sMater | Dr Glenn Gardener | Part 2 - Inutero Spina Bifida

This episode of the three-part mini-series with Dr Glenn Gardener delves into the success of in-utero spina bifida surgery at Mater's Maternal Fetal Medicine Unit.

Dr Gardener successfully performed Australia's first in-utero surgery to correct a developing baby's spinal cord at Mater in 2016.

Since then, more than 200 similar surgeries have been performed, reducing the risk of nerve damage and lifetime mobility restrictions.

Mater's Maternal Fetal Medicine Unit remains the only site in Australia and New Zealand to provide the complex surgery.

GP Education activity log:

• Podcast title - sMater: Spina Bifida
• Provider - Mater Misericordiae Ltd Date published - February 21, 2025
• Certificate of completion - click here 

To learn more about Mater, visit https://www.mater.org.au/

Transcript

Hello and welcome to this episode of sMater. A podcast by clinicians for clinicians brought to you by Mater, an Australian leader in healthcare for more than a century. My name is Jillian Whiting and we're coming to you from Meanjin the land on which this podcast is being recorded.

In this three-part miniseries we're talking about in-utero surgery with Dr Glenn Gardener. A Maternal Fetal Medicine specialist and director of the Mater
Center for Maternal Fetal Medicine Mater Mothers' hospitals. This episode is about Spina Bifida which affects about 150 babies born in Australia every year. Glenn was the first to perform this surgery in Australia on a 24 week old inutero baby in 2016.

We are Mater. We are Mater. We are Mater. This is sMater.

That was in 2016 that was that first surgery with your team from Mater in collaboration with a team from Vanderbuilt University Hospital in the USA it's been a while so what has changed since then and how many other specialists are performing this surgery? We're heading into eight years now of this program and we since that first case with support of the US team have gone and offered this across for all patients across Australia and also New Zealand so we've now done 21 cases I believe on the last count and in that time all alive and and doing well which is good to good to report so no one else is doing it and I think it's very hard to undertake this type of surgery it's better to concentrate your expertise. We've got a great team here. We now have you know the ability to do the surgery not relied upon single people so we have enough kind of critical mass so that should someone be sick or someone away the surgery can still be performed that's an important for succession planning into the future for a procedure that you're the only place offering it so we're confident going into the future that for patients across Australia and New Zealand will be able to continue offering this service it's not really funded by anyone but the Mater chooses to provide funding so patients don't have to pay to have the surgery which is very nice as well there are some costs that would be involved for patients having to relocate here to have the surgery but we would return them home as soon as we can.

That is wonderful. There was a lot of attention at that time a lot of media attention on that surgery a lot of people talking about it. Can you briefly describe what that was like to go through that surgery and have that spotlight so brightly on you at that point?
Yeah like I had been overseas and had been in theatre both in the US and in Europe so I kind of already had a pretty good understanding of the surgery. Actually performing the surgery
is a different experience you know really comes home not only the potential to improve the outcome for that particular child and the family but actually the you know what you're undertaking in terms of risks as well so it's very sobering.

I probably aged more in 2016 with there was a lot of there's a lot of stress when you do something new like that and you know the media attention I wasn't expect. I mean I knew there'd be some but certainly you know across the country there was interest that that was kind of a little bit beyond what I imagined but I think people's imagination is piqued when you when you say you're actually opening the uterus and operating on a baby and then putting it all back. 

It really is extraordinary. If we take a step back now, why does Spina Bifida occur? It's a good question and you know we haven't actually nutted out the cause of Spina Bifida. The theory at the moment is that there probably is some candidate genetic gene you know a candidate 
genetic basis for the condition that's affected by the environment. There's no single gene there's no kind of testing say someone's going to have a baby with Spina Bifida it's a multiple factors all coming together it's also affected by folate metabolism so we know that women who take folate around the time of conception and in the first few weeks of pregnancy does confer some protection it doesn't protect every pregnancy against Spina Bifida but it's it's intricately involved in how Spina Bifida occurs. When is it diagnosed and how is it diagnosed so traditionally it was diagnosed at the routine morphology scan which is kind of mid pregnancy about kind of 20 weeks. Nowadays we've got markers that we can look at as early as 12 and 13 weeks and whilst we we're not keen to make a diagnosis we can actually bring those patient back bring bring those patients back sooner and make the diagnosis at around 16 weeks is we can be very certain of the diagnosis and the point of making a diagnosis at 16 weeks is that you can start the counseling process and the shock of that diagnosis you know is not lost on me. Still today when I see patients you know most patients would be expecting a healthy baby and you know there's a lot of you know time that's required to digest that information explain what the outcomes are possible for their child and and now of course what can we do to make those outcomes better.

