Spina bifida is a
birth defect that
occurs when the spinal cord
fails to form properly,
leaving a section of the spinal
cord and spinal nerves exposed
through an opening in
the unborn baby's back.
There are several scientific
names for spina bifida.
It is also known
as myelomeningocele
or meningomyeocele.
Although there are many
theories about why this happens,
the exact cause of
spina bifida is unknown.
However, we do know
that spina bifida
a occurs early in pregnancy
during the development
of the spinal cord,
typically about 35 to 42 days
since your last
menstrual period or LMP.
This rare condition
is reported to occur
in one out of every 1,500 to
2,000 births in the United
States every year.
To better understand
the problems associated
with spina bifida, let's first
review the normal development
of the spinal cord.
In early fetal life, the tissue
that covers the spinal cord
closes like a zipper.
This typically begins in the
middle of the spinal cord
and closes in both
directions, toward the head
and toward the bottom
of the unborn baby.
This process starts at about
35 days into fetal life.
At 36 days since your
last menstrual period,
there is almost complete
closure of the spinal cord,
with only small openings
near the head and bottom.
By 42 days since your
last menstrual period,
there should be complete closure
of the spinal cord, also known
as the neural tube.
However, failure of the neural
tube to completely close
will result in a
neural tube defect.
If the tissue fails to
close near the fetus's head,
a condition known as
anencephaly can occur.
Failure of the tissue to close
at the bottom end of the fetus
results in a myelomeningocele,
or spina bifida.
Here you can see the
differences in development
of a normal fetus in
comparison to a fetus
with an open neural tube defect
at the bottom of the fetus,
an example of spina bifida.
Several variations of
spina bifida can occur.
These variations depend
on how the neural tube
defect continues
to develop, on what
is protruding through
the open neural tube,
and what is covering the
spina bifida abnormality.
These variations include spina
bifida occulta, or hidden spina
bifida.
This is a covered neural tube
defect where a layer of skin
covers the opening in the spine.
This form of spina bifida
occurs in approximately 15%
of patients and rarely causes
any neurological problems.
Myeloschesis is this
is a flat neutral tube
defect without a
layer of skin covering
the opening in the spine.
The spinal cord and the
surrounding nerve tissue
are exposed to the
amniotic fluid.
These forms of spina bifida
have similar risks and symptoms
as myelomeningoceles.
Meningocele contains
only spinal fluid
that sticks out through
an outpouching or sac
through an abnormal
opening in the spine.
This abnormality does not
contain any nerve tissues.
Babies with meningocele
have few or no symptoms,
while others may develop
degrees of paralysis
with bladder and
bowel dysfunction.
myelomeningocele is
the most severe form
of a neural tube defect.
It contains both fluid and
nerve tissue within a sac.
This occurs when the spinal
cord or neural elements
are exposed through the
opening in the spine, which
results in nerve damage with
partial or complete paralysis
of the body below the level
of the spinal opening.
Individuals may
be unable to walk
and may have bladder
and bowel dysfunction.
Both meningoceles
and myelomeningoceles
have a covering of skin with or
without an outpouching, known
as covered neural tube defect.
These conditions typically
have very mild to no symptoms.
During the end of
the second trimester,
you can see the opening of the
spinal cord and spina bifida
defect developing.
The image on the left
is a view from the side.
As you can see,
there is an opening
in the spinal cord that allows
an outpouching of tissue.
This is myelomeningocele.
The image on the right
demonstrates an outpouching
from the defect as you look
down on the fetus's back.
The spinal column is
divided into four sections.
Each segment of the
spinal cord corresponds
with a specific region
of sensory, or sensation,
and motor, or movement,
function in the body.
Starting from the head, there
are seven cervical vertebrae
found in the neck.
Spinal nerves at this level
supply movement and feeling
to the arms, neck, and
upper trunk of the body.
