Fetoscopic MMC Repair

What is fetoscopic MMC repair?

Fetoscopic MMC repair is an advanced prenatal (before birth) procedure used to surgically treat myelomeningocele, a severe form of spina bifida. This minimally invasive procedure allows surgeons to repair and close neural tube defects like MMC while the baby is still in the womb.

For fetoscopic MMC surgery, we make an incision on the mother’s abdomen to bring out the uterus so we can repair the MMC. Once the uterus is exposed, we place three small working ports to perform the MMC repair. One port is for the camera and the other two are for instruments to perform the surgery. After making the repair, we close the incision and let the baby heal and continue to develop in the womb.

Research shows that when compared to surgery after birth, prenatal MMC repair results in better motor function and a decreased risk of hydrocephalus (fluid buildup in the brain) in babies with MMC. Surgery before birth also allows the baby’s skin to grow around the repair as they continue to develop in the womb. And repairing the myelomeningocele prenatally helps reduce the chance of the complications it can cause if it grows larger. We can treat MMC with open fetal surgery or fetoscopic surgery.

What is the difference between fetoscopic surgery and open fetal surgery?

Both open fetal surgery and fetoscopic MMC repair require that we make an open incision on the mother’s abdomen to access the uterus. Open fetal surgery also requires an open incision on the uterus to expose the baby’s back to perform the repair. Fetoscopic MMC repair, on the other hand, requires just three small incisions on the uterus.

Fetoscopic MMC repair usually takes more time than open fetal MMC repair, but this doesn’t affect your baby.  After open surgery for MMC, future pregnancies will require a cesarean section (C-section) delivery. Those who have fetoscopic MMC repair can choose vaginal or C-section delivery for future pregnancies which is the main advantage to having fetoscopic surgery as opposed to open surgery.

Research suggests that outcomes (success rates) for open and fetoscopic repair are similar, but we continue to study these surgeries to better understand long-term outcomes.

What are the risks for fetoscopic MMC repair?

With fetoscopic MMC repair, as well as open surgery, the main risk is a premature delivery. The anticipated delivery time is about 32 to 34 weeks gestation, but some pregnancies go beyond that.

What to expect during fetoscopic MMC repair

There are two main phases involved in fetoscopic MMC repair.

Phase 1 of fetoscopic MMC repair

Phase 1 is your time to learn about your treatment options and ask questions of our fetal care experts. We’ll assess your baby’s health through imaging tests and introduce you to your entire care team.

Initial tests and meeting

The process begins with a full day at our Colorado Fetal Care Center. We start with an ultrasound of your baby, followed by an echocardiogram to look at your baby’s heart and a fetal MRI to get detailed imaging of your baby. After lunch, you’ll meet with our multidisciplinary team, which includes a:

• Fetal radiologist to review the MRI images with you
• Maternal fetal medicine surgeon to outline the plan for the remainder of your pregnancy
• Pediatric neurosurgeon to describe what life looks like for kids with MMC
• Neonatologist to review care in the Neonatal Intensive Care Unit (NICU) for babies with MMC
• Pediatric and fetal surgeon to discuss the details of fetal surgery
• Social worker to assist with any pre- or post-natal logistical concerns, such as living accommodations

During your Phase 1 visit, we’ll discuss both fetoscopic and open MMC repair and provide you with all the necessary information to help you make the right decision for you and your family. We’ll provide our expert opinion, make sure you are a good candidate for fetal surgery and answer any questions you have. If you think fetal surgery is the best option for you and your family, we’ll schedule an amniocentesis at least a week before surgery. For an amniocentesis, we use a needle to take a small amount of amniotic fluid for lab tests that check for chromosomal or genetic issues.

Phase 2 of fetoscopic MMC repair

If fetal surgery sounds right for you after your Phase 1 visit, you will return for a Phase 2 appointment to meet with one of our neonatologists and maternal fetal medicine doctors to discuss the procedure in more detail and what affect prematurity may have at each week of gestation. The level of prematurity is a major consideration for both open and fetoscopic MMC repair.

Consent meeting

Prior to surgery, you’ll meet with members of our team again to review and sign the consent form as well as with one of our anesthesiologists to discuss their role in your care.

Day of fetoscopic surgery

On the day of surgery, we’ll start early. You will typically arrive around 5 a.m. to check in and prepare for surgery. Once we connect an IV and draw blood for testing, we’ll take you to the operating room where our maternal fetal anesthesiologists will provide an epidural and general anesthesia through an IV. We’ll place additional IVs to monitor your blood pressure during surgery. The operation usually takes 3 to 6 hours. We use ultrasound imaging to monitor the procedure and make sure we place instruments accurately. We perform the operation with a small camera called a fetoscope and small, specialized instruments. During the procedure, we also use the ultrasound to monitor your baby’s heart rate. After surgery, we’ll take you directly to your room to recover. The morning before you are discharged from the hospital, we’ll perform one more ultrasound to make sure everything looks good.

What to expect after a fetoscopic MMC repair

Most patients remain in the hospital for 4 to 5 days after surgery. We perform daily ultrasounds to monitor your baby and continue to use the IV to administer medication for pain and to help decrease the risk of contractions following surgery.

Following both open and fetoscopic MMC repair, we recommend that you stay somewhere close to the hospital for two weeks following surgery. That means that if you live more than an hour away from our hospital in Aurora, we ask that you stay somewhere local for two weeks. This is for you and your baby’s safety. We can help you find local lodging.

Two weeks after surgery, we’ll meet again to perform an MRI to evaluate the surgical repair. If everything looks good, you can return home and continue care with your primary doctor, which we will help coordinate. We ask that you avoid any strenuous activity for the rest of your pregnancy.

Why choose the Colorado Fetal Center for fetoscopic MMC repair?

The Colorado Fetal Care Center is one of only a handful of centers in the United States offering fetoscopic MMC repair. As one of the best fetal care centers in the country, we pride ourselves on offering innovative procedures as well as comprehensive, compassionate care to both you and your baby.

While myelomeningocele is a rare condition, caring for it is not rare for us. We see more babies with MMC than most programs and the more we see, the better we become at treating MMC. We also track and display our data and outcomes to show how we’re improving. For example, shunts to help fluid drain from the brain after surgery used to be somewhat common for babies with MMC. However, in recent years, we rarely need to place shunts, which reduces the risk for complications.

We are constantly improving our care options and using technology to increase safety and precision for all our procedures. Every baby we treat adds to our experience and expertise and has helped us set the high standard we have today. Whether it’s a common procedure or a new, innovative procedure like fetoscopic MMC repair, we take the time to walk you through your options, looking at both the risks and benefits in order to help you reach the absolute best decision for you and your baby.