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Backley S, Bergh EP, Garnett J, Li R, Maroufy V, Jain R, Fletcher S, Tsao K, Austin M, Johnson A, Papanna R. Fetal cardiovascular changes during open and fetoscopic in-utero spina bifida closure. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 64:193-202. [PMID: 38207160 DOI: 10.1002/uog.27579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/30/2023] [Accepted: 12/21/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVE Fetoscopic closure of spina bifida using heated and humidified carbon dioxide gas (hhCO2) has been associated with lower maternal morbidity compared with open closure. Fetal cardiovascular changes during these surgical interventions are poorly defined. Our objective was to compare fetal bradycardia (defined as fetal heart rate (FHR) < 110 bpm for 10 min) and changes in umbilical artery (UA) Doppler parameters during open vs fetoscopic closure. METHODS This was a prospective cohort study of 22 open and 46 fetoscopic consecutive in-utero closures conducted between 2019 and 2023. Both cohorts had similar preoperative counseling and clinical management. FHR and UA Doppler velocimetry were obtained systematically during preoperative assessment, every 5 min during the intraoperative period, and during the postoperative assessment. FHR, UA pulsatility index (PI) and UA end-diastolic flow (EDF) were segmented into hourly periods during surgery, and the lowest values were averaged for analysis. Umbilical vein maximum velocity was measured in the fetoscopic cohort. At each timepoint at which FHR was recorded, maternal heart rate and systolic and diastolic blood pressure were measured. RESULTS Fetal bradycardia occurred in 4/22 (18.2%) cases of open closure and 21/46 (45.7%) cases of fetoscopic closure (P = 0.03). FHR decreased gradually in both cohorts after administration of general anesthesia and decreased further during surgery. FHR was significantly lower during hour 2 of surgery in the fetoscopic-repair cohort compared with the open-repair cohort. The change in FHR from baseline in the final stage of fetal surgery was significantly more pronounced in the fetoscopic-repair cohort compared with the open-repair cohort (mean, -32.4 (95% CI, -35.7 to -29.1) bpm vs -23.5 (95% CI, -28.1 to -18.8) bpm; P = 0.002). Abnormal UA-EDF (defined as absent or reversed EDF) occurred in 3/22 (13.6%) cases in the open-repair cohort and 23/46 (50.0%) cases in the fetoscopic-repair cohort (P = 0.004). There were no differences in UA-EDF or UA-PI between closure techniques at the individual stages of assessment. CONCLUSIONS We observed a decrease in FHR and abnormalities in UA Doppler parameters during both open and fetoscopic spina bifida closure. Fetal bradycardia was more prominent during fetoscopic closure following hhCO2 insufflation, but FHR recovered after cessation of hhCO2. Changes in FHR and UA Doppler parameters during in-utero spina bifida closure were transient, no cases required emergency delivery and no fetoscopic closure was converted to open closure. These observations should inform algorithms for the perioperative management of fetal bradycardia associated with in-utero spina bifida closure. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S Backley
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - E P Bergh
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - J Garnett
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - R Li
- Department of Biostatistics and Data Science, UTHealth School of Public Health, Houston, TX, USA
| | - V Maroufy
- Department of Biostatistics and Data Science, UTHealth School of Public Health, Houston, TX, USA
| | - R Jain
- The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
- Division of Pediatric Anesthesia, Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - S Fletcher
- The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
- Division of Pediatric Neurosurgery, Department of Pediatric Surgery and Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - K Tsao
- The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
- Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - M Austin
- The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
- Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - A Johnson
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - R Papanna
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
