Friday, April 19, 2024

Spina Bifida Surgery After Birth

Living With Spina Bifida

Delivery after Fetal Surgery for Spina Bifida (8 of 12)

Spina bifida can range from mild to severe. Some people may have little to no disability. Other people may be limited in the way they move or function. Some people may even be paralyzed or unable to walk or move parts of their body.

Even so, with the right care, most people affected by spina bifida lead full, productive lives.

Delivery Of A Baby With Myelomeningocele

The delivery of a baby with any type of spina bifida should be at a hospital that is prepared for high-risk births, including immediate access to a neonatal intensive care unit and pediatric surgical services. This will simplify communication between obstetrical, neonatal and pediatric surgical teams as well as limit the separation between mother and baby.

Michigan Medicine is one of only a few centers nationwide at which the birth center is co-located within a comprehensive childrens hospital. This unique setting allows for seamless integration between our private-room birth center, state-of-the-art newborn intensive care unit , and access to around-the-clock pediatric surgical services in one convenient location.

The method of delivery for babies with a myelomeningocele remains under debate. There is no clear evidence that having a Cesarean section will improve the outcome of these babies. However, a C-section may be needed for an obstetrical reason, such as for a baby with very large ventricles who has an increased head circumference. A vaginal delivery is recommended whenever it is a safe option.

Who Will Be On My Care Team

At Midwest Fetal Care Center, a collaboration between Childrenâs Minnesota and Allina Health, we specialize in individual attention that starts with you having your own personal care coordinator to help you navigate your babyâs complex treatment process. We use a comprehensive team approach to spina bifida. That way, you are assured of getting the best possible information by some of the most experienced physicians in the country. For spina bifida treatment, your care team will include a maternal-fetal specialist, a pediatric surgeon, a neonatologist, a geneticist, a nurse specialist care coordinator, a fetal care clinical social worker and several other technical specialists. This entire team will follow you and your baby closely through the evaluation process, and will be responsible for designing and carrying out your complete care plan.

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What Is Fetal Echocardiography

Fetal echocardiography is performed at our center by a pediatric cardiologist . This non- invasive, high-resolution ultrasound procedure looks specifically at how the babyâs heart is structured and functioning while in the womb. This exam is important because babies with spina bifida may be at increased risk of heart abnormalities. A fetal echocardiogram is also a necessary part of the evaluation process when prenatal surgery is being considered.

What Is The Moms Trial

Fetal surgery for spina bifida

In 2011, the Management of Myelomeningocele Study , sponsored by the National Institutes of Health, found that infants who undergo surgery in utero had a decreased need for ventriculoperitoneal shunting and improved motor function when compared to the surgical repair of the spina bifida after birth. Based on the results of the MOMS trial, open fetal surgery for spina bifida is now considered an alternative option for select fetuses prenatally diagnosed with spina bifida.

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Physical Healthwhat To Expect

No two babies with spina bifida are exactly alike. Health issues will be different for each baby. Some babies have issues that are more severe than other babies. With the right care, babies born with spina bifida will grow up to reach their full potential.

Open Spina Bifida

When a baby is born with open spina bifida, in which the spinal cord is exposed , doctors will perform surgery to close it before birth or within the first few days of the babys life.

Hydrocephalus

Many babies born with spina bifida get hydrocephalus . This means that there is extra fluid in and around the brain. The extra fluid can cause the spaces in the brain, called ventricles, to become too large and the head can swell. Hydrocephalus needs to be followed closely and treated properly to prevent brain injury.

If a baby with spina bifida has hydrocephalus, a surgeon can put in a shunt. A shunt is a small hollow tube that will help drain the fluid from the babys brain and protect it from too much pressure. Additional surgery might be needed to change the shunt as the child grows up or if it becomes clogged or infected.

For more information, please visit the Spina Bifida Association website:Hydrocephalus and Shuntsexternal icon

Mobility and Physical Activity

People affected by spina bifida get around in different ways. These include walking without any aids or assistance walking with braces, crutches or walkers and using wheelchairs.

