Prenatal Surgery for Myelomeningocele
The Fetal Care Center is now offering prenatal surgery to repair myelomeningocele (MMC).
The criteria used to qualify patients for this treatment option are based on our previous experience with open fetal surgery for MMC and the results of the MOMS trial. In order to be considered for prenatal MMC repair the following criteria must be met:
Inclusion Criteria:
- Myelomeningocele at T1 through S1 with hindbrain herniation, level of MMC confirmed by ultrasound and hindbrain herniation confirmed by MRI.
- Maternal age greater than or equal to 18 years.
- Gestational age 19 0/7 weeks to 26 6/7 at the time of prenatal surgery.
- Normal karyotype or FISH.
- Normal fetal echocardiogram.
- Singleton pregnancy.
- Willing to remain in greater Cincinnati area for remainder of pregnancy and deliver at The Fetal Care Center for postnatal management at Cincinnati Children’s.
Exclusion Criteria:
- Significant fetal anomaly not related to MMC.
- Kyphosis in fetus of greater than 30 degrees.
- History of incompetent cervix, cervix less than 20mm or presence of a cerclage.
- Morbid obesity as defined as a BMI of greater than 35.
- Maternal – fetal Rh isoimmunization, Kell sensitization or a history of neonatal alloimmune thrombocytopenia.
- Maternal HIV, Hepatitis B, Hepatitis C due to increased risk of transmission to the fetus during maternal – fetal surgery.
- Uterine anomaly such as large or multiple uterine fibroids or mullerian duct abnormality.
- Maternal medical condition which is a contraindication to abdominal surgery or general anesthesia.
- No support person to stay with mother at Ronald McDonald House.
- Patient does not meet psychosocial criteria as determined by the social worker evaluation.
- Previous hysterotomy in the active segment of the uterus either from previous classical cesarean section, uterine anomaly such as an arcuate or bicornuate uterus, major myomectomy resection or previous open fetal surgery.
If a mother and her baby meet all of the qualifying criteria and wishes to proceed with prenatal surgery there is a several step process to be considered for this surgery. The mother will undergo counseling by a Maternal-Fetal Medicine Specialist who is not part of the operative team to insure: 1.) that she has been appropriately counseled about the potential obstetric, maternal and fetal risks and complications and; 2.) she has an accurate appreciation of the implications of these risks and complications prior to being consented for the surgery. The mother will also undergo counseling by a Neonatologist who is not part of the team initially counseling her to insure she has been appropriately counseled about the potential risk of prematurity and potential complications associated with prematurity. Each patient being considered for prenatal repair of MMC will be reviewed by a special Oversight Committee for Prenatal Surgery for MMC. Once approved, a separate consent team meeting is held to review the potential anesthetic, obstetrical, neurosurgical and fetal surgical and neonatal risks of the procedure with representation of each respective discipline present to review these potential risks and complications.
Oversight of prenatal surgery for MMC
Prenatal repair of MMC is a new treatment option that has only recently become available with reporting of the MOMS Trial results. In order to independently assess each case offered prenatal MMC repair, the Fetal Care Center of Cincinnati has a Prenatal MMC Repair Oversight Committee. The committee is composed of a senior pediatric neurosurgeon, maternal-fetal medicine specialist, neonatologist, pediatric surgeon and a biomedical ethicist. The members of the committee will review the case of every mother offered prenatal MMC repair to be certain that a.) all criteria are met, b.) she was appropriately counseled about the potential risks and complications, and c.) review each adverse event or complication, d.) review maternal, fetal and neonatal outcomes of the surgery. This committee will be empowered to stop prenatal MMC repair surgery being offered in the event of a maternal or fetal complication until a more thorough investigation can be completed. This committee will decide the number of cases necessary to discontinue oversight as indicated when results comparable or superior to the MOMS trial are achieved.