Next are 12 thoracic
vertebrae associated
with the chest, followed by
five lumbar vertebrae found
in the lower back,
and six sacral
vertebrae that
fuse at the bottom
to form the tailbone or coccyx.
In the normal spine
and spinal cord,
nerves leave the
spinal cord and are
numbered according to the
vertebrae at which they
exit the spinal column.
Their function is linked
to the level at which they
leave the spinal cord.
The location of
spina bifida defect
can result in abnormal function.
A spina bifida defect
is defined based
on the level and extent
of the bony opening
along the spinal canal.
The level of bony
defect can help
us predict the nerve damage
that a child may experience.
The level of the
nerve damage may
result in loss of sensation or
problems with motor function,
including bowel, bladder,
and sexual dysfunction.
Since most spina bifida defects
are associated with the lumbar
spine, which is
responsible for the nerve
function in the
legs and lower body
we will focus on
consequences associated
with these types of defects.
In general, the nerves
associated with L1 to S1
are associated with movement
and sensation of the lower legs.
Nerves associated
with L1 to L3 are
responsible for
flexing the knee,
whereas nerves
associated with L4 to L5
allow the knee to extend.
At the same time, all
the nerves from L1 to L5
are required to provide
nerve function to the thighs
and hips.
The motor function
of the foot and ankle
are controlled by
the lower nerves.
However, all of the nerves in
the lumbar and sacral spine
are needed to
properly coordinate
movement of the hips, legs,
and feet in order to walk.
Spinal levels L4 and L5
allow one to raise the foot.
Spinal levels S1 and S2
allow one to lower the foot.
In general, when
the spina bifida
involves a level above L3,
the ability to walk normally
is significantly impaired.
In addition to the movement
of the lower extremities,
nerves in the lumbar
and sacral regions
help control functions
of the internal organs.
Since many cases of
spine of spina bifida
involve the sacral nerves,
children with spina bifida
often have problems with
urination and bowel control.
In later life, sexual
function may also be affected.
Typically, children
with bladder problems
are unable to completely
empty the bladder.
Problems with bowel control
may result in soiling.
Patients with spina
bifida may experience
some sexual dysfunction,
but this may not affect
their reproductive ability.
The exact mechanism by which
the spina bifida defect
causes nerve damage is unclear.
There are several theories,
but the most popular one
is a two-hit approach.
The first hit is the
failure of the spinal column
to properly close, resulting in
the exposure of the spinal cord
and its nerves, which may cause
nerves to abnormally develop.
This by itself may or may not
directly cause nerve damage.
However, a second hit
occurs where the open nerve
fibers are exposed to
the amniotic fluid, which
can be damaging.
And nerves can also
be directly damaged
by trauma due to
bumping and rubbing
against the uterine wall.
In addition to the
spinal cord problems,
patients with spina bifida can
develop two distinct problems
related to the brain, buildup
of fluid within the spaces
of the brain, called
hydrocephalus,
and a sinking of the
lower part of the brain
into the base of the skull,
known as hindbrain herniation
or Chiari Malformation.
In the normal brain,
the brain tissue
contains and is surrounded by
cerebrospinal fluid, otherwise
known as CSF.
Normally most of the CSF fluid
is made by special tissue
that lines the open
spaces within the brain
called the ventricles.
This fluid then
flows around the back
of the brain in a region
that contains the cerebellum
and brain stem, and
into the spinal canal
to surround the spinal cord
all the way to the tailbone.
In the case of spina
bifida, the defect
at the bottom of the spine
allows the CSF to leak out
the opening of the spinal
canal and pulls the brain
downward into the base of
the baby's skull, which is
called Chiari II Malformation.
This blocks the normal
flow of cerebrospinal fluid
and causes the
ventricles to enlarge,
a secondary brain abnormality
known as hydrocephalus.
Traditionally, spina
bifida is repaired shortly
after the baby is born.
If the defect is diagnosed
during pregnancy,
babies with spina
bifida are typically
delivered by C-section.
