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Spina Bifida Treatment

General Information »Criteria and Requirements »What to Expect »

What is the traditional treatment for spina bifida?

Since the 1930s, the first step in the treatment of newborns with spina bifida has been to surgically close the incompletely developed portion of the spinal cord soon after birth. Additional procedures after the baby is born are focused on treating the complications associated with spina bifida. These may include hydrocephalus, which is a buildup of fluid in the brain (“water on the brain”) that requires surgical placement of a ventriculoperitoneal (VP) shunt to drain the excess fluid into the child’s abdomen through a tube running under the skin. A newer procedure called endoscopic third ventriculostomy (ETV) may be performed in some babies instead of a shunt.

What is the MOMS trial?

In 2011, the Management of Myelomeningocele Study (MOMS), sponsored by the National Institutes of Health, found that infants who undergo surgery in utero had a decreased need for ventriculoperitoneal (VP) shunting and improved motor function when compared to the surgical repair of the spina bifida after birth. Based on the results of the MOMS trial, open fetal surgery for spina bifida is now considered an alternative option for select fetuses prenatally diagnosed with spina bifida.

When is open fetal surgery for spina bifida treatment recommended?

For select cases, fetal surgery may benefit infants prenatally diagnosed with spina bifida. Early diagnosis of spina bifida is important. Due to the small window of opportunity for fetal repair, specialists prefer to see mothers at 22 or 23 weeks of gestation, which allows the family time to complete the consultation, return home and consider their decision. Surgery typically occurs between 24 – 26 weeks’ gestation.

Are there other options to open fetal surgery for the repair of spina bifida?

Some centers are offering repair of fetal spina bifida through an experimental fetoscopic approach. In this procedure, a small telescope is placed into the womb; part of the amniotic fluid is then removed and replaced with a gas. Although this procedure is in the early phase of development, outcomes to date have been limited and there is no current data to compare the results of this surgery to the MOMS trial. For this reason, the American College of Obstetricians and Gynecologists have deemed this procedure experimental.1 The Fetal Center at Children’s Memorial Hermann Hospital has decided not to offer fetoscopic repair for fetal spina bifida until more is known about the long-term benefits to the child.

The Fetal Center selects patients based on the criteria established in the MOMS trial. A specialized research approval is in place to consider some patients that do not qualify for fetal surgery based on the original MOMS trial. As a member of the North American Fetal Therapy Network (NAFTNet), The Fetal Center maintains its adherence to the best practices network members have established. The selection process for in utero repair is based on a strict prenatal algorithm that emphasizes education, preparing families to make an informed decision about treatment.

The Fetal Center is now screening patients for potential fetal intervention of prenatally diagnosed conditions.

For questions regarding fetal surgery for myelomeningocele and other prenatally diagnosed anomalies, please contact The Fetal Center at (832) 325-7288.

Fetal Surgery Criteria

Candidates are accepted for open maternal-fetal surgery based on the criteria set forth by the MOMS Trial. The risks and benefits to both mother and baby are considered in this process. Specific factors that exclude mother or baby from undergoing fetal surgery include, but are not limited to the following:

Fetal Exclusion Criteria

  • Variants of spina bifida that are not considered open neural tube defects
  • A significant fetal condition not related to myelomeningocele
  • Kyphosis, an exaggerated curving of > 30 degrees of the fetal spine
  • Pregnancy of twins, triplets or more
  • Significant clubbing of the legs or evidence of existing paralysis

Maternal Exclusion Criteria

  • Morbid obesity (Body Mass Index > 40)*
  • Medical or personal reasons for withholding a patient from surgery or anesthesia
  • Previous or planned incision on the cervix or documented history of a weak cervix
  • A short cervix (less than 20 millimeters by vaginal ultrasound)
  • Preterm labor in the current pregnancy
  • History of spontaneous preterm delivery in previous pregnancies*
  • Bleeding in current pregnancy or placental abruption - a partial or full separation of the placenta from the uterus
  • Red cell or platelet alloimmunization, a blood condition*
  • Insulin-dependent diabetes prior to pregnancy*
  • Abnormal anatomy of the uterus such as uterine fibroids
  • Infection with HIV or hepatitis B or C
  • Inability to adopt a lifestyle change of restrictive activity during the remaining portion of the pregnancy
  • Inability to travel to The Fetal Center at Children’s Memorial Hermann Hospital or to comply with follow-up care requirements

*Under research protocol only

What counseling and evaluation is required for fetal surgery?

