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.
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.
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.
We are pleased to inform you that the affiliated physicians at The Fetal Center at Children's Memorial Hermann Hospital are enrolling patients for fetoscopic spina bifida repair. After rigorous review by the FDA, the Fetal Center’s team received approval for the research protocol titled "Early Feasibility Study: Fetoscopic NEOX Cord 1K® Myelomeningocele (MMC) Repair." NEOX Cord 1K is a cryopreserved human umbilical cord patch that has anti-inflammatory, anti-scarring and regenerative properties, which has shown to reduce spinal cord damage in preclinical studies of in-utero spina bifida repair. The study is aimed to improve upon the benefits of open in-utero spina bifida repair and reduce maternal morbidity through minimally invasive approach. Patients who underwent fetoscopic repair will be able to deliver vaginally at term and reduce the risk of uterine rupture in future pregnancies.
Historically, techniques used in fetoscopic surgery for neural tube defects (NTDs) have been a tradeoff between minimally invasive benefits to the mother and an alternative method of NTD repair for the baby. Early attempts at fetoscopic surgery used a variety of techniques with varying degrees of success. We believe that fetoscopic spina bifida surgery leading to water-tight closure and scar tissue minimization may provide excellent outcomes for both mother and baby. To date, our multidisciplinary team approach for open repair has produced comparable outcomes to MOMS study for babies.
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:
*Under research protocol only
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:
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.
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.
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.
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.
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.
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.
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.
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
To contact The Fetal Center at Children's Memorial Hermann Hospital, please fill out the form below.
Located within the Texas Medical Center, The Fetal Center is affiliated with McGovern Medical School at UTHealth Houston, UT Physicians and Children’s Memorial Hermann Hospital.