Fetal surgery for open spina bifida

Abstract

Key content Spina bifida is a congenital neurological condition with lifelong physical and mental effects. Open fetal repair of the spinal lesion has been shown to improve hindbrain herniation, ventriculoperitoneal shunting, independent mobility and bladder outcomes for the child and, despite an increased risk of prematurity, does not seem to increase the risk of neurodevelopmental impairment. Open fetal surgery is associated with maternal morbidity. Surgery at our institution is offered and performed according to internationally agreed criteria and protocols. Further evidence regarding long‐term outcomes, fetoscopic repair and alternative techniques is awaited. Learning objectives To understand the clinical effects, potential prevention and prenatal diagnosis of spina bifida. To understand the rationale and evidence supporting the benefits and risks of fetal repair of open spina bifida. To understand the criteria defining those who are likely to benefit from fetal surgery. Ethical issues The concept of the fetus as a patient, and issues surrounding fetal death or the need for resuscitation during fetal surgery. The associated maternal morbidity in a procedure performed solely for the benefit of the fetus/child. The financial implications of new surgical treatments.

Preclinical stem cell therapy in fetuses with myelomeningocele: A systematic review and meta‐analysis

“…Although our findings are encouraging for clinical translation, further work is needed to determine the optimal source and dose of P‐MSCs with appropriate toxicology studies before moving to a phase 1 clinical trial of P‐MSCs as an adjunct to fetal surgery. Using autologous AF‐MSCs for clinical treatment is also a feasible option as the majority of MMC fetuses are diagnosed in the second trimester, and women who wish to proceed to fetal surgery are mandated to undergo an amniocentesis to determine fetal karyotype 5 . Hence, amniotic fluid would be available for MSC isolation in most cases.…”

“…The condition can be detected by prenatal ultrasound scan as early as the first trimester; however, the majority of cases are diagnosed during the second trimester (anomaly) ultrasound scan 3,4 . Apart from preventive therapy using periconceptual vitamins such as folic acid, current management following prenatal diagnosis may include termination of pregnancy, postnatal or more recently fetal surgery 5 . The rationale for fetal repair before birth is that MMC is a ‘progressive’ condition with cumulative spinal cord functional loss throughout gestation, as demonstrated in clinical and animal studies 6–8 .…”

Alternative Hysterotomy Technique for the Reduction of Prenatal Complications of Intrauterine Myelomeningocele Repair

“…The main maternal risks of OFS include surgical complications, uterine dehiscence, or rupture and the need for caesarean delivery in all pregnancies [23]. Fetoscopic repair of spina bifida has the potential to reduce these maternal risks, but it currently carries a higher rate of prematurity and risk for postnatal neurosurgical intervention [24].…”

Maternal and fetal anaesthesia for fetal surgery

“…While 57% of babies born with an L5 lesion will have independent mobility, all of those with an L1–3 lesion will not. Most patients will have impaired bladder and bowel dysfunction, with 80% developing progressive hydrocephalus and will have an overall reduced life expectancy [6]. Historically, the majority of women opted for a termination of pregnancy [7].…”