Introduction: Open spina bifida (OSB) is the most common congenital anomaly of the central nervous system. It is associated with severe neurodevelopmental delay, motor impairment, hydrocephalus, and bowel and bladder dysfunction. In selected cases, intrauterine spina bifida repair has been shown to improve neonatal outcomes. Rarely, the spine can have a double defect compromising two different segments and there is a lack of evidence on the feasibility and benefits of intrauterine repair in these cases. Case Presentation: We present a case with both cervicothoracic and lumbosacral myelomeningocele, Arnold-Chiari malformation type II and bilateral ventriculomegaly, that was treated successfully at 25 weeks with open micro-neurosurgery. Double myelomeningocele was successfully treated through a single 2-cm micro-hysterotomy, by performing external versions to sequentially expose and repair both defects. Weekly postoperative follow-up showed no progression of ventriculomegaly or complications attributable to the procedure. Preterm rupture of membranes prompted a conventional cesarean delivery at 32 weeks of gestation. Neurodevelopmental outcome at 20 months was within normal ranges, having achieved ambulation without orthopedic support and with no need for ventriculoperitoneal shunting. Conclusion: This report demonstrates for the first time the feasibility of double OSB repair through a single 2-cm micro-hysterotomy, suggesting that selected isolated cases of double myelomeningocele could be candidates for fetal intervention. Further prospective studies should be carried out to assess the potential benefit of double OSB intrauterine open repair.

Established Facts

  • Prenatal surgery has been established as the ideal treatment for open spina bifida based on the MOMS trial, which showed a reduction in the need for ventriculoperitoneal shunt placement and better postnatal neurological and motor function.

  • Double myelomeningocele is very rare with only a few cases reported in the literature.

Novel Insights

  • Prenatal repair of double myelomeningocele is feasible throughout a single micro-hysterotomy.

  • Fetuses with isolated double open spina bifida defects should not be excluded from intrauterine spina bifida repair.

A 32-year-old pregnant woman, gravida 1, was referred to our fetal surgery center at 23+3 weeks+days of gestation due to a neural tube defect. Fetal neurosonography showed scalloping of frontal bones (lemon sign), obliteration of cisterna magna with postero-caudal displacement of cerebellar vermis (Arnold-Chiari malformation type II), bilateral ventriculomegaly (Fig. 1). Evaluation of the fetal spine demonstrated a superior neural tube defect from C4 to T1 and an inferior neural tube defect from L3 to S1 (Fig. 2), with adequate mobility of the lower limbs showing ankle plantar flexion (functional level S1). Fetal Doppler evaluation of the umbilical artery, middle cerebral artery, and ductus venosus was normal, and the cervical length was 36 mm. Amniocentesis for karyotyping was performed, reporting a normal female (46, XX). The patient was reassessed at 25 weeks of gestation and presented a progression of ventriculomegaly (mean lateral ventricle diameter of 12 mm) with preserved lower limb mobility.

Fig. 1.

Fetal sonographic imaging of Arnold-Chiari II malformation secondary to myelomeningocele, axial views. a Scalloping of frontal bones (lemon sign). b Obliteration of cisterna magna with postero-caudal displacement of cerebellar vermis (banana sign).

Fig. 1.

Fetal sonographic imaging of Arnold-Chiari II malformation secondary to myelomeningocele, axial views. a Scalloping of frontal bones (lemon sign). b Obliteration of cisterna magna with postero-caudal displacement of cerebellar vermis (banana sign).

Close modal
Fig. 2.

Fetal sonographic imaging of the double myelomeningocele. Sagittal view of the cervical (a) and lumbosacral (d) region of the fetal spine showing a myelomeningocele. Coronal view shows the splayed vertebrae as the result of the spinal defect in the cervical (b) and lumbosacral (e) regions. Ultrasound 3D reconstruction of the fetal spina shows both splayed vertebrae, in the cervical region (arrow on top) and the lumbosacral region (second arrow) (c).

Fig. 2.

Fetal sonographic imaging of the double myelomeningocele. Sagittal view of the cervical (a) and lumbosacral (d) region of the fetal spine showing a myelomeningocele. Coronal view shows the splayed vertebrae as the result of the spinal defect in the cervical (b) and lumbosacral (e) regions. Ultrasound 3D reconstruction of the fetal spina shows both splayed vertebrae, in the cervical region (arrow on top) and the lumbosacral region (second arrow) (c).

