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Surgery for spina bifida is best done in the womb

In utero surgery is highly specialised and currently unavailable in most places

By Dr Joe Kabyemela, MD

In the developed world, a diagnosis of spina bifida is almost invariably made while the baby is still in the womb. Some mothers opt to terminate the pregnancy but many will carry on with the pregnancy. Traditinally, the baby will be operated upon after birth to try to minimise the neurological effects of this condition. These effects tend to be long term and for most, life-long. Increasingly, centres of excellence in many parts of the developed world have offered surgery while the baby is still in the womb.

A March 29th, 2010 online paper in the American Journal of Obstetrics & Gynecology reports  research findings showing that closing a myelomeningocele (the spina bifida defect) in utero, rather than after birth, may improve preschool neuro-developmental outcomes.

The researchers knew from experience that fetal surgery for spina bifida can "significantly reduce the need for ventriculo-peritoneal shunts for hydrocephaly, improve leg function and independent ambulation rates, and decrease the potentially lethal consequences of the Chiari II (hindbrain herniation) malformation," senior author Dr. Mark P. Johnson told Reuters Health.

He added, "The present study suggests that most of these children also had normal neuro-developmental and cognitive function at time of entering school compared to the characterized disabilities and deficits described in populations of children that underwent traditional surgery after birth."

At the University of Pennsylvania in Philadelphia, Dr. Johnson and his colleagues performed in utero myelomeningocele surgery on 54 fetuses. Thirty of those children returned for evaluation when they were 5 years old, including 14 (47%) with shunts.

Overall, neuro-cognitive findings were within the normal population range. The children had high rates of average or even high-average scores for processing speed (60%), verbal intelligence quotient (93%), performance intelligence quotient (90%), and full intelligence quotient (90%).

Mean full intelligence quotient and processing speed were significantly higher in non-shunted children. Mean verbal intelligence and performance intelligence quotients also tended to be higher in these patients.

The authors compared the outcomes in these 30 youngsters to those in patients who only returned for 1-, 2-, or 3-year assessments, "to evaluate whether children who returned serially and those who did not had different early neuro-developmental outcomes." Average scores were similar in patients who did and did not return at 5 years, they said.

"These findings," continued Dr. Johnson, "strongly support and mandate completion of the present NIH/NICHD-sponsored prospective randomised trial (Management of Myelomeningocele Study, MOMS) formally comparing outcomes in children undergoing prenatal fetal repair to those that have more traditional neuro-surgical repair after birth to confirm our findings."

"If fetal surgery is shown to improve outcomes," he concluded, "future generations of children will benefit from this research. If shown to be no different than traditional post-natal repair, then future generations of mothers will not be exposed to the possible complications of this surgery to their present and future pregnancies."