A, the development of fetal medicine abroad 1, fetal medicine includes prenatal diagnosis of birth defects, but not only prenatal diagnosis: prenatal diagnosis of birth defects is the basis of fetal medicine, the main task is to diagnose, without prenatal diagnosis can not really carry out the work of fetal medicine. But birth defects are only one important part of fetal medicine, which includes all diseases that may affect the fetus, as well as the diagnosis and treatment of these diseases. In addition to chromosomal abnormalities and structural defects, twins and multiple births, especially complicated twins, are the focus of fetal medicine attention. Although the etiology of fetal growth restriction is complex and effective treatments are lacking, its study has been another hot topic in fetal medicine. Intrauterine fetal treatment, including surgical and gene therapy, is a major difference between fetal medicine and prenatal diagnosis. The most effective and most performed intrauterine fetal surgery is the treatment of complicated twins, especially laser treatment of twin-twin transfusion syndrome (TTTS), and intrauterine treatment of Rh hemolysis is also relatively well established. However, other intrauterine fetal surgical treatments are still in the exploratory stage and are not suitable for widespread development. 2. Fetal medicine is a multidisciplinary integration and cooperation: the development trend of gynecology is to gradually split up and divide many subspecialties from gynecology, such as general gynecology, gynecologic oncology, gynecologic endocrinology, reproductive medicine, gynecologic urology, cervical disease, etc., but fetal medicine is the opposite, a multidisciplinary process of gradual integration, including biochemical screening, clinical genetics, ultrasound imaging, obstetric clinical, neonatology However, fetal medicine is the opposite of a multidisciplinary process, including biochemical screening, clinical genetics, ultrasound imaging, clinical obstetrics, neonatal medicine, neonatal surgery, etc. These doctors need not only to be experts in their own specialties, but also to have a true understanding of the physiology, pathology and metabolism of the mother-placenta-fetus system, and to know how to perform the appropriate fetal surgery in utero and the postoperative follow-up and management. It’s not just about physicians from various disciplines working together, but physicians themselves need to become versatile, especially clinicians. Obstetric clinicians have to become experts in ultrasound, do genetic counseling, and also perform intrauterine fetal surgery, which cannot be done by ordinary obstetricians. In Europe and the United States, fetal medicine is an independent subspecialty, and doctors engaged in fetal medicine need to be trained as specialists before they can be qualified as specialists. 3.Difference in the development of fetal medicine between Europe and the United States: The contents included in fetal medicine are the same in Europe and the United States, but the development of fetal surgery is different between Europe and the United States. Most of the fetal surgery in Europe is led by obstetricians, and the head of the fetal medicine center is usually an obstetrician. In the United States, most of the large fetal medicine centers are led by pediatric surgeons, and the scope of fetal surgery is more than that of the European fetal medicine centers. 4, twins are the “king of obstetrics”: doctors doing fetal medicine cannot avoid twins. The diagnosis and management of twin pregnancies includes almost all aspects of prenatal diagnosis and intrauterine treatment. For twin pregnancies, Down’s syndrome screening of the mother’s peripheral blood is generally not recommended because of the low detection rate. Twins require nuchal translucency (NT) testing in early pregnancy to predict chromosomal abnormalities, chorionicity in twins needs to be determined in early pregnancy, and ultrasound screening of the fetus for structural malformations is required. In the case of multiple fetuses with more than three fetuses, reduction is required. Chorionicity needs to be determined before reduction and fetal chromosomal abnormalities need to be excluded. In the case of complicated twins, especially TTTS, intrauterine surgery (laser treatment) is required. If there is preterm labor, treatment with fetal preservation, monitoring of the length of the cervical canal and, if necessary, cervical cerclage are required. If preterm labor occurs, a very good NICU is required. if postpartum hemorrhage occurs, a strong ability to resuscitate postpartum hemorrhage with uterine preservation (uterine compression sutures, uterine artery embolization therapy) is required. Twin births encompass almost all the technical and difficult aspects of maternal and fetal medicine. Therefore, twin pregnancy is the “king of obstetrics” and the best reflection of the level of development of fetal medicine. The current situation and development direction of fetal medicine in China (1) Institutional dilemma has become a bottleneck for development In recent years, fetal medicine has just started in China, and its development is facing many difficulties and bottlenecks, and the main problem that hinders the development of fetal medicine is not a technical problem, but a system and institutional problem. Therefore, the development of fetal medicine in China may need to take a different path from that of European and American countries. The most powerful “weapon” of fetal medicine is ultrasound, and we cannot talk about fetal medicine without ultrasound. In Europe and the United States, the most famous fetal medicine experts are the best ultrasound experts. Of course, there are also special ultrasound doctors or technicians abroad, but they mainly do the initial screening, the final diagnosis still depends on the fetal medicine experts. In Europe and the United States, as long as they have received formal training and qualified certificates, obstetricians and gynecologists can do ultrasound and issue reports. However, in China, obstetricians and gynecologists are not allowed to do ultrasound and issue reports. This is because according to China’s physician law, a person can only be registered as a physician in one specialty, and it is impossible to be registered as both an OB/GYN and an ultrasonographer. Therefore, legally speaking, obstetricians who do fetal medicine in China are not allowed to do ultrasound and issue ultrasound reports. As long as this situation does not change, the development of fetal medicine in China will not be able to get a good breakthrough. 2, the lack of real clinical genetic doctors: in Europe and the United States, there are many formally trained and practically experienced clinical genetic doctors, but in China there is no such clinical specialty and physician series. Those who do genetics are not necessarily those who do human genetics, those who do human genetics are not necessarily those who do medical genetics, and those who do medical genetics are not necessarily those who do clinical genetics. At present, very few people who do genetic counseling on the front lines of clinical practice in China have actually received formal clinical genetic training. The practice of fetal medicine often involves the diagnosis or differential diagnosis of hereditary diseases, without the support of a strong genetic laboratory and clinical genetic counseling, fetal medicine can not be well developed. 