Close modal

The parents were counseled regarding the potential risks and benefits of prenatal surgery versus expectant management with postnatal repair. In particular, they were informed that extrapolating the existing evidence from single open spina bifida (OSB) in utero repair would suggest that potential preservation of motor function and reduction of the risk of progression of ventriculomegaly could be expected, but they were aware of the lack of evidence supporting this for double OSB repair. Termination of pregnancy was not an option due to the existing legal impediments in Mexico.

The preoperative protocol included advanced neurosonography, echocardiography, maternal psychological evaluation, and fetal magnetic resonance imaging that confirmed double myelomeningocele with cord tethering (Fig. 3). OSB repair was performed at 25 weeks of gestation by micro-neurosurgery as previously reported [1]. Briefly, under maternal general anesthesia, a maternal laparotomy through a low transverse abdominal incision (Pfannenstiel) was performed to allow uterine exteriorization from the abdominal cavity. Due to anterior position of the placenta, the uterus was tilted anteriorly to expose the posterior wall. The fetus was in a podalic presentation, and therefore, gentle external manipulation was applied until the cervical defect was positioned on the midline against the posterior uterine wall away from the placenta. Under ultrasound guidance, 1–0 absorbable monofilament (Vicryl) was used to fix the uterine membranes by performing 2 trans-myometrial stitches on the midline of the uterine fundus, 2.0 cm away from each other, and following its longitudinal axis. A single 2.0-cm hysterotomy was performed between the sutures with a monopolar cautery pencil. The amniotic membranes were gently opened and fixed to the uterine wall by continuous locking suture, going over the uterine incision circumferentially, with polyglactin 1–0 thread (Ethicon Inc). A self-retaining retractor (Weitlaner) was used to maintain a good surgical window through the hysterotomy for better exposing the fetal defect. An 8Fr feeding tube was introduced into the amniotic cavity through the hysterotomy for continuous infusion of warm (37°C) lactated Ringer’s solution with antibiotic (2 g cefotaxime per L) to maintain the intrauterine amniotic fluid volume throughout the surgery. Single monofilament 4–0 stitches involving healthy fetal skin were placed on each side of the spinal defect, and the threads were exteriorized through the hysterotomy, allowing a gentle pulling of the fetus against the uterine wall to aid in exposing the defect through the surgical window and reduce amniotic fluid leakage (fetal fixation). Due to the small hysterotomy diameter, surgical loupes (×4.5) were used by the pediatric neurosurgeon (FCO) to improve illumination, magnification, and visualization of the neural placode, which was released and positioned within the spinal canal, and then a 3-layer watertight closure of the neural defect was performed using a monofilament 4–0 suture with a 17-mm needle and bipolar cautery (Fig. 4). The cervical defect was first repaired, and then, after removing fetal fixation stitches, the micro-hysterotomy edges were temporarily affronted using 2 Allis forceps. This was to maintain adequate amniotic fluid volume for the ultrasound guidance to perform an external version to cephalic presentation and expose the lumbosacral defect through the same hysterotomy. The fetus was fixed for a second time exposing the lumbar region, and surgical repair was repeated as previously described. The size of both neural tube defects was larger than the hysterotomy, and therefore, dissection and suturing were accomplished by traversing the lesions with a gentle mobilization of the uterine retractor while holding the fetal back against the hysterotomy. During the entire procedure, continuous fetal monitoring was performed by a fetal cardiologist by using fetal Doppler ultrasound. Once the pediatric neurosurgeon completed both myeloplasties, the fetal surgeon performed a 2-layered uterine closure. The uterus was then placed back into the abdominal cavity, and the maternal abdominal wall was closed in 3 layers. The surgical time was 150 min, and no intraoperative complications (chorioamniotic separation, rupture of membranes, placental abruption, massive uterine bleeding requiring maternal blood transfusion, or fetal bradycardia) were reported. Prophylactic tocolysis with indomethacin and nifedipine was administered immediately after wound closure and up to 72 h after the procedure. The patient was discharged 1 week after fetal surgery. A weekly follow-up showed normal amniotic fluid, fetal estimated weight within normal ranges, and normal cervical length. During fetal follow-up, fetal neurosonography showed regression of hindbrain herniation (the obliterated cisterna magna became visible and measurable, and the cerebellar fastigium regressed to a normal morphology and position above the foramen magnum) and mild progression of ventriculomegaly (mean lateral ventricle diameter of 14 mm).

Fig. 3.