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Nunes TS, Araujo Júnior E, Rolo LC, Sañudo A, Cavalheiro S, Moron AF. Analysis of long-term family dynamics in mothers who have undergone fetal myelomeningocele surgery using telemedicine: a pilot study. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2024; 70:e20231327. [PMID: 38896734 PMCID: PMC11185860 DOI: 10.1590/1806-9282.20231327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 03/02/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVE The aim of this study was to understand the dynamics of families with children with myelomeningocele undergoing intrauterine fetal surgery. METHODS A retrospective cohort pilot study was carried out with 11 mothers of children who had undergone intrauterine myelomeningocele repair. Participants in this study responded to an electronic questionnaire (via Google Forms), developed by the study authors, that consisted of 22 multiple-choice questions, of which 17 were closed-ended and 5 had a standardized format. RESULTS The mean (± standard deviation) of the mothers' age was 37.6 (± 3.5) years. The median of gestational age at delivery and birthweight were 34.9 (range, 33 to 36.1) weeks and 2,300 (range, 1,950 to 2,763) g, respectively. The majority of mothers were white (81.8%), had university degree (81.8%), were Catholic (63.6%), and were married (100%). The majority of mothers rated their relationship with their husband, family, and friends as excellent (54.5, 72.7, and 54.5%, respectively). All 11 mothers reported that the newborn with myelomeningocele was born <37 weeks gestation and the birthweight most often<2,500 g. Approximately 64% of the mothers reported that their child required adaptations or had special needs, of which walking aids (50%) and bladder control (50%) were the most common ones. CONCLUSION Telemedicine proved to be a useful tool in the long-term follow-up of children who underwent intrauterine surgery to correct myelomeningocele.
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Affiliation(s)
- Tatiane Santos Nunes
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Department of Obstetrics - São Paulo (SP), Brazil
| | - Edward Araujo Júnior
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Department of Obstetrics - São Paulo (SP), Brazil
| | - Liliam Cristine Rolo
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Department of Obstetrics - São Paulo (SP), Brazil
| | - Adriana Sañudo
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Department of Preventive Medicine - São Paulo (SP), Brazil
| | - Sergio Cavalheiro
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Department of Neurology and Neurosurgery - São Paulo (SP), Brazil
| | - Antonio Fernandes Moron
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Department of Obstetrics - São Paulo (SP), Brazil
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Watananirun K, Vargas AMLF, Vergote S, Lewi L, Filippo MOL, McCulloch P, Devlieger R, Peralta CFA, Deprest J. Length of hysterotomy for fetal spina bifida repair is associated with prematurity risk. Prenat Diagn 2024; 44:644-652. [PMID: 38502037 DOI: 10.1002/pd.6547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 02/14/2024] [Accepted: 02/20/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVE To investigate whether prenatal repair of spina bifida aperta through mini-hysterotomy results in less prematurity, as compared to standard hysterotomy, when adjusting for known prematurity risks. METHODS We performed a bi-centric, propensity score matched, controlled study, that is, adjusting for factors earlier reported to result in premature delivery or membrane rupture, in consecutive women having prenatal repair either through stapled hysterotomy or sutured mini-hysterotomy (≤3.5 cm). Matches were pairwise compared and cox-regression analysis was performed to define the hazard ratio of delivery <37 weeks. RESULTS Of 346 meeting the MOMS-criteria, 78 comparable pairs were available for matched-controlled analysis. Mini-hysterotomy patients were younger and had a higher BMI. Mini-hysterotomy was associated with a 1.67-lower risk of delivery <37 weeks (hazard ratio: 0.60; 95% CI: 0.42-0.85; p = 0.004) and 1.72 for delivery <34 + 6 weeks (hazard ratio: 0.58; 95% CI: 0.34-0.97; p = 0.037). The rate of intact uterine scar at birth (mini-hysterotomy: 98.7% vs. hysterotomy: 90.4%; p = 0.070), the rate of reversal of hindbrain herniation within 1 week after surgery (88.9% vs. 97.4%; p = 0.180) and the rate of cerebrospinal fluid leakage (0% vs. 2.7%; p = 0.50) were comparable. CONCLUSION Prenatal spina bidifa repair through mini-hysterotomy was associated with a later gestational age at delivery and a comparable intact uterus rate without apparent compromise in neuroprotection.
