Fetal Surgery

Minimally Invasive Spina Bifida Repair

• Discuss prenatal diagnosis and management of Spina Bifida

• Fetal surgery treatment and current options available

• From a nurse’s perspective: delivery/NICU timeline

Objectives

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Texas Children’s Fetal Center

https://www.youtube.com/watch?v=bLJc2cusnIA

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Texas Children’s Fetal Center

Spina Bifida by the numbers

• Spina bifida is a neural tube defect caused early in development

• Spinal column is exposed and leaking cerebral spinal fluid

• Different types of Spina Bifida

• Affects about 1 in 3000 live births

• We evaluated around 106 patients from 2011-2014

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Texas Children’s Fetal Center

Spina Bifida Management

•Scheduled C/S delivery

•Traditionally postnatal repair

•Surgical repair 24-48 hours after birth by pediatric neurosurgery

•NICU admission 10-14 days

•80% get hydrocephalus; 20% never get hydrocephalus

•Follow up with Spina Bifida Clinic

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Texas Children’s Fetal Center

Why do fetal surgery?

1. Would early closure result in better outcome?

2. Is there a risk for the mother?

3. What kind of follow-up is needed?

4. When can I get pregnant again?

5. Do all babies get the benefit of the surgery?

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Texas Children’s Fetal Center

MOMs Trial

Management of Myelomeningocele Study was conducted from February 2003-December 2010

3 Initial Fetal Surgery Centers

1. Children’s Hospital of Philadelphia

2. Vanderbilt University

3. University of California, San Francisco

Proved that fetal surgical repair leads to decreased rates of VP shunt placement due to Hydrocephalus and improved leg function compared to standard repair after birth.

Over 11 institutions doing NTD repair today

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Texas Children’s Fetal Center

OPEN METHOD

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Texas Children’s Fetal Center

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Is my baby a candidate for surgery?MOMs Trial/Criteria

Inclusion Criteria

• Lesion begins at T1-S1

• Hindbrain herniation (Chiari)

• Defect is not skin covered

• GA less than 25 6/7 weeks

• Maternal age at least 18

• Single gestation

• Normal Karyotype/Genetics

Exclusion Criteria

• Fetal anomalies

• Fetal kyphosis >30 degrees

• Previous hysterotomy

• Cerclage or TVCL <20 mm

• Placenta previa

• PTD < 37 weeks

• Maternal HIV+, hep B+, hep C+

• Lack of support persons

• Maternal IDDM, Rh, Kell or alloimmume

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Texas Children’s Fetal Center

Referred by Maternal Fetal Medicine (MFM) specialist with diagnosis of Spina Bifida

My role is to process referral and schedule accordingly US/MRI, pediatric neurosurgery, fetal echocardiogram, social work, neonatology, fetal intervention, pediatric surgery

Criteria needs to be met to be considered surgical candidate

Patients and families will need to relocate to Houston for duration of pregnancy

Evaluation Process

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Texas Children’s Fetal Center

Why do fetal surgery?

1. Would early closure result in better outcome?

Closing the exposure of amniotic fluid to nerves, possibly preserve function; reduce need for shunt placement with hindbrain herniation reversal

2. Is there a risk for the mother?

Mother undergoes risk for neonatal benefit, preterm delivery, bleeding

3. What kind of follow-up is needed?

Weekly; relocation to Houston

4. When can I get pregnant again?

2 years

5. Do all babies get the benefit of the surgery?

Some patients may not have reversal of hindbrain herniation, small leak at repair site, 40% still have hydrocephalus post fetal surgery

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Texas Children’s Fetal Center

Patient Issues to Consider

• Patient has to deliver @ 37 weeks with OPEN method

• C-Section delivery-think about primigravida and future pregnancies

• Cannot contract on the incision—Located at active segment of uterus

• Relocation/Financial Situation

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Texas Children’s Fetal Center

New Minimally Invasive Technique

•Here at Texas Children’s Hospital, we have pioneered a new approach to Spina Bifida repair.

•This treatment builds upon the surgery technique under the MOMs trial, but designed to reduce the risk to mom.

•The team at Texas Children’s Fetal Center was the first in the United States to perform this fetoscopicapproach

•Research protocol, experimental

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Texas Children’s Fetal Center

Fetoscopic Method

• Two small scopes are inserted along with carbon dioxide gas into the uterus making small incisions instead of one large incision on the uterus.

• Externalize uterus

• Possible conversion to OPEN method if unable to repair (Hybrid)

• Mothers may deliver vaginally with this technique instead of needing a C-section delivery.

• Longer surgery time

• 1st case 7/30/2014

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Obstetric Management

•Magnesium Sulfate administration (ICU status on L&D)

•Indocin-needs fetal echocardiogram x 2 (Can restrict PDA)

•5-7 days in hospital after procedure

•Transition to Procardia 10 mg PO Q 6

•Epidural catheter stays in place

•May deliver past 37 weeks, vaginal delivery

•Weekly ultrasounds/2x week antenatal testing @ 32 weeks

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Texas Children’s Fetal Center

Postnatal Care

•Average stay is 7-14 days in NICU

•Daily head ultrasounds

•Watch for hydrocephalus

•Monitor surgical site

•Follow up with Neurosurgery/Spina Bifida clinic monthly initially

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Texas Children’s Fetal Center

Outcomes

• 28 Fetoscopic cases, 3 hybrids

• 11 vaginal deliveries-48% Average gestation of delivery is 36 4/7weeks

• 0 cases with infection or abruption

• 23% needed shunt treatment for hydrocephalus

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Texas Children’s Fetal Center

Questions?

To make a referral, form online on website

Order in Epic or by fax

832-825-9403