Well if it is earlier at 16 weeks what can we do apart from counseling? Is there any treatment any scanning that will make the process better?

Yeah so it's about time and so if we are planning surgery at 23 24 weeks there's nothing worse than having the diagnosis made a couple of weeks before because that family have not had adequate time really to come to terms with what their options and choices are. Not everyone continues the pregnancy and that as difficult as it is for couples we understand that and we think the time is important for them to really and and we get them to see a lot of people not they don't just see Maternal Fetal Medicine they get to see doctors at the Children's Hospital that care for children with Spina Bifida, they get to see a neurosurgeon, a neonatologist so we really do make sure that they have the best possible information before they're making what is one of probably one of the most difficult decisions in their life will they go forth with the pregnancy and consider having surgery which has risks to improve the outcome or sadly some choose not to continue so you've made a with either 16 weeks or 20 weeks.

We know that as Spina Bifida is present talk to me about the surgery.

So that happens 24 weeks and why that time frame and tell me about the surgery?

So the principle of the surgery is to close the defect on the lower spine so the nerves are protected because the the the concern is that in utero those nerves are damaged by exposure to amniotic fluid and rubbing up against the side of the uterus such that if we get skin across those nerves there's less damage and that's been shown on animal studies and now that we've done we're doing the surgery we see it in the children. We would love to be able to close that defect earlier but we're limited by the fragility of fetal skin and also entering the uterus at that early gestation and doing such a repair has been shown to be detrimental so we have to wait for a time where the skin integrity is enough to cope with the surgery and that generally is from 22 weeks. 

What are the complications from surgery?

The biggest risk is pre-term birth and on average if you have this surgery you'll deliver at 34 weeks compared to if you don't have surgery with spin we recommend delivery at 37 weeks on average 3 weeks earlier and whilst that might seem acceptable and I think it is acceptable for a number of patients if it was you having a baby much earlier than that then you know your child may then have consequences of prematurity in addition to Spina Bifida so hence why it can be a very difficult decision. We do a lot to prevent early delivery and our cohort of cases that we have at the moment we do run on average about delivery around 34 weeks and that degree of minor prematurity is acceptable we wouldn't expect major long-term kind of consequences of that but of course even that first case that we did with the US team delivered under 30 weeks and that's you know that kind of rams home very heavily you know the consequence of this surgery sometimes yeah are there cases when surgery isn't appropriate yeah so there's very strict criteria some of those criteria have been relaxed over the years.

The criteria were based around a big study in the US published in 2011 now and there are criteria like even High BMI high body mass index may you know preclude the option of surgery just because we're concerned about surgical risk to the mother things of that nature the defect on the fetus is very important as well so it's a very minor defect we wouldn't 

undertake the surgery. They're the major kind of reasons why we wouldn't be able to operate for the inutero surgery that is completely successful.

What care concerns and treatment happens for the mothers up until they deliver?

So we watch them very closely. We see them regularly in Maternal Fetal Medicine where we scan them with and make sure that the the operative site on the uterus and on the baby is intact and remains so we monitor the growth of the baby we plan delivery at 37 weeks as we would for anyone with Spina Bifida and that has to be by elective caesarian section because of the scar on the uterus is too dangerous to have labour wih in case it should it come apart and then and then we hope for the benefits of the surgery which are you know to avoid
a shunt and some babies of Spina Bifida need to have a little shunt put in their brain that drains fluid to keep their brain from being compressed by fluid. You have the rate of need to shunt children if you if you do this surgery before they're born. The other benefit is you increase their ability to mobilize without needing any assistance and whilst you know that's perhaps a secondary benefit it's an important benefit for children who perhaps would have been relegated to wheelchair only may be able to mobilize and that you know leader have a different approach to how they get around make a huge difference.

