A study funded by the National Institutes of Health and published in 2011 showed that fetal surgery reduces complications of spina bifida, and the Fetal Care Center at Barnes-Jewish Hospital and St. Louis Children’s Hospital is one of the few centers in the United States and the only one in the St. Louis region offering fetoscopic myelomeningocele (MMC) repair surgery, which affords patients more flexibility post-surgery but still features the same multilayer watertight closure as in the open fetal technique. A patient’s risk for uterine rupture is greatly reduced, and after recovery patients have minimal restrictions and are able to return home to deliver vaginally at a local hospital with a newborn intensive care unit (NICU), a marked difference from the open technique.

In 2011, a National Institutes of Health-funded study, known as Management of Myelomeningocele Study (MOMS), showed that a surgical procedure to close the opening in the spine of a fetus with spina bifida reduced the rate of disability in the child if the surgery is performed in utero rather than after the infant has been born. 

Washington University physicians who treat patients at the Fetal Care Center — which also draws on the multidisciplinary expertise of the care team at Barnes-Jewish Hospital and St. Louis Children’s Hospital — are now able to perform both the classic prenatal surgery for spina bifida, known as an “open” procedure, as well as a less invasive procedure, known as fetoscopic surgery, making the center one of the few in the United States and the only one in the St. Louis region that offers this surgery. The center’s first fetoscopic myelomeningocele (MMC) repair surgery was performed in early 2023 on a pregnant patient from the Kansas City, Missouri, area. Since that first successful surgery, seven additional fetoscopic MMC repair surgeries have been performed at the Fetal Care Center.

Options for patients with a fetus who receives a spina bifida diagnosis

Myelomeningocele, the most severe form of spina bifida, leaves a portion of the spinal cord and its nerves protruding from an opening in the spine. MMC results in moderate to severe disabilities, including altered brain development, hydrocephalus, decreased ability to move lower extremities, difficulty walking and changes with urination. Open prenatal surgery for fetuses with spina bifida both doubled the chances that a child would walk independently and reduced the need for a shunt to divert excess fluid from the brain by 50 percent when compared with those children who underwent surgery after birth, according to the 2011 study.

During an open surgery, surgeons create a large incision across the mother’s abdomen similar to that in a cesarean section. They open the uterus and turn the fetus so its back is exposed. The protruding sac that holds the fetus’ spinal cord and nerves is placed in its spinal canal. Surgeons close the adjoining tissue and skin over the opening and close the incisions in the mother’s uterus and abdomen.

Open surgery is performed between 24 and 26 weeks of pregnancy. To decrease the risk of uterine rupture and premature birth, patients must significantly limit activity following discharge from the hospital. The pregnant patient is also required to stay with a caregiver and remain within 30 minutes of the hospital. The baby and any future babies must be delivered by cesarean section. All are burdensome to the pregnant patient.

During fetoscopic surgery, once the patient’s uterus is exposed through an incision in the abdomen, three small openings are made in the uterus and ports are placed and secured. A camera is placed through one of the ports, and the operating instruments are placed in the other two. The Fetal Care Center offers both open and fetoscopic surgery for patients whose fetuses are diagnosed with spina bifida. However, for patients who are good candidates and who have fetuses no older than 25 weeks 6 days gestational age, fetoscopic surgery offers certain benefits. These include:

• Three smaller incisions, each about the size of a fingernail, made in the uterus instead of a single large incision.
• Risk of uterine rupture is not increased.
• Patients have fewer activity restrictions following surgery.
• Patients can return home after the surgery and deliver at a local hospital with a NICU.
• Some patients can deliver vaginally.
• Patients may be able to deliver vaginally with future pregnancies.

A rewarding first surgery

Jennifer Strahle, MD, a fetal and pediatric neurosurgeon at the Fetal Care Center, performed the center’s first fetoscopic surgery alongside Jesse Vrecenak, MD, fetal and pediatric general surgeon and the center’s surgical director, and Katherine Bligard, MD, a maternal-fetal medicine specialist at the center.

The center’s providers worked for years to be able to offer the surgery, becoming comfortable with multiple simulations and working together as a team to ensure the best outcome.

“It was great to see the surgery go so well,” Bligard says. “Everything was seamless.”

Bligard checked in on the patient over the next few weeks of her recovery before she was discharged and returned home to the Kansas City area to give birth. Although their baby is receiving follow-up care on the opposite side of the state, the family returned to St. Louis to visit the center’s providers after the patient gave birth.

“Getting to see the baby, to see the scar from his surgery, and to see how well he’s moving his legs is rewarding,” Bligard says.

Strahle says it was important to offer the same closure featured in the open fetal technique, a multilayer watertight closure, so that the fetoscopic approach is as close to that shown to be effective in the large, randomized MOMS trial. Other points of interest include:

• Both open and fetoscopic MMC patients deliver, on average, at 35 weeks gestational age
• Patients have an 80% vaginal delivery rate after fetoscopic surgery
• 24 percent of patients receive a shunt (average)
• There is no spinal tethering or intra-spinal dermoid in the fetal repair cohort

Care that doesn’t end after surgery

For patients traveling to St. Louis to receive either open or fetoscopic surgery, the multidisciplinary care team at Barnes-Jewish Hospital and St. Louis Children’s Hospital, which includes a personal nurse coordinator, will assist with navigating appointments, providing lodging and accessing social supports. That same care and attention does not end once the surgery is complete. Pregnant patients who undergo fetoscopic surgery spend about four days in the hospital recovering. Doctors monitor pain levels and make sure the patient can walk, empty her bladder and eat before being discharged.

Once discharged, patients are seen by Bligard for an ultrasound four days after they leave the hospital, and they stay in the St. Louis area, near the hospital, for about two weeks. Housing options are available for patients who are not from the St. Louis area.

Bligard sees the patient one more time, a week after the initial post-operation checkup. If the patient and fetus are doing well, the patient can return home if they live outside of St. Louis and follow up with their provider for care throughout the rest of the pregnancy. The Fetal Care Center has a well-established and collaborative pathway with referring maternal-fetal medicine providers, allowing patients to return home and deliver vaginally after the fetoscopic repair. After the baby is born, he or she will need additional care for their spina bifida. If the family does not live near a hospital that can provide this care, St. Louis Children’s Spina Bifida Clinic offers a comprehensive and multidisciplinary approach that makes it easier for out-of-town patients to receive care. All specialist appointments can be scheduled for the same day at the same location, with a nurse coordinator guiding parents every step of the way.

If you are an ob-gyn provider whose pregnant patient has received a prenatal spina bifida diagnosis, please consider learning more about the potential benefits of fetoscopic surgery for myelomeningocele. For referrals, consult requests, emergency transfers or questions, call 314-747-6539 or visit the Fetal Care Center, a collaboration with Barnes-Jewish Hospital, St. Louis Children’s Hospital and Washington University Physicians.