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Affiliation(s)
- Kanokwaroon Watananirun
- My FetUZ Fetal Research Center, Department of Development and Regeneration, Cluster Women and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Anna M L F Vargas
- The Heart Hospital of Sao Paulo, Sao Paulo, Brazil
- PROADI-Ministry of Health, Sao Paulo, Brazil
- Gestar Fetal Surgery Center, Sao Paulo, Brazil
| | - Simen Vergote
- My FetUZ Fetal Research Center, Department of Development and Regeneration, Cluster Women and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Liesbeth Lewi
- My FetUZ Fetal Research Center, Department of Development and Regeneration, Cluster Women and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Marcelo O L Filippo
- The Heart Hospital of Sao Paulo, Sao Paulo, Brazil
- PROADI-Ministry of Health, Sao Paulo, Brazil
- Gestar Fetal Surgery Center, Sao Paulo, Brazil
| | - Peter McCulloch
- IDEAL Collaboration, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
- IDEAL Collaboration, Nuffield Department of Surgery, Oxford University Hospitals, John Radcliffe Hospital, Oxford, UK
| | - Roland Devlieger
- My FetUZ Fetal Research Center, Department of Development and Regeneration, Cluster Women and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Cleisson F A Peralta
- The Heart Hospital of Sao Paulo, Sao Paulo, Brazil
- PROADI-Ministry of Health, Sao Paulo, Brazil
- Gestar Fetal Surgery Center, Sao Paulo, Brazil
| | - Jan Deprest
- My FetUZ Fetal Research Center, Department of Development and Regeneration, Cluster Women and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Institute for Women's Health, University College London, London, UK
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Haenen K, Vergote S, Kunpalin Y, De Catte L, Devlieger R, Lewi L, van der Merwe J, Russo F, De Vloo P, Lannoo L, Deprest J. Subsequent fertility, pregnancy, and gynaecological and psychological outcomes after maternal-fetal surgery for open spina bifida: A prospective cohort study. BJOG 2023; 130:1677-1684. [PMID: 37272251 DOI: 10.1111/1471-0528.17557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/07/2023] [Accepted: 05/11/2023] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To determine the medium-term maternal impact of open fetal spina bifida repair. DESIGN Prospective cohort study. SETTING University Hospitals Leuven, Belgium. POPULATION Mothers who had open maternal-fetal spina bifida repair between March 2012 and December 2021. METHODS A patient-reported survey on subsequent fertility, pregnancy, and gynaecological and psychological outcomes. MAIN OUTCOME MEASURES Complications during subsequent pregnancies, and gynaecological and psychological problems. RESULTS Seventy-two out of 100 invited women completed the questionnaire (72%). Despite being advised not to, seven of 13 women attempting to conceive became pregnant within 2 years after fetal surgery and one woman delivered vaginally. Two of the 16 subsequent pregnancies were complicated by an open neural tube defect. One pregnancy was complicated by a placenta accreta and one pregnancy was complicated by a uterine rupture, both with good neonatal outcomes. Nearly half of respondents who did not attempt to conceive reported that this was because of their experience of the index pregnancy and caring for the index child. Three out of four respondents reported medium-term psychological problems, mostly anxiety for the health of the index child, fear for recurrence in subsequent pregnancies and feelings of guilt. CONCLUSIONS Open maternal-fetal surgery for spina bifida did not appear to affect fertility in our cohort. Half of the attempts to conceive took place within 2 years. One uterine rupture and one placenta accreta occurred in 16 subsequent pregnancies. Most respondents reported psychological problems linked to the index pregnancy, which reinforces the need for long-term psychological support.