What is the role of the GP in terms of prevention and  diagnosis of Spina Bifida?

Yeah so GPs are very good at making sure that patients have access to ultrasound early in pregnancy. It can be tricky if a patient presents very late not knowing they're pregnant but GPs do their best to get the necessary and everyone has usually has a scan at around 12 or 13 weeks now and then another scan at 20 to 22 weeks and generally we will diagnose it if anything of of all the possible fetal abnormalities that can exist. Spina Bifida is readily diagnosable on ultrasound I mean it's not like we're missing it and like some you know I'll give you you know a classic example would be cardiac malformations in a baby are very hard and even in the best hands they can sometimes be missed.

Now there's so much interest in the work you're doing so we've asked some GPs to submit their questions so here's some specific ones for you. Fetal surgery for Spina Bifida has been happening at Mater as we've discussed for a few years now. What are we seeing in terms of immediate and longer term outcomes after surgery  and you sort of touched on this a little bit earlier.

Yeah I mean some of the benefits we see

we only realized after we started doing this surgery some of the short-term benefits were that these children don't actually need surgery they go to the ward with their mother and like most other babies are born in the hospital the other children that either don't have surgery or can't have surgery have to go to intensive care they have to have surgery planned because you can't leave their back open exposed and that separation you know you really appreciate the benefit of having the surgery done and the baby goes home at the normal time and has follow up in the children's hospital with the great rehab team there at the Spina Bifida and so that's a very great short-term benefit. Usually if you don't have a shunt inserted in the first year of life you'll be free you'll be free of a shunt forever that's a general truism and so we've seen already in our cohort of children that have had surgery a very low rate of shunting. We're very pleased about that. It's not zero but we wouldn't expect it to be zero. We just want to see a significant benefit of reduced shunting of which we've seen and these children are generally very mobile.

There's another question about time frames which we have discussed as well about the earliest but what about the latest that this surgery can be done?

Yeah so generally in the original trial the latest gestation was 25 weeks and 6 days that has we've actually done a case at 26 weeks just recently based on approval from we kind of discussed it with the US but she came from New Zealand and was at a later gestation and really wanted to have the benefits of the surgery and we felt that for the sake of it was you know 5 days over our usual limit and the US team said that they would offer the surgery and have done in their own setting so we felt confident to proceed but generally a week beyond that you know 26 weeks would be our limit for repair. Internationally how are we sitting in this space. The work that you're doing the work that we're doing in Australia how how are we fairing?

Yeah very well I mean if we look at the world and we look at for example the UK like we were doing the surgery before the surgery was offered in London.

Wow. Yeah so we were very much ahead of the game they've started their program and I've done some training in the UK earlier in my career so I'm very much in touch with them as they kind of set about their program after us within the kind of asia-pacific region. We are really the only centre and it's as difficult as that is its you know we're supporting Malaysia at the moment. They want to start a program and the team from Malaysia has been here to observe two surgeries and then our team will travel a bit like the US team supported us will be traveling to Malaysia to support them for their first case as well helping all those Malaysian children.

That's great to hear. Now finally three quick questions from me to give everyone listening an insight into to Glenn. When he's not at work okay what's on your surgery playlist? You know what I do not play music and that's not because I don't like music I do like music I've always felt that there's a lot of people in the theater and I've never felt that you know my choice of music should dominate if the patient chooses to have a playlist I'm more than happy to play their playlist whether they're asleep or not. Fantastic. I don't mind I think that's more important it is are you a good dancer are you avoiding that question? No that's a fair question when I was young and silly I would you know love to get out on the dance floor. No time for it now. No and now I would you know have more reluctance to let my hair down like that. You and me both. And career-wise if you weren't doing what you are, what would you be? Were you thinking about trying anything else through school? 
I mean I always kind of look at some careers and think oh i'd love to have done that or i'd love to have done that you know I could have easily been a builder or you know some kind of technical
non kind of academic kind of role more using my hands and skills I would have been very happy to do that. But medicine was a clear path for you?

No not really but I got there in the end. And you're doing an amazing job. Glenn thanks again for your time on sMater. Thanks for having me. For our listeners at home or in the car or having a well deserved break between patients, thanks for tuning in. See you next time on sMater.