Because the spinal cord
defect does not directly
affect the heart
or lungs, babies
are generally very
stable and do not require
any immediate treatment.
Nonetheless, babies
are transferred
to the neonatal intensive
care unit for close medication
attention.
At that point, neonatologists
and pediatric neurosurgeons
work together to further
evaluate the baby
and identify any
additional problems.
They also prepare the infant
for repair of the spina bifida.
A pediatric neurosurgeon
will perform the repair
within the first
few days of life,
and depending on the severity
of the hydrocephalus,
infants may or may
not require a tube
that drains the excessive
fluid from the brain
at the same time.
This tube is called a
ventriculo-peritoneal or VP
shunt.
Babies eventually
recover, and once stable,
are able to go home.
Children with spina bifida
are followed very closely
by several pediatric
specialists,
including a pediatric
neurosurgeon,
pediatric neurologist,
pediatric urologist,
pediatric orthopedic
surgeon, and pediatricians
who specialize in spina bifida.
In most centers,
including the Fetal Center
at Children's Memorial
Hermann Hospital,
spina bifida
children are enrolled
in a comprehensive program to
address their medical problems,
monitor them for
long term problems,
and provide support to families.
Many of the complications
of spina bifida
will not show until
later in life.
As mentioned earlier,
these may include problems
with walking, bowel
and bladder function,
and neurological development.
After the initial repair,
future operations and therapy
may be needed to treat
the problems associated
with spina bifida.
For example, VP shunts are
placed to treat hydrocephalus.
The VP shunt drains the
built-up fluid in the brain
into the abdomen, where
it can be absorbed.
This treatment can be
successful in managing
many of the problems
that can occur
in children with spina bifida.
Although VP shunts are
effective in draining the fluid,
they are mechanical
devices and they sometimes
fail due to blockage or
movement and must be replaced.
Shunts can also become
infected and require removal.
A baby with spina
bifida will usually
have several shunt revisions
in his or her lifetime.
These treatments address the
problems associated with spina
bifida, but unfortunately cannot
restore the nerve damage that
has already occurred.
Today, alternative options
exist to treat children
with spina bifida.
After decades of
research, surgery
to repair the spina bifida
defect before the baby is born,
also known as fetal
surgery, is a possibility
for babies and mothers who
qualify for the procedure.
In early 2011, The New
England Journal of Medicine
published the results of the
Management of Myelomeningocele
Study, or MOMS
trial, that studied
the effects of fetal surgery
for the repair of spina bifida
compared to the routine
care of surgery after birth.
This study was sponsored by the
National Institutes of Health
and was conducted
over eight years.
The primary purpose
of the study was
to determine if there was a
difference in infant death
or need for a VP shunt
between fetal surgery patients
and those repaired after birth.
During the eight-year
period, more than 1,000
pregnant mothers
whose fetuses were
diagnosed with spina
bifida were initially
screened for the study.
Due to a variety of factors
following additional exams
and evaluation, 183
patients were randomly
placed into two groups with 92
to the after birth repair group
and 91 in the fetal
surgery repair group.
Ultimately, the study
was stopped early
when the committee that
was monitoring the results
noted a clear benefit
to infants that
had undergone fetal surgery.
The study results were made
public in early February, 2011.
For patients to be eligible
for the MOMS trial,
they had to meet specific
maternal and fetal
requirements.
The fetal requirements
included but were not
limited to a pregnancy
of a single fetus.
Pregnancies with
twins were excluded,
since the twin
without spina bifida
would be put at higher
risk for premature delivery
after fetal surgery.
The pregnancy had
to be associated
with a single fetus
between 19 and 25 completed
weeks of gestation,
which was the time period
for potential fetal surgery.
To qualify for the
MOMS study, the mother
had to be more than
18 years of age.
Her body mass index, or
BMI, had to be less than 35,
which is a number calculated
based on weight and height.
A BMK greater than
35 is considered
to indicate significant
obesity and would increase
the risk of prematurity.
