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t m c » p u l s e | o c t o b e r 2 0 1 6 25 Patch Work New hope for spina bifida's youngest patients B y A l e x a n d r a B e c k e r S even years ago, Lovepreet K. Mann was standing at a crosswalk in Salt Lake City with her husband and colleague, Dr. Ramesha Papanna. They had been testing an underwater glue for fetal surgery, and a thought suddenly occurred to her. There, on the street in Utah, the couple began a discussion that would ultimately lead to a patch made from human umbilical cord. Today, it is being used to help repair spina bifida in babies before they're even born. A "super C-section" Spina bifida is a birth defect character- ized by an incomplete closing of the bones and membranes surrounding the spinal cord. In most cases, tissues and nerves are exposed in an opening along several vertebrae in the baby's back, making him or her highly susceptible to life-threatening infections and some- times triggering complete paralysis of the legs as well as bladder incontinence and a range of cognitive difficulties. The condition is typically detected in a pregnant woman's 20-week anatomy scan, during which time the ultrasound tech identifies either a lemon-shaped head or a "banana sign," both caused by pulls in the cranial area from the spinal malformation. For decades, the standard treatment has included postnatal surgery, but sentiments shifted after the ground- breaking NIH-funded MOMS Trial (Management of Myelomeningocele Study) initiated in 2003, in which stan- dard repair results were benchmarked against more than 90 fetal repair cases. The results spoke volumes. Babies who underwent fetal repair were much less likely to need a ventricular shunt for hydrocephalus. Furthermore, twice as many children from the fetal surgery Ramesha Papanna, M.D., M.P.H., an assistant professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at McGovern Medical School at The University of Texas Health Science Center at Houston and a maternal-fetal medicine specialist at The Fetal Center at Children's Memorial Hermann Hospital, holds a patch made from human umbilical cord. group were able to walk without crutches at 30 months of age, compared to those who received the surgery after birth. Not all patients qualify for the highly specialized, extremely com- plex procedure, which involves either pulling the skin together or stitching a patch directly onto the spina bifida site of the fetus while it is still in the mother's womb. Likened to a "super C-section," the intricate series of sur- gical steps (making an incision in the mother, protecting the placenta, open- ing up the amniotic sac, preserving the fluid, performing the repair through a tiny three-inch by four-inch window in the uterus, replacing the fluid, closing the uterus and then the mother layer by layer) is also not without risk. Most babies who undergo fetal surgery will be born prematurely. There is potential for post-surgical complications and infections. There is the risk of death. And, until Mann, a research instruc- tor in the Department of Obstetrics, Gynecology and Reproductive Sciences at McGovern Medical School, thought of using the regenerative material she and Papanna had been studying to patch the site, there was the likely possi- bility of scar tissue formation, which meant further injury to the spinal cord as the child grew and developed. Every day you could watch the blood vessels and the tissues grow closer together. It was incredible. — RAMESHA PAPANNA, M.D., M.P.H.