetal magnetic resonance imaging, particularly for the central nervous system and chest. Similarly, fetal cardiac assessment has benefited by technical advances not only in fetal echocardiographic imaging but also in the development of fetal magnetocardiography for the accurate diagnosis of tachyarrhythmias.23,24

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In the past, fetal intervention was limited to conditions in singletons in which the life of the fetus was threatened. In recent years, the indications for fetal intervention have been extended to non–life-threatening conditions, such as myelomeningocele,12 and to multiple gestations for twin-twin transfusion syndrome,18-20 which in fact is currently the most common indication for fetal surgery. The sophistication of the average expectant mother also has increased. Expecting parents increasingly seek out expertise in fetal imaging, prenatal diagnosis, and fetal intervention and are willing to travel if expertise is not locally available. The evolution of fetal intervention holds tremendous promise for altering prenatal natural history of a disorder in ways not possible after delivery. It also is fraught with potential risk for mothers considering interventions who derive no direct benefit from these procedures. Critical appraisal of the potential maternal and fetal risks of fetal intervention must be carefully weighed by all parents considering these options.

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Medical treatment options still remain limited if one excludes the use of corticosteroids ...

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