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Published:September 21, 2018DOI:https://doi.org/10.1016/j.ajog.2018.09.022
      We appreciate the thoughtful comments of Dr Worley and his dedication to the care of this special group of children that we set out to help by exploring the possibility of fetal surgery for myelomeningocele more than 20 years ago. To address his concerns specifically:
      • 1.
        We agree that 30 months of age is too young to make definitive assessments in children who grow and mature at varying rates. Thirty months was selected as the earliest time for which there existed validated tools to make an initial attempt at understanding the impact of fetal surgery on motor function. On both the Bayley and Peabody motor scales, the prenatal surgery group had better motor function than the postnatal group, even though those in the prenatal surgery group had more severe anatomic levels of lesions. We very much look forward to the upcoming publication of MOMS 2 results, which evaluates the children at ages 6–10 years.
      • 2.
        Male sex was acknowledged to be an identified finding, and we await longer-term follow-up data from MOMS 2.
      • 3.
        The issue of the role of spinal cord tethering and other postnatal surgeries and their role in long-term motor function impairment is important. The relationship of these interventions to long-term outcomes as well as their impact on cost and quality of life need to be further evaluated.
      • 4.
        We agree that the issue of walking independently, while statistically true as narrowly defined in this rigorous trial, minimizes the complexity of this disorder and does not reflect the full impact of the initial location of the lesion and the role played on the future motor outcome of the child.
      In addition to the improvement in hindbrain herniation and the decreased need for cerebrospinal fluid diversion, one of the important outcomes of the MOMs trial was the demonstration that there is hope for real amelioration of this disease. Previously the medical community believed that myelomeningocele was a fixed defect by 6 weeks of gestation. The MOMS trial has shown that there is ongoing damage in the prenatal period that could be prevented and/or repaired in utero. There are at least 10 laboratories today that are studying ways to improve the motor function with a variety of in utero treatment strategies including stem cells and other tissue engineering techniques as well as exploring ways to reduce the impact on pregnant women and their future reproductive potential.

      Linked Article

      • A clinician’s concerns about motor function outcomes of fetal surgery for myelomeningocele
        American Journal of Obstetrics & GynecologyVol. 220Issue 1
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          In 2011, Adzick et al1 reported the outcomes of the Management of Myelomeningocele Study (MOMS) of fetal surgery vs postnatal surgery for myelomeningocele. Enrollment was closed early because the benefit of fetal surgery was demonstrated in all outcome domains. Farmer et al2 recently (2018) reported in the Journal motor function outcomes at 30 months of age for the complete study population and confirmed that fetal surgery resulted in better motor function segmental level compared with the anatomic level of lesion and better ambulation status than did postnatal surgery.
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