Sagittal slice of fetal magnetic resonance imaging (MRI) T2-weighted sequence demonstrating Arnold-Chiari II malformation. Hindbrain herniation is caused by a downward displacement of the cerebellum resulting in a compressed brainstem, small posterior fossa, and obstructed fourth ventricle. Double myelomeningocele is shown, at cervical region and at lumbosacral region with cord tethering.

Fig. 3.

Sagittal slice of fetal magnetic resonance imaging (MRI) T2-weighted sequence demonstrating Arnold-Chiari II malformation. Hindbrain herniation is caused by a downward displacement of the cerebellum resulting in a compressed brainstem, small posterior fossa, and obstructed fourth ventricle. Double myelomeningocele is shown, at cervical region and at lumbosacral region with cord tethering.

Close modal
Fig. 4.

Intraoperative image of open myelomeningocele defect repair. Stapled micro-hysterotomy (2 cm) shows the edge of the myometrium and chorioamniotic membranes fixed with surgical suture (a), tubulation of the neural placode (b), and closure of dura mater (c) and fetal skin (d). Temperature irrigation tube (blue tube) is inserted into the uterus to maintain the uterine volume.

Fig. 4.

Intraoperative image of open myelomeningocele defect repair. Stapled micro-hysterotomy (2 cm) shows the edge of the myometrium and chorioamniotic membranes fixed with surgical suture (a), tubulation of the neural placode (b), and closure of dura mater (c) and fetal skin (d). Temperature irrigation tube (blue tube) is inserted into the uterus to maintain the uterine volume.

Close modal

At 32 weeks of gestation, preterm rupture of membranes prompted an emergency cesarean delivery 72 h after a course of corticosteroids (betamethasone, 12 mg, 2 doses, 24 h apart) was administered. The neonate had respiratory distress syndrome and required oxygen support for 1 week. Physical examination revealed normal head circumference and two surgical scars, one in the lower cervical region and the other in the upper lumbar region. There was no cerebrospinal fluid (CSF) leak. A computed tomography scan was performed 4 months after birth and reported a supratentorial dilated ventricular system without hydrocephalus nor Chiari II malformation (Fig. 5), and therefore, there was no need for ventriculoperitoneal shunting.

Fig. 5.

Computed tomography scan at 4 months of age after intrauterine myelomeningocele repair. a Axial slice shows no hydrocephalus. b Sagittal slice shows no tonsillar herniation.

Fig. 5.

Computed tomography scan at 4 months of age after intrauterine myelomeningocele repair. a Axial slice shows no hydrocephalus. b Sagittal slice shows no tonsillar herniation.

Close modal

Neurodevelopmental outcome was assessed at 24 months by using Bayley Scales of Infant Development, third edition (BSID-III). Neurodevelopment was within normal ranges with BSID-III psychomotor and mental development index score of ≥70, having achieved ambulation without orthopedic support (Fig. 6).

Fig. 6.

Picture of the child in an orthostatic position showing both cervical and lumbar wound scars.

Fig. 6.

Picture of the child in an orthostatic position showing both cervical and lumbar wound scars.

Close modal

OSB is the most common congenital anomaly of the central nervous system due to a failure of primary neurulation. The dysraphic spinal cord protrudes through the vertebral defect and is exposed to the chemically hostile environment of the amniotic fluid and susceptible to trauma against the uterine wall. There is also CSF leakage to the amniotic cavity, interfering with its normal circulation and leading to hydrocephalus that may require postnatal ventriculoperitoneal shunting. The lifelong consequences include motor and neurodevelopmental impairment, skeletal deformation, and bowel, bladder, and sexual dysfunction [2]. A randomized control trial “Management of Myelomeningocele Study” (MOMS) demonstrated that prenatal surgery improves prognosis [3]. In comparison with postnatal surgery, intrauterine spina bifida repair has shown a significant reduction in the need for postnatal ventriculoperitoneal shunt placement and better neurological and motor function [3‒5]. Therefore, the number of centers offering this fetal intervention for selected cases with isolated OSB is growing worldwide [6, 7]. Double neural tube defects on the spine are rare, accounting for less than 1% of all defects [8], and are considered a severe condition associated with hydrocephalus often requiring postnatal ventriculoperitoneal shunting, severe motor and neurological impairment, and even infant death [9‒15]. There are only a few cases of double neural tube defects reported in the literature, with a very small proportion of them having been diagnosed prenatally [15, 16], and all of them receiving postnatal surgical repair [17‒19]. Thus, there is a lack of previous evidence on fetal surgery for this specific population. We are therefore reporting for the first time a case of double myelomeningocele that was successfully repaired during fetal life by open fetal micro-neurosurgery using a single 2.0-cm micro-hysterotomy.

