Babies with myelomeningocele in Poland: parents' attitudes on fetal surgery versus termination of pregnancy

Understanding perspectives on neural tube defect management: insights from Jordanian parents

INTRODUCTION

Neural tube defects (NTDs) represent a spectrum of heterogeneous birth anomalies characterized by the incomplete closure of the neural tube. In Jordan, NTDs are estimated to occur in approximately one out of every 1000 live births. Timely identification of NTDs during the 18-22 weeks of gestation period offers parents various management options, including intrauterine NTD repair and termination of pregnancy (TOP). This study aims to assess and compare parental knowledge and perceptions of these management modalities between parents of affected children and those with healthy offspring.

MATERIALS AND METHODS

This retrospective case-control study was conducted at Jordan University Hospital (JUH) using telephone-administered questionnaires. Categorical variables were summarized using counts and percentages, while continuous variables were analyzed using mean and standard deviation. The association between exposure variables and outcomes was explored using binary logistic regression. Data analysis was performed using SPSS for Windows version 26 (SPSS Inc., Chicago, IL).

RESULTS

The study sample comprised 143 participants, with 49.7% being parents of children with NTDs. The majority of NTD cases were associated with unplanned pregnancies, lack of folic acid supplementation, and postnatal diagnosis. Concerning parental knowledge of TOP in Jordan, 86% believed it to be legally permissible in certain situations. However, there was no statistically significant difference between cases and controls regarding attitudes toward TOP. While the majority of parents with NTD-affected children (88.7%) expressed a willingness to consider intrauterine surgery, this percentage decreased significantly (to 77.6%) after receiving detailed information about the procedure's risks and benefits (p = .013).

CONCLUSIONS

This study represents the first case-control investigational study in Jordan focusing on parental perspectives regarding TOP versus intrauterine repair of myelomeningocele following a diagnosis of an NTD-affected fetus. Based on our findings, we urge the implementation of a national and international surveillance program for NTDs, assessing the disease burden, facilitating resource allocation toward prevention strategies, and promoting early diagnosis initiatives either by using newly suggested diagnostic biomarkers or early Antenatal ultrasonography.

A study to assess global availability of fetal surgery for myelomeningocele

AIM

To establish the provision of fetal surgery for myelomeningocele (MMC) worldwide.

METHODS

Through the International Society for Prenatal Diagnosis (ISPD) Fetal Therapy Special Interest Group and the North American Fetal Therapy Network (NAFTNet), fetal therapy centres were surveyed (September 2017-June 2018) regarding availability of fetal MMC surgical repair, patient inclusion criteria, repair techniques, number of cases, and outcome reporting. Responses were summarised on an interactive map on the ISPD website.

RESULTS

Forty-four of 59 centres responded (74.6%) of which 34 centres (77.1%) currently offered fetal surgery for MMC and seven centres (15.9%) were awaiting a first case after service set up. Patient inclusion criteria were similar and based on the Management of Myelomeningocele (MOMS) trial. Five centres (14.7%) operated beyond 26 weeks' gestational age, outside the MOMS criteria. Open fetal surgery was provided in 23 centres (67.6%), fetoscopic surgery only in five (14.7%), and six centres offered both types (17.6%). Neurosurgical closure was similar for open surgery but highly variable in fetoscopy surgery. The median number of cases per centre was 21 (range 1-253).

CONCLUSIONS

Fetal surgery for MMC is now offered globally. Two thirds of centres offer open repair via hysterotomy using criteria based on the MOMS trial.

Determination of the Effect of Diameter of the Sac on Prognosis in 64 Cases Operated for Meningomyelocele

OBJECTIVE

To examine the effect of meningomyelocele sac size on prognosis by retrospective review of 64 cases operated for meningomyelocele between January 2009 and December 2012.

METHODS

We evaluated newborn babies operated for meningomyelocele by retrospectively reviewing their files for head circumference, location and with of the defect, accompanying anomalies, treatments administered, drugs that mother used during pregnancy. Based on the defect size, 3 patient groups were created as 0-24 cm² (group I), 25-39 cm² (group II), and 40 cm² and above (group III).

RESULTS

Throughout the study, 64 babies were evaluated. Mean head circumference was 37.4 cm (range, 30.7-50 cm). Based on their location, 49 of the defects (76.5%) were lumbar, 7 (10.9%) were thoracolumbar, 4 (6.2%) were thoracic, 3 (3.1%) were sacral, 1 (1.5%) was cervical. Mean size of the meningomyelocele sac was 4.7 cm×5.8 cm (range, 1 cm×1 cm-10 cm×8 cm), 13 of the babies (20.3%) had skin defect requiring flap. According to accompanying anomalies, 47 of the babies (73.4%) had hydrocephalus, 7 (10.9%) had club foot, 1 (1.5%) had diastematomyelia, 1 (1.5%) had tethered cord. Thirty-nine of the babies (60.9%) had paraplegia, 10 (15.6%) had paraparesis, 8 (12.5%) had monoplegia; neurological examination in the remaining 7 babies was normal.

