Fetal Surgery Guidelines for Prenatal Myelomeningocele Repair

At Children's Hospital of Philadelphia, we follow these guidelines to determine who qualifies for prenatal repair of myelomeningocele, the most severe form of spina bifida. Comprehensive evaluation of each individual pregnancy is essential to determine whether fetal surgery for myelomeningocele is an appropriate intervention. 

To discuss a potential referral for prenatal spina bifida repair, schedule a comprehensive prenatal evaluation or seek a second opinion, please call 1-800-IN-UTERO (1-800-468-8376). Our fetal specialists are available 24 hours a day, seven days a week.

Guidelines for Fetal Surgery for Myelomeningocele

Fetal surgery for myelomeningocele may be offered in the following circumstances

1. Myelomeningocele at level T1 through S1 with hindbrain herniation. The lesion can extend below S1, but the highest level cannot be outside the T1-S1 range. Lesion level and hindbrain herniation will be confirmed by ultrasound and MRI.
2. Gestational age at the time of fetal surgery for myelomeningocele must be no greater than 25 weeks, 6 days.
3. Maternal age ≥ 18 years.
4. Singleton pregnancy.
5. Written confirmation of normal karyotype, elevated AFAFP and positive acetylcholinesterase (AChE). 

Fetal surgery for myelomeningocele will NOT be offered if the mother has any of the following conditions

1. Insulin-dependent pregestational diabetes.
2. Fetal anomaly not related to myelomeningocele — such as a cardiac defect or intracranial hemorrhage.
3. Fetal kyphosis of 30 degrees or more at the level of the myelomeningocele lesion determined by MRI and ultrasound at CHOP.
4. Cerclage or documented history of incompetent cervix.
5. Placenta previa.
6. Placental abruption — a suggestion of a recent abruption or chronic placental edge bleeding (marginal abruption).
7. A history of vaginal bleeding will be evaluated before fetal surgery will be offered.
8. Short cervix (< 20 mm) based on the measurement taken at the time of evaluation.
9. BMI greater than 40.
10. Previous spontaneous delivery prior to 37 weeks — If membranes were intact and labor was induced, this is not considered spontaneous. A history of a stillbirth will require further review.
11. Maternal-fetal Rh isoimmunization, Kell sensitization or a history of neonatal alloimmune thrombocytopenia.
12. Maternal HIV or Hepatitis-B status positive.
13. Maternal Hepatitis-C status known positive.
14. Uterine anomaly such as multiple fibroids, Mullerian duct abnormality, bicornuate or unicornuate uterus, uterine septum, and double uterus. Any patient with a previous hysterotomy in the active segment of the uterus (whether from a previous classical caesearean, uterine abnormality such an arcuate or bicornuate uterus, myomectomy, or previous fetal surgery).
15. Maternal hypertension which would increase the risk of preeclampsia or preterm delivery (including, but not limited to: uncontrolled hypertension, chronic hypertension with end organ damage and new onset hypertension in current pregnancy).
16. Other maternal medical condition which is a contraindication to surgery or general anesthesia, such as some cases of asthma, cardiac disease or the refusal of a blood transfusion. Examples of medical conditions that are NOT exclusionary are: epilepsy, abnormal pap results and thyroid nodules.
17. No support person.
18. Inability to comply with the travel and follow-up requirements after fetal surgery.
19. Patient does not meet other psychosocial criteria as evaluated by our social worker.