Some babies with a birth defect may benefit from surgery while still in the womb, according to a new study.
Children who had surgery before birth for spina bifida, a condition in which the spinal cord is underdeveloped, were twice as likely as those undergoing postnatal surgery to walk without assistance when they were 2 years old.
The children who received surgery while in the womb also fared better in terms of their mental capabilities, and had fewer neurological problems, researchers found.
The study was the first to systematically evaluate the benefits and risks of this type of fetal surgery. While the surgery is not a cure, “this trial demonstrates scientifically that we can now offer fetal surgery as a standard of care for spina bifida,” said study researcher Dr. N. Scott Adzick, chief of pediatric surgery at the Children’s Hospital of Philadelphia.
However, there are risks. Babies who underwent the fetal surgery were more likely to be born prematurely, which put them at risk of breathing problems and other serious conditions. And the mothers of these infants had to deliver them — and any subsequent babies — by Caesarean section, or risk a ruptured uterus.
“We’re all very excited that there may be some real advance in treating patients with spina bifida,” said Dr. Joseph Madsen, a professor of neurosurgery at Children’s Hospital Boston, who was not involved in the study.
“I’m sure many places will being doing this procedure much more regularly once we can figure out how to broaden the scope,” Madsen said. The training of doctors to perform the procedure would need to be standardized, he said. And researchers still need to figure out which patients will benefit, he said.
The study appears online today (Feb. 9) in the New England Journal of Medicine.
Surgery for spina bifida
In babies with spina bifida, the structure that will form the baby’s brain and spinal cord, called the neural tube, fails to form correctly. The condition affects about 1,500 infants born each year in the United States, according to the researchers.
Babies in this study had the most serious form of the spina bifida, in which part of the spinal cord is exposed. Many children with this disorder require assistance to walk or use a wheelchair. They also may experience paralysis, loss of bladder control or a condition known as hydrocephalus, in which fluid accumulates in the brain.
The surgery, which covers the exposed cord with skin, is traditionally performed after birth. But by then, Adzick said, exposure to the environment inside the uterus has progressively damaged the nerves in the spinal cord. Performing the surgery before birth may save some nerve function and allow more-normal development.
The study, conducted between February 2003 and this past December, involved 158 women pregnant with fetuses with spina bifida. The women were randomly assigned to receive surgery at either 26 weeks of pregnancy or after the birth of the child. Four babies died after their surgery: two from the group that received fetal surgery and two from the group that had postnatal surgery.
After one year, about 40 percent of the infants in the fetal surgery group required more surgery, to place a tube to allow fluid to be removed from their brains. In the group that received spinal surgery after birth, this portion was 83 percent.
Because such a fluid build-up is associated with a high risk of disability, “the reduction in the need for this intervention by prenatal surgery is itself impressive,” said Simon Manning, a neonatologist at Brigham and Women’s Hospital in Boston who was not involved with the study.
After 30 months, 42 percent of children in the fetal surgery group could walk unassisted, compared with just 21 percent in the post-birth surgery group.
Not for everyone
Further research will be needed to learn whether the advantages seen at the 30-month mark persist over the long term, the researchers said.
Not all pregnant women may be candidates for this surgery. Obese women are at higher risk for complications after surgery and were not included in the study, Adzick said.
Pass it on: Babies with spina bifida who receive surgery before they are born fare better than those with receive surgery after birth. However, the procedure comes with risks, including premature birth.
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