Prenatal surgery can reduce complications from spina bifida

Prenatal surgery to repair myelomeningocele, the most common form of spina bifida, can reduce severe complications such as paralysis and brain damage that often occur when the condition isn’t corrected until after birth, a new randomized, multicenter study indicates.

The surgery involves making a 3-inch incision in the uterus, putting the exposed section of spinal cord back inside the fetus, and covering it with tissue to keep it in place and prevent leakage of cerebrospinal fluid. A study that randomized 183 women to surgical repair before 26 weeks’ gestation or standard postnatal repair found that only 40% of children operated on in utero needed a shunt to drain cerebrospinal fluid, compared with 82% of children who had postnatal surgery (P<.001).

Children in the prenatal surgery group also had higher composite scores for mental development and motor function at 30 months (P=.007) and were twice as likely to walk unaided at 3 years of age as children who had surgery after birth (42% vs 21%).

Prenatal surgery is risky for both mother and child. Nearly 4 out of 5 babies who underwent fetal surgery were born prematurely with associated complications, compared with 15% who had surgery after birth. Both groups had 2 deaths, however.

Prenatal surgery weakens the uterus and can lead to uterine rupture if the mother goes into labor; subsequent babies must be delivered by cesarean delivery before the onset of labor. One third of the mothers who underwent prenatal surgery had an area of uterine dehiscence or a very thin surgical scar at delivery. Pregnancy complications, including oligohydramnios, chorioamniotic separation, placental abruption, and spontaneous membrane rupture, were more common in the prenatal surgery group.

The study published online February 9 in The New England Journal of Medicine.