A history of a previous
incision on the uterus,
such as a classical C-section,
puts the pregnant patient
at risk for scar separation
late in pregnancy
and therefore was
excluded from the study.
Because the risk
of preterm delivery
is higher in patients
with fetal surgery,
mothers with any
conditions or history
that increased the risk
of preterm delivery,
such as short cervix, were
also excluded from the trial.
Additional risk factors
that prevented a woman
from being included
in the study were
insulin dependent diabetes,
infection with hepatitis B
or C, HIV infection, red
cell aloe immunization,
and unwillingness to
accept blood transfusions
for various reasons.
The unborn baby also had to
meet certain criteria in order
to enter the MOMS trial.
These included the presence of
a myelomeningocele beginning
with the first
thoracic vertebra, T1,
and the first sacral
vertebra S1 levels.
Chiari II Malformation
had to exist
at the time of evaluation.
There could be no evidence
of an exaggerated curving
of the spine.
The spina bifida could
not be associated
with other major fetal anomalies
such as a heart defect.
Finally, the fetus had to
have normal chromosomes found
by amniocentesis.
Because of the research
aspect of this study,
patients were carefully
chosen to maximize
the benefits of fetal
surgery while minimizing
the risks to both mom and baby.
There were two main
outcomes of the study.
The first was death or need for
a VP shunt by one year of age.
The designers of the trial felt
that if the children did not
receive a shunt by
one year of age,
they were not likely to need
a shunt during their lifetime.
The second main
outcome of the study
was to measure the
mental and motor
development using standardized
tests at 30 months of age.
In addition to the
outcomes on the baby,
one of the greatest
contributions from the MOMS
trial was the
information provided
on the risks of fetal surgery
for the pregnant mother.
Some complications directly
affected the mother,
while others were
effects of the pregnancy.
6% of women who
underwent fetal surgery
suffered from extra
fluid on their lungs,
known as pulmonary edema.
This often requires
oxygen support
but eventually correct itself.
Problems with the membrane
sac that surrounds the fetus
are a known complication
with any fetal surgery,
and this was certainly
seen in the MOMS trial.
One in four patients
was noted to have
a separation of the membranes
from the uterine wall
after the surgery.
Membrane separation
is a risk factor which
may lead to early delivery.
Membrane separation occurred
in almost half of the patients
after fetal surgery
and was six times more
likely to occur than
when the spina bifida
repair was postponed until
after the delivery of the baby.
The risk for decreased
amount of amniotic fluid
around the fetus, also
known as oligohydramnios,
was twice as likely to
occur in the fetal surgery
group as a result
of leakage of fluid
through the surgical incision.
Infection rates
were slightly higher
in the fetal surgery groups.
Any fetal surgery is at risk
for separation of the placenta
from the uterus, also known
as placental abruption.
This can occur at any
point during the surgery
and afterward.
Depending on the severity
of the abruption,
some fetuses may require
emergent delivery.
During the MOMS trial,
the obstetricians
examined the uterine incision
used for the fetal spina
bifida repair
earlier in pregnancy
at the time of the
C-section delivery.
They found that the
scar was very thin
in one out of four
cases, and that there
was evidence of
uterine scar separation
in an additional 10% of cases.
Keep in mind, most of
these complications
are known problems
with fetal surgery
and would have only been
expected in the fetal surgery
group of patients.
In normal pregnancies,
some of these problems
can occur but are rare.
Fetal repair of
spina bifida was also
associated with
significantly increased
risks for the newborn.
Most of the neonatal
complications
were related to the
prematurity at birth.
The average gestational
age at delivery
was about three weeks earlier
in the fetal surgery group,
at 34.1 weeks versus 37.3 weeks.
13% of babies were delivered
before 30 weeks gestation.
An additional one third were
delivered between 30 and 34
weeks, and another one
third were delivered
between 35 and 36 weeks.
This means that only
one in five babies that
underwent fetal surgery
were delivered at term.