3.No specialist training in fetal medicine: In foreign countries, to see whether a discipline can be well developed, we must first see whether the discipline can become an independently developed subspecialty, and then see whether there is a systematic training system for specialists. In Europe and America, the training of fetal medicine specialists is already a mature system, which has played a good role in promoting the rapid development of fetal medicine. At present in China, the entire clinical medicine has not yet established a formal specialist training system, not to mention the relatively young fetal medicine. 4. There is no clinical standard for fetal medicine: in China, fetal medicine is an emerging interdisciplinary discipline, still in its infancy, and there are few doctors with formal training, so how to talk about clinical standard? The more this is the case, the more need for regulation and the more need for system first. In addition to formulating corresponding clinical norms based on evidence-based medical evidence, in the absence of good evidence-based medical evidence, expert consensus is needed to solve many difficult problems faced in clinical practice. (2) How exactly should fetal medicine be developed in China? 1. To design first, not to form naturally: Reviewing the history of the development of fetal medicine in Europe and America, we will find that it is also a long and complicated process with many experiences and lessons learned. The development of fetal medicine in China is at its initial stage, so we can learn from the development experience of European and American countries and design a good development framework and roadmap from the beginning, which is called “top-level design”. Through close communication with foreign counterparts, we can recognize the current situation in China, learn from foreign good experiences and practices, avoid problems and difficulties that may be encountered in the development, and achieve the system and standard first, which can lay a solid foundation for the development of Chinese medicine. 2, to vigorously develop fetal medicine, but not everywhere: the future and focus of obstetrics development lies in fetal medicine, fetal medicine is also a highlight of the development of the entire clinical medicine, it involves genomics, proteomics, metabolomics, minimally invasive surgery, gene therapy and other cutting-edge biomedical technology, is the collection of modern biomedicine. Fetal medicine should be vigorously developed, both from the perspective of solving patients’ practical problems and from the perspective of discipline development. However, even in Europe and America, fetal medicine is the work of a few medical centers and a few people. Now, there have been some worrying signs in China that everyone wants to develop fetal medicine, every hospital wants to buy fetal scopes, and everyone wants to do fetal surgery (especially laser treatment for TTTS). Some cities have more than 4 hospitals at the same time that have established or intend to establish fetal medicine centers. A fetal medicine center cannot be established by just one or two specialists; it requires multidisciplinary teamwork and a cluster of mutually supportive disciplines to support it. A sustainable development of a fetal medicine center requires a large source of patients. Fetal-related diseases, especially those requiring fetal surgery, are already rare, so where will there be so many patients when everyone is doing fetal surgery? For example, in the Netherlands, there is only one fetal medicine center in the whole country, and all the fetuses that need consultation and treatment in the Netherlands are referred to this center, so that the quality of medical care can be ensured and medical resources will not be wasted. Therefore, it is very important for China to plan the design of the fetal medicine referral center and referral process from the beginning, and not to have a large flowering area where everyone performs fetal surgery. The establishment and management of assisted reproduction centers provide a good model for us to learn from. 3, academic organizations should play an important role: in Europe and the United States, the development and standardization of the discipline is mainly the corresponding academic organizations playing a leading role, which includes the development and revision of clinical guidelines and expert consensus and the development and implementation of specialist training programs. The development of fetal medicine in China should also learn from these good experiences, under the leadership of corresponding academic organizations, refer to foreign evidence-based medical guidelines, and formulate corresponding fetal medicine guidelines or consensus as soon as possible according to the real situation in China, so as to effectively solve the situation that there is no basis for the development of fetal medicine in China. At the same time, it is also necessary to reach a consensus, refer to the curriculum and training programs of foreign fetal medicine specialists, and develop training programs for Chinese fetal medicine specialists, so as to train qualified personnel and lay a solid foundation for the development of fetal medicine. 4. Technical development of fetal medicine is important, but management system and standard are more important: from the development of fetal medicine in Europe and America, the technology itself is important, but the design of management system is more important to really carry out fetal medicine sustainably. The failure rate of intrauterine fetal treatment, especially intrauterine surgery, is relatively high, and the cost of failure is often expensive medical care, but the incidence of serious complications and sequelae, such as fetal death, preterm birth, and cerebral palsy, is high. If the patients themselves and their family members are not well prepared mentally, it can cause great mental stress and financial burden to all parties. Therefore, the application of new technologies in fetal medicine, especially the indications for the application of fetal surgery must be strictly controlled, and the most appropriate fetal treatment, not necessarily fetal surgery. Medical institutions that carry out fetal medicine, especially fetal surgery, should set up corresponding ethics committees to conduct corresponding ethical discussions and approvals for newly developed technologies and special cases involving ethical issues. Before carrying out fetal surgery, the corresponding clinical guidelines and management system must be well formulated to achieve system first and standardization first. The entire medical team should be well trained, patients and family members should go through a detailed informed consent process, and patients and family members should be provided with appropriate psychological counseling and psychological testing if necessary to avoid the negative consequences of unacceptability or psychological breakdown of patients when “people and money are both empty”.