This surgical technique has recently been described by our group in a prospective cohort of 60 consecutive cases with isolated OSB [1]. We demonstrated that intrauterine spina bifida repair through a 1.5–2.0-cm micro-hysterotomy was feasible and showed better perinatal outcomes and similar short-term neurological outcomes than the classic open fetal surgery technique. Maintaining normal amniotic fluid and uterine volume by continuous amnioinfusion and minimizing amniotic fluid leak and fetal manipulation by fetal fixation sutures are keys to the procedure [20]. This technique has been shown to be associated with lower risk of oligohydramnios, preterm rupture of the membranes, and preterm delivery than the standard open technique using 6–8-cm hysterotomy [21, 22]. In the current case, double spina bifida repair was feasible by a single micro-hysterotomy by performing an internal version for exposing the second defect while the hysterotomy was temporally occluded. Considering that umbilical cord prolapse is a potentially lethal complication that may occur during open fetal surgery [23], the relevance of a small hysterotomy and affronting its edges during internal version should be remarked, since these avoid rapid loss of amniotic fluid and possible umbilical cord prolapse during fetal manipulation.

Compared to postnatal treatment, prenatal surgery for single myelomeningocele has been shown to reduce hindbrain herniation and the need for CSF shunting, improve motor function, and increase the probability of independent ambulation [24, 25]. Alike to single myelomeningocele repair, in this case, intrauterine double OSB repair resulted in regression of Chiari II malformation, avoiding the need of ventriculoperitoneal shunting, and allowing good neurodevelopmental and motor outcomes. Nevertheless, in the current case, fetal intervention was mainly indicated by the lumbosacral defect since cervical spinal defects are usually not associated with hydrocephalous or motor dysfunction, and therefore, further prospective and multicenter studies are required to confirm the potential benefit of this intervention in cases with isolated multiple neural tube defects.

Of note, no complications were observed during or after surgery in our case, but we recognize that this surgical procedure is not risk-free and has been associated with fetal complications such as placental abruption, bradycardia, and intrauterine fetal demise. Although no maternal deaths have been reported, severe life-threatening maternal complications such as severe uterine bleeding, uterine rupture, pulmonary edema/embolism, and even cardiac arrest requiring resuscitation have also been reported [1, 26, 27].

In our previous series of 60 cases with single spina bifida treated with intrauterine repair by micro-hysterotomy, the surgery time was on average 107 min (SD 30 min) [1]. Although double myeloplasty implied longer neurosurgical time (150 min), it could be speculated that maternal or fetal risks are not increased during prenatal surgery for double defects in comparison with single defects, since this was a single-stage surgery using only one micro-hysterotomy.

We recognize that double spina bifida is unusual and its prenatal diagnosis may be very challenging [10]. Some series have demonstrated that in a proportion of cases, only one of the defects was observed during pregnancy while the second defect was only diagnosed after birth [17]. Therefore, once an OSB is diagnosed in pregnancy, a thorough ultrasound examination of the entire fetal spine should be performed to look for a second hidden defect. In conclusion, simultaneous intrauterine repair of double spina bifida through a single 2-cm micro-hysterotomy in a single-stage surgery is feasible and therefore selected cases of isolated double myelomeningocele with Chiari II malformation should not be excluded for the potential benefits of fetal intervention.

Rogelio Cruz-Martínez was supported by the Mexican National Council for Science and Technology (CONACyT) and wishes to thank the Fetal Medicine Mexico Foundation for supporting the national project of fetal surgery for intrauterine spina bifida repair in Mexico.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review. Due to the study design, this retrospective review of patient data did not require ethical approval in accordance with local/national guidelines.

The authors have no conflicts of interest to declare.

No financial support was needed for this study.

All authors had access to the data included in this study and took responsibility for its integrity and accuracy. Karla Aguilar-Vidales, Felipe Chavelas-Ochoa, Rogelio Cruz-Martínez, Miguel Martínez-Rodríguez, Iván Gutiérrez Gómez, and Antonio Helue-Mena participated in the fetal surgery; Antonio Helue-Mena, Carmen Julia Gaona-Tapia, and Miguel Martínez-Rodríguez did the acquisition of data; Rogelio Cruz-Martínez and Felipe Chavelas-Ochoa made the surgery design; Virginia Medina-Jiménez, Rosa Villalobos-Gómez, and Ma de la Luz Bermúdez-Rojas drafted the manuscript; Rogelio Cruz-Martínez and Savino Gil-Pugliese reviewed the final manuscript.