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Affiliation(s)
- Kobe Haenen
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Simen Vergote
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Yada Kunpalin
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Luc De Catte
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Roland Devlieger
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Liesbeth Lewi
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Johannes van der Merwe
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Francesca Russo
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Philippe De Vloo
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Lore Lannoo
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, KU Leuven and Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- University College London Institute for Women's Health, London, UK
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Van Mieghem T, Smith MK, Murji A. Laparoscopic repair of uterine dehiscence after open maternal-fetal surgery. Am J Obstet Gynecol 2023; 229:686-687. [PMID: 37148959 DOI: 10.1016/j.ajog.2023.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/01/2023] [Accepted: 04/29/2023] [Indexed: 05/08/2023]
Affiliation(s)
- Tim Van Mieghem
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada; Fetal Medicine Unit and Ontario Fetal Center, Mount Sinai Hospital, Toronto, Canada
| | - Martha K Smith
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada
| | - Ally Murji
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada.
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Krispin E, Hessami K, Johnson RM, Krueger AM, Martinez YM, Jackson AL, Southworth AL, Whitehead W, Espinoza J, Nassr AA, Cortes MS, Donepudi R, Belfort MA. Systematic classification and comparison of maternal and obstetrical complications following 2 different methods of fetal surgery for the repair of open neural tube defects. Am J Obstet Gynecol 2023; 229:53.e1-53.e8. [PMID: 36596438 DOI: 10.1016/j.ajog.2022.12.317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 12/11/2022] [Accepted: 12/17/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND In utero repair of open neural tube defects using an open hysterotomy approach (hereafter referred to as "open") has been shown to reduce the need for ventriculoperitoneal shunting and to improve motor outcomes for affected infants. Laparotomy-assisted fetoscopic repair (hereafter referred to as "hybrid") is an alternative approach that may confer similar neurologic benefits while reducing the incidence of hysterotomy-related complications. OBJECTIVE This study aimed to analyze procedure-related maternal and fetal complications of in utero repair using the Clavien-Dindo classification, and to compare the outcomes of the hybrid and open approaches. STUDY DESIGN This was a retrospective cohort study conducted in a single center between September 2011 and July 2021. All patients who met the Management of Myelomeningocele Study criteria and who underwent either hybrid or open fetal surgery were included. Maternal complications were classified using a unique adaptation of the Clavien-Dindo scoring system, allowing the development of a comprehensive complication index score specific to fetal surgery. Primary fetal outcome was defined as gestational age at delivery and summarized according to the World Health Organization definitions of preterm delivery. RESULTS There were 146 fetuses with open neural tube defects who were eligible for, and underwent, in utero repair during the study period. Of these, 102 underwent hybrid fetoscopic repair and 44 underwent open hysterotomy repair. Gestational age at the time of surgery was higher in the hybrid group than in the open group (25.1 vs 24.8 weeks; P=.004). Maternal body mass index was lower in the hybrid than in the open group (25.4 vs 27.1 kg/m2; P=.02). The duration of hybrid fetoscopic surgery was significantly longer in the hybrid than in the open group (250 vs 164 minutes; P<.001). There was a significantly lower Clavien-Dindo Grade III complication rate (4.9% vs 43.2%; P<.001) and a significantly lower overall comprehensive maternal complication index (8.7 vs 22.6; P=.021) in the hybrid group than in the open group. Gestational age at delivery was significantly higher in the hybrid group than in the open group (38.1 vs 35.8 weeks; P<.001), and this finding persisted when gestational age at delivery was analyzed using the World Health Organization definitions of preterm delivery. CONCLUSION Use of our adaptation of the standardized Clavien-Dindo classification to assess the maternal complications associated with in utero open neural tube defect repair provides a new method for objectively assessing different fetal surgical approaches. It also provides a much-needed standardized tool to allow objective comparisons between methods, which can be used when counseling patients. The hybrid open neural tube defect repair was associated with lower rates of maternal adverse events , and later gestational age at delivery compared with the open approach.