CONCLUSION

In our study, increased diameter of meningomyelocele sac was associated with greater amount of neural tissue within the sac, which worsens the prognosis. Sac localization was not changing prognosis but infection rates, hospitalization duration were increased in babies with bigger diameter of sacs.

Texture analysis of the developing human brain using customization of a knowledge-based system

Background: Pattern recognition software originally designed for geospatial and other technical applications could be trained by physicians and used as texture-analysis tools for evidence-based practice, in order to improve diagnostic imaging examination during pregnancy.Methods: Various machine-learning techniques and customized datasets were assessed for training of an integrable knowledge-based system (KBS), to determine a hypothetical methodology for texture classification of closely-related anatomical structures in fetal brain magnetic resonance (MR) images. Samples were manually categorized according to the magnetic field of the MRI scanner (i.e. 1.5-tesla (1.5T), 3-tesla (3T)), rotational planes (i.e. coronal, sagittal and axial), and signal weighting (i.e. spin-lattice, spin-spin, relaxation, proton density). In the machine-learning sessions, the operator manually selected relevant regions of interest (ROI) in 1.5/3T MR images. Semi-automatic procedures in MaZda/B11 were performed to determine optimal parameter sets for ROI classification. Four classes were defined: ventricles, thalamus, grey matter, and white matter. Various textures analysis methods were tested. The KBS performed automatic data pre-processing and semi-automatic classification of ROIs.Results: After testing 3456 ROIs, statistical binary classification revealed that combination of reduction techniques with linear discriminant algorithms (LDA) or nonlinear discriminant algorithms (NDA) yielded the best scoring in terms of sensitivity (both 100%, 95% CI: 99.79-100), specificity (both 100%, 95% CI: 99.79-100) and Fisher coefficient (≈E+4, ≈E+5, respectively). Conclusions: LDA and NDA in MaZda can be useful data mining tools for screening a population of interest subjected to a clinical test.

Spinal cord malformations

Malformations of the spinal cord are one of the most frequent malformations. They should be clearly divided into two completely different families of malformations: open dysraphisms and occult dysraphisms. Open dysraphism mostly consists in myelomeningocele (MMC). Its incidence is 1/1000 live births with a wide variation. Folic acid supplementation has been shown to reduce its risk. In most cases, the diagnosis is done prenatally by serum screening and ultrasound and may lead to termination of pregnancy. In case of decision to continue pregnancy, surgical treatment must be achieved during the first days of life, and in 50 to 90% of cases, a ventricular shunt must be installed. The follow-up of these children must be continued throughout life looking for late complications (Chiari II and syringomyelia, vertebral problems, neuropathic bladder, tethered cord). Occult dysraphisms are a heterogeneous group of malformations. Lipomas (filum and conus) are the most frequent and their treatment remains controversial. Diastematomyelia, neurenteric cysts, dermal sinus, and more complex forms (Currarino syndrome) belong to this group. Most of them can and must be diagnosed prenatally or at birth by careful examination of the lower back for the cutaneous stigmata of the disease to decrease the risk of neurological, urological, or orthopedic permanent handicap.

The effect of surgery time on prognosis in newborns with meningomyelocele

OBJECTIVE

To investigate the effect of surgery time on prognosis of newborns with meningomyelocele.

METHODS

The records of neonates with meningomyelocele were retrospectively analyzed. Demographic and clinical characteristics as well as information, timing of surgery, and durations of hospital stay and antibiotic therapy were recorded.

RESULTS

The records of 30 babies were included in the final analysis. Overall, the mean gestational age was 37.7±2.7 weeks, with a mean birth weight of 2967±755 g and head circumference of 35.8±3.8 cm. In terms of localization, 46.6% of the meningomyeloceles were lumbosacral, 40% were lumbar, 10% were thoracolumbar and 3.3% were thoracal. The mean size of the meningomyelocele sacs was 4.33±1.2 cm. Newborns underwent surgery on average of 8.2±5.9 days after birth, with an overall mean duration of hospital stay of 30±25.1 days. Patients were divided into two groups based on timing of surgery (group 1, ≤5 days; group 2, >5 days), and comparisons between groups revealed that earlier surgery was associated with significantly shorter durations of hospital stay (p<0.001) and antibiotic therapy (p<0.05).

CONCLUSION

Early surgical intervention (≤5 days) was associated with a shorter duration of hospital stay and antibiotic therapy as well as a lower complication rate. We recommend that corrective surgery be undertaken as soon as reasonably possible.