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.

1.
Cruz-Martinez
R
,
Chavelas-Ochoa
F
,
Martinez-Rodriguez
M
,
Aguilar-Vidales
K
,
Gamez-Varela
A
,
Luna-Garcia
J
, et al
.
Open fetal microneurosurgery for intrauterine spina bifida repair
.
Fetal Diagn Ther
.
2021
;
48
(
3
):
163
73
. .
2.
Bowman
RM
,
McLone
DG
,
Grant
JA
,
Tomita
T
,
Ito
JA
.
Spina bifida outcome: a 25-year prospective
.
Pediatr Neurosurg
.
2001
;
34
(
3
):
114
20
. .
3.
Adzick
NS
,
Thom
EA
,
Spong
CY
,
Brock
JW
3rd
,
Burrows
PK
,
Johnson
MP
, et al
.
A randomized trial of prenatal versus postnatal repair of myelomeningocele
.
N Engl J Med
.
2011
;
364
(
11
):
993
1004
. .
4.
Paslaru
FG
,
Panaitescu
AM
,
Iancu
G
,
Veduta
A
,
Gica
N
,
Paslaru
AC
, et al
.
Myelomeningocele surgery over the 10 years following the MOMS trial: a systematic review of outcomes in prenatal versus postnatal surgical repair
.
Medicina
.
2021
;
57
(
7
):
707
. .
5.
Hassan
AS
,
Du
YL
,
Lee
SY
,
Wang
A
,
Farmer
DL
.
Spina bifida: a review of the genetics, pathophysiology and emerging cellular therapies
.
J Dev Biol
.
2022
;
10
(
2
):
22
. .
6.
Sacco
A
,
Simpson
L
,
Deprest
J
,
David
AL
.
A study to assess global availability of fetal surgery for myelomeningocele
.
Prenat Diagn
.
2018
;
38
(
13
):
1020
7
. .
7.
Sepulveda
W
,
Cruz-Martinez
R
,
Etchegaray
A
,
Sanin-Blair
J
,
Ventura
W
,
Corral
E
, et al
.
Open intrauterine repair of spina bifida aperta: historical aspects, current availability, and clinical outcomes from the Latin American Spina Bifida Consortium
.
Prenat Diagn
.
2021
;
41
(
8
):
933
41
. .
8.
Ahmad
FU
,
Dwarakanath
S
,
Sharma
BS
,
Mahapatra
AK
.
Multiple neural tube defects: a clinical series of seven cases and their embryological basis
.
Pediatr Neurosurg
.
2008
;
44
(
4
):
280
7
. .
9.
Etus
V
,
Ilbay
K
,
Akansel
G
,
Ceylan
S
,
Ceylan
S
.
Double myelomeningocele in a neonate: case report and review of the literature
.
Clin Neurol Neurosurg
.
2006
;
108
(
6
):
595
600
. .
10.
Keshavarzi
S
,
Nejat
F
,
Kazemi
H
.
Double spinal dysraphism. Report of three cases
.
J Neurosurg
.
2007
;
106
(
4 Suppl
):
316
8
. .
11.
Vashu
R
,
Liew
NS
.
Double neural tube defect: a case report and discussions on neural tube development
.
Childs Nerv Syst
.
2010
;
26
(
5
):
697
701
. .
12.
Bertal
A
,
Hilmani
S
,
Elkamar
A
,
Elazhari
A
.
Double myelomeningocele: case report
.
Br J Neurosurg
.
2011
;
25
(
3
):
335
6
. .
13.
Mahalik
SK
,
Vaze
D
,
Kanojia
RP
,
Narasimhan
KL
,
Rao
KL
.
Multiple neural tube defects may not be very rare
.
Childs Nerv Syst
.
2013
;
29
(
4
):
609
19
. .
14.
Deora
H
,
Srinivas
D
,
Shukla
D
,
Devi
BI
,
Mishra
A
,
Beniwal
M
, et al
.
Multiple-site neural tube defects: embryogenesis with complete review of existing literature
.
Neurosurg Focus
.
2019
;
47
(
4
):
E18
. .
15.
Elarjani
T
,
Khairy
S
,
Al-Karawi
S
.
Presentation of a double myelomeningocele in the upper thoracic and thoracolumbar spine: a case report
.
Int J Surg Case Rep
