A Randomized Trial of Prenatal Versus Postnatal Repair of Myelomeningocele [MOMS Trial]
- Spina bifida is the most common congenital CNS malformation and can result in neurologic deficits and shunt-dependent hydrocephalus.
- Prenatal repair of myelomeningoceles has been performed for over 20 years.
- This study compared infants who underwent prenatal myelomeningocele repair (n=91) between the weeks of 19 to 25.9 gestational age to those who underwent postnatal myelomeningocele repair (n=92). A total of 183 patients were randomly assigned to either group.
- The study was prematurely terminated after the recruitment of 183 patients (out of planned 200 patients) due to efficacy of prenatal surgery.
- Primary outcome, which was defined as death or need for shunt by age of 12, occurred in 68% of the prenatal cohort and 98% in the postnatal cohort.
- Patients who underwent prenatal repair had significantly lower rates of shunt placement, hindbrain herniation, brainstem kinking, abnormal location of the fourth ventricle, and syrinx by the age of 12 months. Additionally, of those who did have hindbrain herniation or brainstem kinking, the severity was lower for the prenatal cohort.
- Patients in the prenatal cohort were more likely to have a neurologic level of function two levels higher than expected, were more likely to be able to walk without assistive devices, and had higher levels of mobility and self-care reported.
- Prenatal repair patients had a significantly higher rate of preterm birth (earlier than 30 weeks) and the associated respiratory complications.
- Patients who underwent postnatal repair had significantly lower rates of surgical repair for tethered cord.
- There were no significant differences between the groups in mortality or cognitive scores.
- Careful evaluation of the benefits of neurologic outcomes of prenatal myelomeningocele repair must be weighed against the risk of preterm birth and intraoperative complications.