Because of the
prematurity, birth weight,
which corresponds with their
gestational age at birth,
was less in the
fetal surgery group.
The increased rate
of prematurity
in the fetal surgery
group was also
associated with a 21% incidence
of respiratory distress
syndrome seen in
preterm infants,
requiring oxygen and ventilator
support in the babies.
This was three times higher
than the postnatal repair group.
The benefits of fetal
repair of spina bifida
appeared to be statistically
superior to postnatal repair.
The primary outcome
of the study,
which was death or
need for a VP shunt
in the first year of life,
was 30% less frequent
in the fetal surgery group than
in the postnatal repair group.
The major differences
in the two groups
appeared to be related to the
improvement of the Chiari II
Malformation in the
fetal repair group.
Babies who underwent
fetal repair
were half as likely
to need a VP shunt
at one year, 40% versus 82%.
In addition, while
all fetuses that
were entered into the
study had evidence
of hindbrain herniation on
MRI during their mother's
pregnancy, it appeared that
the Chiari II Malformation
was less common and
less severe among babies
that underwent fetal surgery as
compared to postnatal repair.
In fact, 36% of infants
who underwent fetal surgery
had no evidence of hindbrain
herniation, compared to only 4%
in the postnatal surgery group.
However, at 12 months, there
was a higher percentage
of infants needing
operations for tethered cord
syndrome, a condition where
the spinal cord becomes
stuck to the surrounding
tissue within the spinal canal,
causing the spinal cord
to become abnormally
stretched as the child grows.
This occurred more often
in the fetal surgery group
compared to the
postnatal surgery.
At 30 months of age,
neurological outcomes
were reviewed and mental
development in both groups
was similar.
However, motor
development scores
seemed significantly better
in the fetal surgery group.
While the ability
to walk depends
on the level of the
spina bifida lesion,
the study found that
twice as many children who
underwent fetal surgery were
walking independently as
compared to the postnatal
group, 42% in the fetal surgery
group compared to only 21% in
the postnatal repair group.
Overall, the degree of
disability in a child
was lower among fetal
surgery patients.
The MOMS trial was
a landmark study
in the world of fetal therapy.
Historically, fetal
surgery was used only
for life-threatening conditions
in which the fetus would likely
die during pregnancy
if left untreated.
However, the MOMS trial
was the first study
that demonstrated significant
benefit in children
who had undergone
fetal surgery for spina
bifida, a non-lethal disease.
Careful analysis of
the study results
demonstrated the benefits
outweighed the risks and harms
of fetal surgery,
including those
associated with the mother.
Although there are still unknown
answers to many more questions,
especially those about
long term outcomes,
it appears that babies who
underwent fetal surgery
have benefited in
the short term.
Unfortunately, the MOMS trial
provides only statistics,
and not specifics about
your baby, which is
what all parents want to know.
For many families, this
comprehensive multi-day
evaluation and consultation
is the first opportunity
to meet health care
professionals who specialize
in this condition, and
ask questions and receive
information specific to them.
The extensive
consultation process
is designed to help patients
learn about spina bifida
and what life is like for
a child with the condition.
Families also learn about
all of the treatment options
so they have a full
understanding of the risks
and benefits of conventional
treatment versus fetal surgery.
When patients are referred
to the Fetal Center
at Children's Memorial
Hermann Hospital,
they undergo comprehensive
evaluation and education
consultations.
This includes a
multi-disciplinary team
approach, including
specialists from
both maternal fetal medicine
and pediatric subspecialties.
Before fetal surgery can
be considered further,
thorough counseling
and evaluations
are provided to ensure there
are no unnecessary risks
to the mother, and that the baby
is in an appropriate candidate
for surgery.
Early in the evaluation process,
families meet a dedicated nurse
coordinator from
the Fetal Center
who will guide them through
a step-by-step process that
includes the following.
A maternal fetal
medicine specialist
will perform a complete
maternal and pregnancy history
evaluation and a
physical examination,
and will evaluate
the fetal ultrasound
to ensure there are no
other complications.
