This is a guest article by Silvio Aladjem MD.
Predicting the future is a hopeless task. The famous crystal ball does not help. But we can venture a thought, based on what we know or do not know about a subject. Here is my crystal ball about the future of obstetrics.
Not too longtime ago, the fetus was out of our reach. As late as 1950, all we could do was listening to the baby’s heart beating, without understanding the meaning of its variations. We could palpate its body parts through the maternal abdomen and, with experience; we could tell if the head was down into the maternal pelvis or up into the upper part of the uterus, which allowed us to determine if the baby will be born head first or buttock first. If you really knew your trade, you could most likely tell if there was too much or not enough amniotic fluid, but we knew little about what that meant.
In the early 1950s, Drs. Alvarez and Caldeyro, in Montevideo, Uruguay, decided to put a needle through the maternal abdomen into the uterine cavity and started measuring the pressure of the amniotic fluid at rest and during labor. The practice of Obstetrics has never been the same after that.
During the second half of the 20th century, we learned what labor was really all about. We learned how the uterine contractions come and go, measured their intensity and how they varied in certain circumstances. We also learned how these contractions affected the baby’s heart rate and what we believed it meant. We started talking about the “fetus as a patient”. We were able to transfuse the baby before its birth, thus avoiding death in certain serious conditions of anemia. We invaded its privacy by using ultrasound, to look at the baby and see how it was developing and in the process made diagnosis of anomalies or other complications. We made prenatal diagnosis possible as well as prenatal surgery, in order to correct certain problems before its birth. Maternal mortality decreased as did the neonatal mortality. Very premature babies that would have never lived before now were surviving. Improved surgical techniques allowed for the feared cesarean section to be performed safely, without the threat of losing the mother. Women that would have never dared to get pregnant before because of existing medical problems, less they faced death during pregnancy now were having healthy babies. Assisted reproduction has made possible for women that could not conceive, to become pregnant through in-vitro fertilization or other reproductive techniques.
In spite of all the knowhow, much remains to be done. We are at the dawn of a new era, where we begin to understand that, while in utero, the intrauterine environment can have an impact on the infant which will become apparent later during the adult life of the fetus. It seems more and more, that whether you will have high blood pressure, a heart attack, or other problems, is predetermined, before you are born, by what happens in the womb.
A recent study done in identical twins, showed how, regardless of their genetic similarity as twins, one twin can be affected while the other not, by events which chemically modify certain DNA, a phenomenon known as epigenetic tagging. (http://bit.ly/MrnCWS)
If such epigenetic tagging can be detected at birth, how are we to interpret such changes? Can we diagnose future diseases like diabetes, hypertension, heart disease, and a multitude of other by studying routinely our DNA at birth? And if we do so, can we avert the predetermined illness? Furthermore, will we be able to avoid such epigenetic changes in the first place?
If this sounds like science fiction, it is not. It is just a matter of time before all this will be “standard practice”.
But let us go a step further. We know today that certain diseases are genetically controlled. If we know that there is a bad gene in the family, today we can calculate the odds of occurrence in the baby. That, however, will soon not be enough. The day will come when we will be able to mutate the bad gene into a good one and avoid the whole problem altogether.
Surgery before birth has its limitations. Only certain problems can be corrected before birth. As we advance our technology and understanding, I predict that intrauterine surgery will become easier, safer, and routine in some cases.
The time will come when we will cure many diseases that today we can only treat and control, but not cure. Stem cells technology will get better and will open the door to yet unthinkable cures. By the same token, it is likely that new diseases will make their appearance. The future doctors will wonder at how poor our medicine was when we did those terrible procedures, like coronary by-pass for the heart, or chemotherapy for cancer. Not much different from what we think about our predecessors that were giving a drink of whisky before amputating the leg of a patient.
Just recently, Wall Street Journal published an article entitled: ”How digital medicine will soon save your life” written by R. Cook and E. Topol (WSJ 2-22-2014). It dealt primarily with the practice of medicine in general in the digital age. The only reference to pregnancy was how digital medicine will make your diagnosis of pregnancy. Make no mistake however; there will be more to that.
Actually I can imagine that with time and technological advances, the routine prenatal visit, as we know it today, will be no more. Technology will be available –smartphones with special apps- that will check your blood pressure, transmit laboratory data, peek at the infant with a micro-ultrasound- and voila, you do not have to go and see the doctor. They will call you if there is any problem.
That will be true for labor and delivery as well. Labor monitoring will disappear in favor of digital & wireless information which will tell you when you should go to the hospital. All your .information will be there before you reach the hospital.
Last but not least, you may have heard the term “designer babies”, where certain genetic manipulations will be able to delete certain genetic defects before conception, in order to avoid certain familial traits that can cause inherited disease. The sky is the limit.
But don’t get carried away, however. Like a good friend of mine, the late Prof. Andre Hellegers, a distinguished medical ethicist in addition to being a wonderful obstetrician, once told me: ”When we’ll be able to cure all the diseases, eventually we all will have to die of something”
SILVIO ALADJE MD, an obstetrician/gynecologist and Maternal Fetal Medicine (high risk obstetrics) specialist, is Professor Emeritus in obstetrics and gynecology at Michigan State University, College of Human Medicine, in Lansing, MI. He is the author of “10,000 babies: my life in the delivery room” now available on Amazon, Barnes and Noble and other book stores. Dr. Aladjem published extensively in Scientific Medical Journals and wrote several textbooks in the specialty. He can be reached through his website, www.drsilvio