For more information, please visit the following websites:

Skin

The Worlds First Human Trial

When Emily and her husband Harry learned that they would be first-time parents, they never expected any pregnancy complications. But the day that Emily learned that her developing child had spina bifida was also the day she first heard about the CuRe trial.

For Emily, it was a lifeline that they couldnt refuse.

Participating in the trial would mean that she would need to temporarily move to Sacramento for the fetal surgery and then for weekly follow-up visits during her pregnancy.

After screenings, MRI scans and interviews, Emily received the life-changing news that she was accepted into the trial. Her fetal surgery was scheduled for July 12, 2021, at 25 weeks and five days gestation.

Farmer and Wangs team manufactures clinical grade stem cells mesenchymal stem cells from placental tissue in the UC Davis Healths CIRM-funded Institute for Regenerative Cures. The cells are known to be among the most promising type of cells in regenerative medicine.

The lab is a Good Manufacturing Practice Laboratory for safe use in humans. It is here that they made the stem cell patch for Emilys fetal surgery.

Its a four-day process to make the stem cell patch, said Priya Kumar, the scientist at the Center for Surgical Bioengineering in the Department of Surgery, who leads the team that creates the stem cell patches and delivers them to the operating room. The time we pull out the cells, the time we seed on the scaffold, and the time we deliver, is all critical.

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What Is Myelomeningocele Repair

Myelomeningocele repair, also known as fetal spina bifida repair, is a surgery to close the spinal defect during pregnancy. It is typically performed between 19 and 26 weeks gestation.

There are various techniques for fetal spina bifida repair. Traditional fetal repair is performed through a large incision in the uterus. Due to the open nature of this surgical approach, it carries maternal risk, including:

  • Requiring delivery by cesarean section for the current and all future pregnancies
  • Other complications, such as uterine rupture at the site of the scar at any time after surgery

Because of the significant maternal risks of open fetal surgery, our physicians also offer a less invasive technique known as fetoscopic spina bifida repair. During this procedure, we gain access to the uterus using tiny incisions to pass a small camera . This minimally invasive procedure can have many benefits, including:

  • Babies may deliver closer to their due dates.
  • Mothers have the option of vaginal delivery .
  • There is no known risk of uterine rupture after surgery.

Prenatal repair requires the highest level of care from multiple medical specialties and therefore can only be performed at specialized centers. Members of the multidisciplinary team at the Johns Hopkins Center for Fetal Therapy are leading experts in fetoscopic spina bifida repair and are at the forefront of research on how to make these procedures safer for both mother and baby, and more effective.

Fetoscopic Repair Of Spina Bifida

How do we treat spina bifida after a baby’s birth?

Fetal surgery to repair spina bifida can improve infant outcomes compared to after-birth repair.

There are two options for prenatal repair: open fetal surgery and fetoscopic fetal surgery, a minimally invasive approach that reduces the risks associated with a large uterine incision.

While surgery can repair the birth defect, spina bifida is a lifelong condition.

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About The In Utero Mmc Repair Procedure

Prenatal repair of myelomeningocele is performed between 23 weeks and 25 weeks 6 days gestation. Mothers must be willing to stay in Philadelphia with a support person for the surgery and for the duration of the pregnancy to allow close monitoring.

In prenatal repair, the mother receives general anesthesia, which also relaxes the uterus and anesthetizes the fetus. Fetal surgeons perform a laparotomy . A maternal-fetal medicine specialist performs sterile intraoperative ultrasound to map the position of the placenta and the fetus, and your babys back is rotated into view. The uterus is then opened with a uterine stapling device that pinches off all blood vessels and keeps membranes secured to the muscle.

A pediatric neurosurgeon removes the MMC sac, if one is present, returns the spinal cord to the spinal canal, and closes the surrounding tissue and skin over the defect to protect the spinal cord from exposure to the amniotic fluid. The uterus and the abdominal incision are then closed.

