DESCRIPTION
Myelomeningocele is a type of spina bifida that occurs at the end of the fourth week of fetal development in approximately one in every 1000 pregnancies the United States each year. The diagnosis of myelomeningocele is determined with measurement of maternal serum alpha-fetoprotein levels, the use of amniocentesis, and high-resolution ultrasonography.
Myelomeningocele occurs when the spinal cord rather than closing remains open exposing the meninges and neural tube to the intrauterine environment. The neural tube gives rise to the brain, spinal cord, and other neural tissue of the central nervous system. This neural tube defect results in varying degrees of deformities and functional disabilities (e.g., spine, limbs, bladder, bowel, sexual dysfunction, learning disabilities and neurologic deformities). Although the exact cause of the neurologic deficits is unknown, possible cause is attributed to either the primary defect in closure of the neural tube or secondary injury to exposed neural tissue throughout gestation by amniotic fluid and mechanical trauma. Based on the latter, intrauterine myelomeningocele repair has been investigated in an attempt to reduce the neurologic dysfunction associated with this condition or disorder.
Generally, surgical repair of the myelomeningocele takes place after birth. Investigation is underway involving the surgical repair prior to birth by opening the uterus, surgically correcting the fetal abnormality, and restoring uterine closure for completion of gestational development. The intrauterine myelomeningocele repair is performed between the 19th and 25th week of pregnancy. Around the 37th week, a C-section is performed for the delivery.
POLICY
Intrauterine myelomeningocele repair is considered investigational.
ADDITIONAL INFORMATION
Published scientific evidence in the form of well-designed studies in peer-reviewed journals regarding intrauterine myelomeningocele repair is lacking.
There is insufficient evidence to permit conclusion regarding intrauterine myelomeningocele repair compared to postnatal repair, or whether the intrauterine repair improves short or long term health outcomes for the baby and the mother.
SOURCES
American College of Obstetricians and Gynecologists. (2005, November). Maternal decisions making, ethics, and the law. Retrieved February 15, 2007 from http://www.acog.org/publications/pdfs/co321.pdf.
American College of Obstetricians and Gynecologists. (2003, July). Retrieved February 16, 2007 from http://www.acog.org/publications/educational_bulletins/pb044.cfm.
BlueCross BlueShield Association, Medical Policy Reference Manual. (6:2007). Fetal surgery for prenatally diagnosed malformations. (4.01.10). Retrieved April 8, 2009 from BlueWeb. (22 articles and/or guidelines reviewed)
Chescheir, N. C. & D'Alton, M. (2005), Evidence-based medicine and fetal treatment: How to get involved. Obstetrics & Gynecology, 106 (3), 610-613.
Farmer, D. L., von Koch, C. S., Peacock, W. J., Danielpour, M., Gupta, N., Lee, H., et al. (2003). In utero repair of myelomeningocele: Experimental pathophysiology, initial clinical experience, and outcomes. Archives of Surgery, 138 (8), 872-878.
Fichter, M. A., Dornseifer, U., Henke, J., Schneider, K. T., Kovacs, L., Biemer, E., et al. (2008). Fetal spina bifida repair--Current trends and prospects of intrauterine neurosurgery. Fetal Diagnosis and Therapy, 23 (4), 271-286.
Hayes. Medical Technology Directory. (2004, November). In utero fetal surgery. Retrieved April 8, 2009 from www.Hayesinc.com/subscribers. (56 articles and/or guidelines reviewed)
MOMS. (2003). Management of myelomeningocele study. Retrieved February 15, 2007 from http://www.spinabifidamoms.com/english/overview.html.
National Guideline Clearinghouse. (2003, July). Neural tube defects. Retrieved April 9, 2009 from http://www.guidelines.gov.
National Institute of Neurological Disorders and Stroke. National Institutes of Health. (2007, December). NINDS spina bifida information page. Retrieved April 14, 2009 from http://www.ninds.nih.gov/health_and_medical/disorders/spina_bifida.htm.
Sutton, L. N. (2008). Fetal surgery for neural tube defects. Best Practice & Research. Clinical Obstetrics & Gynaecology, 22 (1), 175-188.
ORIGINAL EFFECTIVE DATE: 7/14/2007
MOST RECENT REVIEW DATE: 5/14/2009
ID_BT
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