Families will meet with a spina
bifida pediatric specialist,
who will provide valuable and
unique information on what
life is like for spina bifida
children and their families.
The pediatric
neurosurgeons will educate
families about spina bifida
and the surgical treatments
involved with fetal surgery,
as well as postnatal surgery.
If it has not already been
performed by your referring
perinatologist.
An amniocentesis
will be performed
to be sure the fetal
chromosomes are normal.
In any event, you will meet
with a genetic counselor
to review your family's
history for birth defects.
In addition to the
consultation, patients
undergo extensive testing.
A comprehensive
ultrasound is performed
to assess the presence of
the Chiari II Malformation
and determine the level of
the spina bifida defect.
A fetal MRI will
also be performed,
as some features of
the spine and brain
are better seen on MRI.
MRI utilizes
magnetic waves, which
are safe during pregnancy.
For mothers and babies who
qualify for fetal surgery,
additional consultations and
evaluations are necessary.
An obstetric
anesthesiologist affiliated
with the Fetal Center's
multi-disciplinary team
will meet with the mother,
assess any anesthetic risks,
and explain any
anesthesia concerns.
A neonatologist who specializes
in critically ill newborns
will educate each family about
the potential complications
of a premature birth.
Preterm delivery is a potential
risk factor of fetal surgery.
Families will meet
with a social worker
to discuss the importance of
the family and friends support
systems.
Undergoing fetal
surgery is a commitment
through the entire
pregnancy which
requires the help of others
to ensure a safe pregnancy
after fetal surgery.
If there are other
small children at home,
a child life specialist at
Children's Memorial Hermann
Hospital will meet
with each family.
This individual will
provide valuable tools
to help explain the unborn
baby's surgery to the baby's
siblings.
Finally, families will
meet with the fetal surgery
specialist who will be
involved in the surgery.
The Fetal Center's
affiliated team
will go over the
actual procedure
and answer any questions
you may still have.
Fetal surgery is not
for every patient.
Often patients do not qualify
because of reasons involving
the fetus, and sometimes
they don't qualify
because of maternal factors.
There are also families who
qualify for fetal surgery
but do not think it is the best
option for them after spending
time learning about spina
bifida and fetal surgery.
For those who qualify
for fetal surgery,
we typically ask
families to take
a few days to consider
all of the options that
have been presented with.
Undergoing fetal
surgery for your baby
is a major commitment,
and a lifestyle
change for the remainder
of the pregnancy
and future pregnancies.
It typically includes a
five-day hospitalization
following the fetal surgery,
three weeks of strict bed
rest after the procedure,
and weekly ultrasounds
to monitor the fetus and
assess for complications
of the surgery.
More importantly,
there maybe prolonged
subsequent hospitalizations
during the pregnancy
if complication should arise.
Membrane separation,
preterm labor,
or leakage of amniotic
fluid may require
you to stay in the
hospital for the remainder
of your pregnancy.
Should you elect to proceed
with fetal intervention,
your surgery will
typically be scheduled
before 26 weeks gestation.
Fetal surgery for spina bifida
is a complicated operation
that requires the expertise of
many physicians and surgeons.
Two patients are
undergoing an operation,
the unborn baby
with spina bifida,
and the pregnant mother.
Care of the mother starts before
entering the operating room.
During the morning of
surgery, the mother and baby
undergo another full assessment,
including a fetal ultrasound.
An epidural for
post-operative pain control
is placed before surgery.
Once inside the operating
room, the mother and baby
are again evaluated
prior to the mother
falling asleep with
guided anesthesia.
Meanwhile, the
entire surgical team
is preparing for the operation.
Mothers undergoing
fetal surgery are
administered general
anesthesia and an epidural
for pain control.
The skin incision is
similar to an incision
used for cesarean
section deliveries.
As the pregnant
uterus is exposed,
the well-being of the fetus
and position of the placenta
is again reevaluated
via ultrasound.