What Are The Types Of Spina Bifida

There are three main types of spina bifida:

Spina bifida occulta

Spina bifida occulta is the mildest and most common form of this disorder. It usually only involves a minimal portion of the spine it usually shows no symptoms, and it does not require treatment. When an infant is born with spina bifida occulta, the skin covers the deformity of the spinal bone.

Spina bifida occulta literally means “a hidden spot on the spine,” and for many people with this type of spina bifida, the spot remains hidden. In some people, though, the skin overlying the bony defect will show subtle changes, such as a dimple, red or purple coloring or a tuft of hair. It has been estimated that about 10% to 20% of the U.S. population has spina bifida occulta — and most dont even know they have it.

Rarely, spina bifida occulta will cause problems when a child grows to adolescence. By this time in the child’s life, the spinal cord has become fastened to the backbone. When the growth spurt of adolescence begins, the nerves of the spinal cord become stretched. The result can be difficulties such as weakness and numbness in the legs, bladder infections and incontinence . The more the spinal cord is stretched, the worse the symptoms become. Surgery to relieve these symptoms by reducing the tension on the spinal cord is simple and often successful.

Meningocele

Myelomeningocele

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What Happens During Prenatal Surgery For Spina Bifida

Prenatal MMC repairâwhether the surgery is open or fetoscopicâis done before the 26th week of pregnancy. For both procedures, mother and baby are placed under general anesthesia so that both can be operated on simultaneously.

During the open procedure, a horizontal incision is made in the motherâs lower abdomen. Then, using ultrasound imaging, the surgical team makes a safe incision in the uterus, exposing the spinal defect in the unborn baby . With the babyâs back in view, the surgeons remove the sac, if present, and then create a watertight closure of the defect and surrounding tissue .

During the fetoscopic procedure, a similar incision is made in the motherâs abdomen to expose the uterus. Guided by ultrasound images, the surgical team then inserts long, thin tubesâmedical devices known as trocarsâinto the uterus at the location of the gap in the babyâs spine. Using tiny surgical instruments, including miniature cameras, inserted through the trocars, the surgeons then repair the gap in the babyâs spine. This technique eliminates the need for a large incision in the uterus and reduces potential complications for the mother. Once the closure is completedâand watertightâthe tubes are removed and the incision in the motherâs abdomen is closed.

In rare cases, the surgical team may switch from a fetoscopic to an open procedure during the surgery in order to ensure the best outcome for both mother and child.

Figure 7

Figure 8

What Are The Long

Fetoscopic Spina Bifida Repair Using a Human Umbilical Cord Patch ...

Some children will require intensive spina bifida treatment throughout their lives due to the range of complications associated with the defect. The level of the spinal defect can provide some prediction of the severity and extent of the neurological problems. However, the severity of the problems of spina bifida will only be determined over time. The Fetal Center will help coordinate all of the specialists and services necessary to help patients care for their child.

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Hindbrain Herniation And Ventricular Shunting

  • Hindbrain herniation is a common finding for babies with spina bifida in which the lower, back part of the brain starts to come down into the top of the spinal canal. Pictured here: Hindbrain in normal position.
  • This herniation of the hindbrain blocks the circulation of cerebrospinal fluid, causing hydrocephalus . Pictured here: Hindbrain descending into spinal canal.
  • Ventricular shunting involves placement of a thin tube into the ventricles of the brain to drain fluid and relieve hydrocephalus.

Spina bifida can lead to a variety of social and emotional challenges and lifelong quality-of-life issues.

Mobility And Physical Activity

People affected by spina bifida get around in different ways. These include walking without any aids or assistance walking with braces, crutches or walkers and using wheelchairs.

People with spina bifida higher on the spine might have paralyzed legs and use wheelchairs. Those with spina bifida lower on the spine might have more use of their legs and use crutches, braces, or walkers, or they might be able to walk without these devices.