Patients will meet with a comprehensive team of affiliated specialists for complete counseling and evaluation over three days prior to being approved for the surgery. Physician consultation is non-directive and provides families with a complete understanding of the risks and benefits of open fetal surgery. Process steps include:

Initial Steps for The Fetal Center’s Counseling and Education

  • Screening by phone with a dedicated nurse coordinator

First Day

  • MRI

Second Day

  • Comprehensive ultrasound with 3D imaging of the fetal spine
  • Maternal history and physical
  • Initial meeting with maternal-fetal medicine specialist with uses of models to explain the findings in their fetus
  • Genetic counseling/amniocentesis if not already performed
  • Meeting with pediatric surgery
  • Counseling with a pediatric neurosurgeon

Third Day

  • Meeting with a social worker
  • Meeting with a neonatologist
  • Meeting with an anesthesiologist
  • Financial counseling
  • Meeting with a Child Life specialist, when other small children are at home
  • Wrap-up meeting with a maternal-fetal medicine specialist and pediatric surgeon to discuss the procedure and answer any additional questions

The patient is asked to return home and discuss her decision with her family. If the patient decides to proceed with fetal surgery, we ask her to call her nurse coordinator with her decision. The patient’s case is then presented at a group meeting of physician specialists to ensure it is the best option for both mom and baby.

When does the fetal surgery occur?

Fetal surgery is scheduled between 24 and 25 6/7 weeks of pregnancy. The patient is asked to return to Houston 24 hours before surgery for preoperative laboratories to be drawn and special instructions. She will then be admitted to Children’s Memorial Hermann Hospital the morning of her surgery.

What are the details of fetal surgery?

Fetal repair of spina bifida requires a multidisciplinary team of specialists. An epidural is placed the morning of surgery to be used for pain relief when the patient returns from the operating room. Although the operation is much like a cesarean section, it is performed with the mom asleep (general anesthesia). The fetus, however, is not removed from the uterus. An incision is made in the mother’s abdomen and a smaller incision is then made in the uterus, just large enough for the spinal defect to be operated on. The spina bifida defect is surgically repaired by the affiliated pediatric neurosurgeon, much as it would be after the baby is born if the maternal-fetal surgery were not undertaken. After the procedure, the amniotic fluid that is lost is replaced with sterile fluid and the incisions in the uterus and the mother’s abdomen are closed.

What will happen after fetal surgery?

After the operation, the mother will return to Labor and Delivery for the next four days. One nurse will be assigned to the mother during recovery for the first 24 hours. Several medications will be given to prevent labor. An epidural is used for the first two days to prevent pain. If there are no complications, the mother should expect to be discharged on the fourth day after surgery. Strict bed rest is required for three weeks following the procedure, and an ultrasound is conducted every week to check on the baby. Patients are allowed to return to their home town after a two-week stay in Houston after consultation with their local obstetrician-gynecologist in conjunction with their referring maternal-fetal medicine specialist. In some cases, patients undergoing a “patch” repair may be encouraged to return to Children’s Memorial Hermann Hospital for their delivery so that their baby’s recovery can be managed by experienced personnel.

What happens during and after delivery?

Delivery by C-section will be scheduled at 37 weeks to prevent the mother from going into labor. This is done to prevent any stretching or tearing of the scar that was left on the uterus from the fetal intervention.

After delivery, the baby will typically undergo evaluation of bladder function and additional tests including ultrasound and/or MRI to determine if hydrocephalus is present. Treatment for hydrocephalus is individualized through the care of a local pediatric neurosurgeon in consultation with our Center. If there is evidence of club feet (talipes), early treatment with splints may be initiated by pediatric orthopedics. Although the baby will need routine pediatric care with a general pediatrician, parents are encouraged to seek multidisciplinary care at a regional spina bifida clinic to help the patient and their family develop a plan for long-term care and follow-up.

What are the long-term outcomes and considerations?

Some children will require intensive spina bifida treatment throughout their lives due to the range of complications associated with the defect. The level of the spinal defect can provide some prediction of the severity and extent of the neurological problems. However, the severity of the problems of spina bifida will only be determined over time. The Fetal Center will help coordinate all of the specialists and services necessary to help patients care for their child.

Contact Us

When you contact The Fetal Center, you will be in touch with a dedicated coordinator who will walk you through the process step-by-step and help you to understand every aspect of your care.

Contact UsMap & Directions

The Fetal Center at Children's Memorial Hermann Hospital
UT Professional Building
6410 Fannin, Suite 210
Houston, Texas 77030

Phone: (832) 325-7288
Toll free: (888) 818-4818
Fax: (713) 383-1464
Email: thefetalcenter@memorialhermann.org

Note: This information regarding your condition is meant to be a helpful, informative introduction. Because every newborn is different, this may not be applicable to all cases, especially if there are additional defects. Your team of specialists at The Fetal Center will provide you with information specific to your pregnancy.