The monitoring
process is continued
throughout the entire operation.
In order to expose
the back of the baby,
the uterus is opened with an
incision called a hysterotomy.
The location of the
incision is made
to provide the best exposure of
the spina bifida of the baby.
Careful attention is made
to avoid the placenta
and large blood vessels
within the uterine wall,
as both are important
for the baby's stability.
A stapling device especially
designed for fetal surgery
is used to make the incision to
prevent unnecessary bleeding.
An opening in the uterus
is made in an area away
from the placenta
just large enough
to expose the baby's back to
see the spina bifida defect.
Once the uterus is
open, only the area
of the back with
the spina bifida
is exposed for the operation.
The normal amniotic
fluid is removed,
and warm fluid is
circulated into the uterus
to replace it during
the operation.
This keeps the fetus
warm and prevents
kinking of the umbilical cord.
Once the baby is
properly positioned,
pediatric neurosurgeons repair
the defect in much the same way
they would after birth.
Once the spina bifida is
repaired, the uterus is closed.
Throughout the entire
procedure, the baby and mother
are continuously monitored by
the surgical and anaesthesia
teams.
The entire fetal surgery
team works together
to accomplish a very safe
and efficient operation
for both patients.
While the fetal surgery team is
working during the operation,
the neonatology team
is on standby, prepared
to act quickly if the
fetus demonstrates
any signs of
instability that would
require immediate delivery.
After surgery, you
will be awakened
from general anesthesia and
go to recovery in your room
in the labor and
delivery unit, where
you will receive one on one
nursing care for the first two
days.
Both you and your baby are
monitored during the remaining
hospitalization.
The first day after surgery
is the most difficult.
You will be asked to
stay in bed and not
allowed to drink or eat.
Most patients have a hot
and flushed sensation
and often describe their
feeling as losing a day.
This is due to a
medication called
magnesium sulfate that helps
prevent uterine contractions.
As you continue to
improve, this IV medication
will be changed to an
oral medication, which
you will continue for the
remainder of your pregnancy.
You will be slowly encouraged
to eat, drink, and get out
of bed over the next few days.
The epidural for pain
control will be changed
to oral medications as well.
Typically, mothers stay at
Children's Memorial Hermann
Hospital for five to seven days
following surgery for recovery
and evaluation, followed by
a two-week stay in Houston
for further monitoring.
Often, patients choose to
transfer their obstetrical care
to an affiliated physician and
deliver at Children's Memorial
Hermann Hospital.
The team of coordinators
at the Fetal Center
works closely with families
to make arrangements
for their entire
stay in Houston.
If you choose to return
to your local obstetrician
for delivery, the team
at the Fetal Center
will work closely with
the referring physician
to ensure an open
line of communication
and coordinate your care
throughout the remainder
of your pregnancy.
Several complications
may occur after surgery,
and can occur during the
hospitalization or thereafter.
Upon discharge
from the hospital,
patients and their families are
given very specific monitoring
instructions to look
for signs of problems.
These include contractions,
leaking of amniotic fluid,
bleeding from the
vagina, fevers,
and separation of the amniotic
membranes based on ultrasound.
If you begin to experience
uterine contractions,
please contact the Fetal
Center or your family physician
immediately, because
only 20% of pregnancies
reach term delivery
after fetal surgery.
Mothers who have
undergone surgery
can go into labor at any time.
Since the fetal membrane around
the sac containing the baby
were entered during
the surgery, there
is a significant risk of
leaking amniotic fluid.
Patients will usually experience
fluid coming out of the vagina
when they first stand up.
This is a serious
complication of the surgery,
as it can lead to infection.
If this occurs, seek
immediate medical attention.
If such leakage
occurs, you will be
likely in the hospital for the
remainder of your pregnancy.
Bleeding from the
vagina may be a sign
of abruption, a
critical situation where
the placenta is
becoming dislodged
from the uterine wall.
