Meningomyelocoele: A case report and discussion

Ruby1, Sonya Mercy Anbu2, Suganya Periya Nayaki3, Malarvizhi4

1Senior DNS – Clinical Nursing, MAA Kauvery, Trichy

2Nurse Educator – Clinical Nursing, MAA Kauvery, Trichy

3Nursing Incharge – Clinical Nursing, MAA Kauvery, Trichy

4Staff Nurse – Clinical Nursing, MAA Kauvery, Trichy

Introduction

It is a most severe type of Spina bifida. The Spina bifida means split spine

These are four types

  1. Spina bifida occulta
  2. Meningocele
  3. Spina bifida cystica or Meningomyelocele
  4. Lipomeningocele

Definition

It is failure of closure of the neural tube during third week of gestation leading to abnormal differentiation of embryonic neural tube

Incidence

  • 1-2/1000 live births
  • Neural tube defect is second most common type of birth defect
  • 85%occur in lumbosacral region
  • Higher in females than in males

Etiology

  • Poor nutrition –folic acid deficiency
  • Genetics (people of northern European &Hungarian have highest rates)
  • Chromosome abnormalities: Trisomies 13&18, Triploidy
  • Single gene mutations
  • Maternal obesity
  • Diabetes mother

Pathophysiology

Clinical features

  • Both meninges &spinal cord protrude into the skin of the back. Leak of CSF, Paraplegia
  • and risk of bacterial meningitis. Diminished control of lower limbs, bladder&bowel
  • Hydrocephalus often accompanies
  • Short stature, precocious puberty
  • Orthopedic abnormalities (club foot, hip dislocation), Pressure sore &skin irritations
  • Abnormal eye movement, Paralysis, Scoliosis, Back pain

 

 

Other symptoms

Hair at the back part of the pelvis called the sacral area, Dimpling of sacral area, difficulty swallowing which can lead to chocking hoarseness breath holding & problems breathing during sleep .

Diagnosis

  • USG at second trimester
  • Positive screening for maternal serum alpha feto protein (AFP)
  • Screening of amniotic fluied for AFP as well as for presents of acetyl cholinesterase, MRI

Treatment

  • Intra Uterine surgery
  • Post natal surgery; closure of Meningomyelocele is performed immediately after birth if external CSF leakage is present.

Medical Management

  • Anticholinergics
  • To suppress detrusor over activity, eg: Oxybutynin chloride
  • Tricyclic Antidepressents; eg: Imipramine, Hydrochloride
  • Alpha adrenergic antagonist
  • Decreases bladder outlet resistance, increases urinary flow rate, e.g., Terazosin

Immediate care

  • Place the child in prone position
  • Cover the affected area with sterile gauze piece dipped in normal saline
  • Maintain hydration, monitor for associated defects

Lifelong treatment

Catheter, Braces, High fiber diet, Antibiotics for present infection such as meningitis or urinary tract infection.

Nursing management

  • Preventing trauma to meningal sac & preventing infection before surgical repair of the defect.
  • Preventing infection
  • Promoting urinary elimination
  • Assessing urinary function

Meningomyelocele – Patient profile

A 1-day-old male child admitted for respiratory distress, ruptured Meningomyelocele. During admission baby weighed 2.7 kg

Antenatal history: Antenatal scan was normal .There is no significant medical problems during pregnancy; mother was on no maternal drugs

  • Clinical findings: Activity-Weak
  • Cry-Dull
  • Color – peripheral cyanosis
  • Spo2-96% with O2 0.5L/mt,HR-166/min,RR-68/min, Perfusion-poor

Systemic Examination

  • CVS: S1S2 Heard
  • RS: B/L Air entry equal, Downs score: 3/10
  • CNS: AF open&Level, New born reflexes –Fair
  • Bone, Joint cavity & soft tissue-Meningomyelocele.
  • MRI Findings: Cerebellar Tonsilar Herniation with spina bifida in the Lumbosacral region with large Meningomyelocele and tethered cord.

Baby was operated for Meningomyelocele under GA.Baby was on mechanical ventilation throughout post operative period and weaned off from ventilator to oxygen

Treatment given:

  1. Antibiotics inj.piptaz, Inj.Amikacin, inj meropenem,
  2. Analgesics inj .paracetamol
  3. Anticonvulsive drugs inj.Gardenal, inj.Fosollin, inj.Levipil, Tab.Acetazolamide
  4. A&D drops,

Advice on discharge:

  1. Syr.Gardinal 20mg/5ml 1.5ml 1-0-1
  2. Tab.Acetazolamide 4mg 1-0-0
  3. A&D drops 8 drops 1-0-0

Recommendation

  • To keep the baby warm
  • To encourage exclusive breast feeding
  • To follow up with Paediatrician for Vaccination
  • To follow for Neuro development
  • To follow precautions when carer has flu or any communicable infections.

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