Regular physical activity is important for all people, but especially for those with conditions that affect movement, such as spina bifida. CDC recommends 60 minutes of physical activity a day. There are many ways for people with spina bifida to be active. For example, they can:

  • Engage in active play with friends.
  • Roll or walk in the neighborhood.
  • Participate in community programs, such as the Early Intervention Program for Infants and Toddlers with Disabilities and Special Education Services for Preschoolers with Disabilities, which are free programs in many communities.
  • Enjoy parks and recreation areas with playgrounds that are accessible to people with disabilities.
  • Do exercises recommended by a physical therapist.
  • Attend summer camps and recreational facilities that are accessible for those with disabilities.
  • Participate in sports activities and teams for people with or those without disabilities.

For more information, please visit the following websites:

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The Benefits Of In Utero Spina Bifida Surgery

In the United States, more than 1,500 babies are born every year with a condition known as spina bifida, a congenital condition that occurs when the spinal cord does not develop normally . The lack of protective structures such as bone, muscle and skin exposes the spinal cord and nerves to the amniotic fluid in the womb, making them susceptible to damage. In many cases, spina bifida is diagnosed in utero with a sonogram as early as 18 to 20 weeks.

Depending on the severity of the condition, symptoms for children born with spina bifida can range from almost no symptoms or symptoms that dont appear until later in life, to an inability to walk or have feeling in the legs or feet, and even the buildup of spinal fluid in the brain.

Historically, babies born with spina bifida have undergone surgery to close the neural tube and reconstruct the spine shortly after delivery. However, once damage to the nerves has occurred, it cant be reversed, so any neurological damage that occurred in utero was likely permanent.

Types Of Spina Bifida

Spina Bifida Surgery-Mayo Clinic

Myelomeningocele When people talk about spina bifida, most often they are referring to myelomeningocele. Myelomeningocele is the most serious type of spina bifida. With this condition, a sac of fluid comes through an opening in the babys back. Part of the spinal cord and nerves are in this sac and are damaged. This type of spina bifida causes moderate to severe disabilities, such as problems affecting how the person goes to the bathroom, loss of feeling in the persons legs or feet, and not being able to move the legs.

Meningocele Another type of spina bifida is meningocele. With meningocele a sac of fluid comes through an opening in the babys back. But, the spinal cord is not in this sac. There is usually little or no nerve damage. This type of spina bifida can cause minor disabilities.

Spina Bifida Occulta Spina bifida occulta is the mildest type of spina bifida. It is sometimes called hidden spina bifida. With it, there is a small gap in the spine, but no opening or sac on the back. The spinal cord and the nerves usually are normal. Many times, spina bifida occulta is not discovered until late childhood or adulthood. This type of spina bifida usually does not cause any disabilities.

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What Is Fetal Magnetic Resonance Imaging

Fetal MRI is another non-invasive test. It uses a large magnet, pulses of radio waves and a computer to create detailed images of your babyâs spine and other structures while in the womb. This procedure involves both mom and baby being scanned while partially inside our MRI machine. The test is a bit loud, but it takes about 30 minutes and is not uncomfortable.

Other Types Of Spina Bifida

There are other types of spinal bifida as well, all involving a bony defect in the vertebral bodies. Meningocele is another common form similar to myelomeningocele in that a sac is covering the bony defect without skin covering it. However, in meningocele, the spinal cord is not involved. A third form of spina bifida, myeloschisis, is a bony defect involving the spinal cord without a covering sac. A fourth, less severe form of bony defect is spina bifida occulta. This involves a bony defect with skin covering the defect and usually has a normal spinal cord. While most of the spina bifida occulta cases do not need surgical repair before or after birth, the first three types will require surgery to repair. Myelomeningocele and myeloschisis may benefit from fetal surgery performed before 26 weeks gestation to improve function after birth.

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