Because this can have
serious consequences,
please contact the Fetal Center
or your physician immediately.
During weekly ultrasounds
after discharge,
the fetal membranes
may become separated
from the uterine wall.
This is called
chorioamnion separation.
This condition puts
you at high risk
for leaking amniotic fluid.
If membrane separation is
detected by ultrasound,
you will be admitted to the
hospital for observation
for the remainder
of your pregnancy
with potential for
early delivery.
In about 20% of cases
in the MOMS trial,
patients experienced
no complications
and underwent a
scheduled delivery
by C-section at 37
weeks gestation.
Even though this gestational
age three weeks earlier
than the usual due date
at 40 weeks gestation,
your fetal surgery team feels
that a delivery at 37 weeks
is relatively safe for the
baby while minimizing the risks
of spontaneous delivery.
37 weeks is also picked
as a time for delivery
to keep the fresh scar
from your fetal surgery
from stretching too much
as the uterus gets bigger,
and to prevent tearing
with labor contractions.
Because the heart
and lungs are usually
normal in babies
with spina bifida,
most infants are
stable at delivery
but will receive
their initial care
in the neonatal
intensive care unit.
Although the MOMS trial was a
well-designed clinical study,
it only provides
overall statistics
for the benefits
of fetal surgery
compared to postnatal
repair of spina bifida.
It incorporated various
types of patients
with various severities of
spina bifida, all of which
have unique outcomes.
Although many
patients may medically
qualify for fetal
surgery, fetal surgery
may not be the right choice for
every mother and her family.
Many factors go into this
decision making process,
including maternal health and
family well-being in addition
to the overall
health of the baby.
Most parents ask
about the outcome
if they decide on fetal surgery.
Although physicians
do everything
possible to minimize
the risks of surgery,
there is no way to
predict the exact outcome.
The Fetal Center at Children's
Memorial Hermann Hospital
and the affiliated physicians
at UT Health Medical School
value the importance
of patient education.
Not every patient will
require fetal surgery,
but every family deserves
to be thoroughly educated
about their child's condition
and the expected outcomes based
on the specific findings
of their child's condition,
as well as a complete
understanding of how this will
affect their child's
life and the family
throughout their lifetime.
The Fetal Center at Children's
Memorial Hermann Hospital
is a multi-disciplinary
clinical and research center
whose affiliated physicians are
faculty members at UT Health
Medical School in
Houston, Texas.
The Fetal Center provides
comprehensive maternal, fetal,
and neonatal health
care to pregnant women
whose unborn babies have
been diagnosed with a birth
defect or a genetic condition.
Located in the heart of the
world-renowned Texas Medical
Center, the Fetal Center at
Children's Memorial Hermann
Hospital includes
affiliated fetal, pediatric,
and adult specialists
who provide
a superior level of care for
high-risk expectant mothers
with complex disorders
of the fetus.
The Fetal Center and its
affiliated physicians
offer coordinated maternal,
fetal, and neonatal care
by providing a full spectrum
of prenatal diagnostic
evaluations, fetal surgery,
and follow-up care.
For all conditions,
the Fetal Center
works closely with
patients to deliver
the most comprehensive care
for mothers and their babies.
The Fetal Center's
affiliated physician team
aims to provide all families
with a complete understanding
of their child's
condition and prognosis
through prenatal counseling
and educational materials.
Patients are evaluated
with advanced fetal imaging
including fetal MRI and
fetal echocardiography
to provide the most
accurate prenatal diagnosis.
This educational video,
produced by the Fetal Center
at Children's Memorial
Hermann Hospital,
is designed to provide an
overall understanding of spina
bifida and available
treatment options.
It should be used in conjunction
with personal evaluations
and consultations
with your doctor.
Patients should not base
decision making solely
on the information
provided in the video.
The physicians affiliated
with the Fetal Center
at Children's Memorial
Hermann Hospital
provide medical services
as members of UT Health
and the University of
Texas Health Science
Center at Houston.
