In a United Kingdom first, a team of specialists from University College London (UCL), University College London Hospitals (UCLH), and Great Ormond Street Hospital (GOSH) performed surgeries on two different babies with spina bifida while they were still in their mothers’ wombs. The specialists conducted the two surgeries over the summer and now report that both mothers and both babies are doing well.
This was the first time that surgeons have conducted the procedure in Britain, where only postnatal operations had been possible up to this point. Over the summer, however, the British surgeons teamed up with specialists from the University Hospitals Leuven in Belgium to make the intervention more widely available.
The U.K. experts explain that babies who receive the corrective intervention in utero are more likely to develop better than those who receive postnatal procedure. “In spina bifida, the spinal canal does not close completely in the womb, leaving the spinal cord exposed from an early stage in pregnancy,” explains lead neurosurgeon Dominic Thompson, from GOSH. “This results in changes to the brain, as well as severe permanent damage to the nerves on the lower half of the body,” he adds, which means that the child may often need additional surgical interventions later in life.
However, tackling the problem as early as possible — ideally while the baby is still in the mother’s womb — may allow it to avoid some of these developmental problems.
A complex surgical procedure
The prenatal surgery is complex and difficult to perform, but the British surgeons were keen to make it accessible to a larger number of people. “Operating in the womb involves opening the uterus, exposing the spina bifida without delivering the baby, closing the defect, and then repairing the uterus to leave the baby safely inside,” says lead fetal surgeon Jan Deprest, who works with both UCLH and University Hospital Leuven.
“Closure of spina bifida in the womb using this method is an alternative to postnatal surgery, and has been shown to improve short and medium-term outcomes. While neither intervention is fully curative, in fetal surgery, the defect is closed earlier, which prevents damage to the spinal cord in the last third of pregnancy.”
The surgeon also notes that he and his colleagues are hard at work to see whether a specialized endoscopic procedure called fetoscopy would be useful in correcting spina bifida. This type of intervention is minimally invasive and would allow the doctors to operate on the fetus without opening the mother’s uterus. “We are […] researching the minimal access (fetoscopic) technique through the GIFT-Surg Project framework and, if we can show it to have equal benefit, we will be offering this option to patients,” Deprest says.
The intervention makes a crucial difference
The British surgeons had been working closely not just with the Belgian specialists, but also with experts from the Children’s Hospital of Philadelphia in Pennsylvania, where the prenatal procedure for spina bifida was first devised, and where such surgeries have taken place since 2011.
“We have been working for 3 years to bring this service to U.K. patients through the creation of a Centre for Prenatal Therapy at UCL, UCLH, and GOSH,” notes Prof. Paolo De Coppi, from the UCL Great Ormond Street Institute of Child Health.
“Our resolve to offer this service was based on the findings of a large, multicenter, randomized control trial in the United States which compared prenatal closure to postnatal closure, and the observation that fetal surgery could be safely reproduced in Europe by proper training,” he adds. The findings of the study that Prof. De Coppi cites are convincing, and they point to a considerably higher rate of improvement in the babies that received the surgery while in the womb.
“The U.S. trial authors found that prenatal closure was associated with a 50 [percent] reduction in the need for surgical shunt placement in the newborn baby and a significant improvement in motor function at 30 months of age,” explains Prof. De Coppi.
“The reduction in need for shunts is particularly important,” he adds, “as long-term follow-up of children that have undergone prenatal closure in the womb suggests that brain function, mobility, and total independence were higher in nonshunted than shunted children aged 5.” Thanks to generous funding offered by U.K. nonprofit organizations, particularly GOSH Children’s Charity and UCLH Charity, the in utero procedure for spina bifida will be available free of charge for the first few expectant mothers who solicit it.
“These vital funds have provided training for the surgical team and will fund surgery for the first 10 patients,” says Prof. Donald Peebles, the UCLH clinical director for Women’s Health.