Nearly halfway through a traditional 40-week pregnancy, doctors can better understand the anatomy and health profile of a fetus, allowing for a comprehensive evaluation of the baby’s health. It is around this point in a pregnancy when an in-utero surgical procedure, operating on a baby while in the womb, may be performed to assist the fetus. In rare circumstances, in utero surgery needs to be done to help a baby survive through delivery. In many cases, prenatal surgery can stop progressive damage, while also keep the baby in utero long enough to grow and continue developing.
Paul Kingma, MD, Ph.D., is the neonatal director for the Cincinnati Fetal Center, part of Cincinnati Children's Hospital Medical Center. Since 2004, doctors at the center have performed more than 1,500 fetal surgical procedures. Kingma says there are many reasons this line of high-risk work is rewarding, especially “helping families through difficult times either by treating their infant in the womb or having a specialized team ready at the time of delivery and, in some cases, just helping the family understand why and cope with the fact that their infant is suffering,” says Kingma.
Kingma believes he was destined to be a physician. His father was a physician and he always admired the impact his father had on his patients. However, while in school, Kingma found a passion beyond clinical practice; he was inspired by the possibility of also making research a focus of his career. “I love the challenge of and creativity of identifying and finding ways to answer research questions and ultimately improve the way we take care of patients,” Kingma says.
“My curiosity in academic medicine and research began during my last years of college and was fully ignited during my research as a medical student with Neil Osheroff at Vanderbilt University,” says Dr. Kingma.“Neil was instrumental in showing me how research is very satisfying both creatively and knowing that you are doing something that has the potential to help people.”
Kingma outlines three primary research areas: tracheal esophageal (TE) development, congenital diaphragmatic hernias, and premature infant lung injury.
“My first goal is to develop effective clinical management strategies to predict, prevent and treat complications in infants with tracheal esophageal (TE) defects,” says Kingma.
Normally the trachea and the esophagus are not connected in any way. Very early in the development of a fetus, a single tube will divide to form the esophagus and the trachea. For an unknown reason, sometimes the esophagus and trachea do not separate properly, and a fistula connecting the two forms, a birth defect that can become deadly if the baby cannot breathe or swallow food properly.
Kingma is utilizing several high-tech tools to research and correct TE defects. Cincinnati Children's Hospital Medical Center recently installed the first and only MRI located within a neonatal intensive care unit (NICU) in North America. This unique resource provides him with a powerful new opportunity to study the formation and progression of tracheal esophageal defects in fetuses and newborns.
Another essential technology advance for in utero research and surgery has been the fetoscope, according to Kingma. A fetoscope is a tiny endoscope that is put in the mother during a fetal operation to help surgeons see and treat the fetus. It has reduced the need to make large, open incisions through the mother’s abdomen and uterus to operate on the baby. Thanks to this invention, several in utero surgeries can be done with a less invasive scope including repairing spina bifida and helping lung growth in congenital diaphragmatic hernias (CDH). CDH means the baby’s intestines and abdominal organs herniate into the chest through a hole in the diaphragm area, not allowing the lungs to properly develop and expand in the womb, in many cases, leading to respiratory distress and possibly even death after the infant is born.
“My goal (in this area) is to improve our understanding of the diagnosis, pathophysiology, and treatment of infants with congenital diaphragmatic hernia,” Kingma says. His published studies include the evaluation of CDH using prenatal MRI and the clinical care of these infants. Kingma is now researching different ventilation strategies and how they can reduce the impact of CDH.
“My laboratory began a collaboration with Dr. Jason Woods and the Center for Pulmonary Imaging Research. Through this collaboration we have developed novel neonatal MRI techniques that allow us to evaluate the critical aspects of the premature infant cardiopulmonary system including lung growth, lung inflammation, lung performance on mechanical ventilation, airway structure and stability, pulmonary vascularity and pulmonary hypertension, and cardiac function,” Kingma says.
The final goal of Dr. Kingma’s research is to improve his understanding of the molecular pathogenesis of neonatal lung injury in bronchopulmonary dysplasia (BPD). He is currently working with a major biotechnology company to develop a treatment that improves the function of surfactant, a protein and lipid coating made naturally in healthy lungs during the late stages of pregnancy that allows the lungs to stretch. In premature infants that are born prior to the normal production of surfactant, the lungs fail to work properly, they could not expand to allow oxygen to get inside. A special component of surfactant, surfactant protein D, is especially important as it is responsible for fighting off toxins, decreasing inflammation and improving lung function. It also plays a role in lubricating the lung and preventing it from collapsing.
The most inspiring part of Kingma’s work is being able to apply it to high-risk pregnancies to improve outcomes.
“We need to improve our ability to identify infants that will benefit from fetal surgery,” he says. “We also need to decrease the risk to the fetus, mainly the risk of premature delivery.”
Using the information collected during research can help physicians better understand not only which in utero intervention methods work best to help babies thrive, but also detect which fetuses may need the interventions the most.
David Allen is a contributing writer. Feedback welcome at feedback@cityscenemediagroup.com.
About the Expert
Paul S. Kingma, MD, Ph.D., serves as an attending physician in the Cincinnati Children’s NICU and as neonatal director of the Cincinnati Fetal Center and Co-Director of the Cincinnati Bronchopulmonary Dysplasia Center. Dr. Kingma leads several basic science and translational research projects. After he received his undergraduate degree at Calvin College, MI, Dr. Kingman attended and graduated from Vanderbilt University with a medical degree as well as a Ph.D. He completed his residency and a fellowship at Cincinnati Children's Hospital Medical Center. Dr. Kingman’s research has been published in several journals including Pediatrics, Journal of Pediatrics, American Journal of Respiratory and Critical Care Medicine, Journal of Perinatology and Journal of Pediatric Surgery.