.
2020
;
76
:
484
7
. .
16.
Belfatmi
N
,
Motawei
AS
,
Rezkallah
A
,
Benarous
ND
,
Ahmed
AH
,
Ghozy
S
, et al
.
Double lumbar localization of myelomeningocele: case report
.
Pediatr Neurosurg
.
2023
;
58
(
2
):
97
104
. .
17.
Richards
TA
,
Kortesis
BG
,
Glazier
S
,
Argenta
LC
,
David
LR
.
Double myelomeningocele: case report and review
.
Br J Plast Surg
.
2003
;
56
(
3
):
306
8
. .
18.
Singh
N
,
Singh
DK
,
Aga
P
,
Singh
R
.
Multiple neural tube defects in a child: a rare developmental anomaly
.
Surg Neurol Int
.
2012
;
3
:
147
. .
19.
Shiferaw
MY
,
Awedew
AF
,
T/Mariam
TL
,
Aklilu
AT
,
Akililu
YB
,
Andualem
AM
.
Multiple site neural tube defects at Zewuditu Memorial Hospital, Addis Ababa, Ethiopia: a case report
.
J Med Case Rep
.
2021
;
15
(
1
):
429
. .
20.
Cruz-Martinez
R
,
Gamez-Varela
A
,
Cruz-Lemini
M
,
Martinez-Rodriguez
M
,
Luna-Garcia
J
,
Lopez-Briones
H
, et al
.
Doppler changes in umbilical artery, middle cerebral artery, cerebroplacental ratio and ductus venosus during open fetal microneurosurgery for intrauterine open spina bifida repair
.
Ultrasound Obstet Gynecol
.
2021
;
58
(
2
):
238
44
. .
21.
Molina-Giraldo
S
,
Zapata Salcedo
R
,
Rojas Arias
JL
,
Acuna Osorio
E
,
Pinto Quinones
ML
,
Restrepo
HF
, et al
.
Open surgery for in utero repair of spina bifida: microneurosurgery versus standard technique – a systematic review
.
Prenat Diagn
.
2021
;
41
(
13
):
1615
23
. .
22.
Sosa
C
,
Rivas
M
,
Mascareno
P
,
Amarilla
L
,
Ricardo
A
,
Rojas
M
, et al
.
Outcome of fetal microneurosurgery for intrauterine spina bifida repair in country with deficient healthcare system
.
Ultrasound Obstet Gynecol
.
2022
;
59
(
1
):
120
2
. .
23.
Sepulveda
W
,
Corral
E
,
Alcalde
JL
,
Otayza
F
,
Muller
JM
,
Ravera
F
, et al
.
Prenatal repair of spina bifida: a 2-center experience with open intrauterine neurosurgery in Chile
.
Fetal Diagn Ther
.
2020
;
47
(
12
):
873
81
. .
24.
Farmer
DL
,
Thom
EA
,
Brock
JW
3rd
,
Burrows
PK
,
Johnson
MP
,
Howell
LJ
, et al
.
The Management of Myelomeningocele Study: full cohort 30-month pediatric outcomes
.
Am J Obstet Gynecol
.
2018
;
218
(
2
):
256 e1
e13
. .
25.
Houtrow
AJ
,
MacPherson
C
,
Jackson-Coty
J
,
Rivera
M
,
Flynn
L
,
Burrows
PK
, et al
.
Prenatal repair and physical functioning among children with myelomeningocele: a secondary analysis of a randomized clinical trial
.
JAMA Pediatr
.
2021
;
175
(
4
):
e205674
. .
26.
Winder
FM
,
Vonzun
L
,
Meuli
M
,
Moehrlen
U
,
Mazzone
L
,
Krahenmann
F
, et al
.
Maternal complications following open fetal myelomeningocele repair at the Zurich center for fetal diagnosis and therapy
.
Fetal Diagn Ther
.
2019
;
46
(
3
):
153
8
. .
27.
Vonzun
L
,
Kahr
MK
,
Noll
F
,
Mazzone
L
,
Moehrlen
U
,
Meuli
M
, et al
.
Systematic classification of maternal and fetal intervention-related complications following open fetal myelomeningocele repair: results from a large prospective cohort
.
BJOG
.
2021
;
128
(
7
):
1184
91
. .