Tuesday, September 4, 2012

Why pre-natal surgery makes sense, for some, for spina bifida

Why pre-natal surgery makes sense, for some, for spina bifida

Posted: Aug 24, 2012, 9:17 am
By Jeff Hansel
The Post-Bulletin, Rochester MN

Mayo Clinic surgeons in May performed surgery on a fetus before birth to decrease almost certain complications of spina bifida.

The baby was born by cesarean section in early August and is doing well, though she might face struggles.

In "myelomeningocele,"(the most severe form of spina bifida, the spinal cord is open to the amniotic fluid during pregnancy, and complications build as the pregnancy progresses. Almost all infants with this form of spina bifida have complications, such as the brain essentially sagging toward the spinal column.

Standard treatment has been surgery after birth, and babies often need a permanent shunt to drain fluid the brain isn't able to dispose of on its own.

Many believed surgery before birth would help because it would allow babies' neural systems more time to develop naturally. But no one knew for sure if this would keep more babies alive or, because of a higher risk of premature birth and other factors, would be harmful.

So researchers convinced every prenatal surgical center in the U.S. to cease early-intervention surgeries unless they were part of a national research study, says a March article in the New England Journal of Medicine.

From February 2003 to December 2010, women were offered the surgery at one of only three locations — Children's Hospital of Philadelphia, Vanderbilt University and the University of California at San Francisco. The data was analyzed at an independent center.

"Children in the prenatal-surgery group were more likely than those in the postnatal-surgery group to be able to walk without orthotic devices," the New England Journal article reported. Also, prenatal surgery before 26 weeks of gestation "decreased the risk of death or need for shunting by the age of 12 months and also improved scores on a composite measure of mental and motor function."

Results were so good that the trial, randomly assigning women to prenatal surgery or post-natal surgery, was stopped early after 183 of a planned 200 women pregnant with babies diagnosed with spina bifida were recruited for the study.

That doesn't mean spina bifida was cured, nor were all associated problems fixed. Two babies in each group died. The percentage of deaths overall was dramatically decreased in the prenatal group, but it remained high.

Because of the potential for fetal death, severe physical impairments, lifelong complications and mental deficits, parents of babies with severe spina bifida typically are asked whether they want to terminate the pregnancy.

Most of those who survive surgery after birth can't get a job without the presence of a vocational assistant, said Mayo Clinic pediatric neurosurgeon Dr. Nick Wetjen.

The hope with the surgery is to improve quality of life and decrease complications. Parents need to be fully informed of the possible risks and benefits of the procedures.

"There are some people that will be helped by this, and there are some people that we will end up harming, too, because of the nature of the procedure," said Mayo maternal fetal medicine specialist Dr. Norman Davies.

Health reporter Jeff Hansel writes the Pulse on Health column every Monday. Follow him on Twitter @JeffHansel.

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