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Affiliation(s)
- Eyal Krispin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Kamran Hessami
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Rebecca M Johnson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Angel M Krueger
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Yamely Mendez Martinez
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Aimee L Jackson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Annie L Southworth
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - William Whitehead
- Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Jimmy Espinoza
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Ahmed A Nassr
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Magdalena Sanz Cortes
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Roopali Donepudi
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Michael A Belfort
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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Premkumar A, Fry JT, Bolden JR, Grobman WA, Michelson KN. The value and limitations of using predetermined criteria in decision making for maternal-fetal interventions. Prenat Diagn 2023; 43:792-797. [PMID: 37139690 DOI: 10.1002/pd.6363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/06/2023] [Accepted: 04/26/2023] [Indexed: 05/05/2023]
Abstract
Maternal-fetal interventions-such as prenatal fetal myelomeningocele (MMC) repair-are at the forefront of clinical innovation within maternal-fetal medicine, pediatric surgery, and neonatology. Many centers determine eligibility for innovative procedures using pre-determined inclusion and exclusion criteria based on seminal studies, for example, the "Management of Myelomeningocele Study" for prenatal MMC repair. What if a person's clinical presentation does not conform to predetermined criteria for maternal-fetal intervention? Does changing criteria on a case-by-case basis (i.e., ad hoc) constitute an innovation in practice and flexible personalized care or transgression of commonly held standards with potential negative consequences? We outline principle-based, bioethically justified answers to these questions using fetal MMC repair as an example. We pay special attention to the historical origins of inclusion and exclusion criteria, risks and benefits to the pregnant person and the fetus, and team dynamics. We include recommendations for maternal-fetal centers facing these questions.
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Affiliation(s)
- Ashish Premkumar
- Department of Obstetrics and Gynecology, Pritzker School of Medicine, The University of Chicago, Chicago, Illinois, USA
- Department of Anthropology, The Graduate School, Northwestern University, Evanston, Illinois, USA
| | - Jessica T Fry
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Janelle R Bolden
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - William A Grobman
- Department of Obstetrics and Gynecology, The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Kelly N Michelson
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Oliveira GHD, Acácio GL, Gonçalves RTR, Svetliza J, Callado GY, Dias CDM, Vaz-Oliani DCM, Chmait RH, Lapa DA. Prenatal repair of gastroschisis using partial carbon dioxide insufflation fetoscopy: lessons learned. EINSTEIN-SAO PAULO 2023; 21:eRC0543. [PMID: 37255063 DOI: 10.31744/einstein_journal/2023rc0543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/20/2023] [Indexed: 06/01/2023] Open
Abstract
We report the long-term outcomes of a case of prenatal gastroschisis repair using a fully percutaneous fetoscopic approach with partial carbon dioxide insufflation. Surgery was performed as an experimental procedure before the scheduled elective birth. The fetal intestines were successfully returned to the abdominal cavity without any fetal or maternal complications. Ultrasonography performed 24 hours later revealed bowel peristalsis and no signs of fetal distress. After 48 hours, partial extrusion of the small bowel was observed, and the fetus was delivered. Gastroschisis repair was immediately performed upon delivery using the EXIT-like procedure as per our institutional protocol. The newborn did not require assisted mechanical ventilation, was discharged at 14 days of age and was then exclusively breastfed. At 3-year follow-up, the patient had no associated gastroschisis-related complications. This is the first case of prenatal repair of gastroschisis, which provides baseline knowledge for future researchers on the potential hurdles and management of prenatal repair.
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Affiliation(s)
| | | | | | - Javier Svetliza
- Hospital Interzonal General de Agudos Dr. José Penna, Bahía Blanca, Argentina
| | - Gustavo Yano Callado
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | | | | | - Ramen H Chmait
- Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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Hosseini-Siyanaki MR, Liu S, Dagra A, Reddy R, Reddy A, Carpenter SL, Khan M, Lucke-Wold B. Surgical Management of Myelomeningocele. NEONATAL 2023; 4:08. [PMID: 38179156 PMCID: PMC10766379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
Myelomeningocele (MMC) is one of the most common abnormalities of the central nervous system that causes significant neurological impairment. Traditionally, treatment consisted of postnatal closure with the management of the complications, such as ventricular shunting. MMC is a plausible candidate for in-utero surgery because of the mechanism of neurologic damage that begins with abnormal neurulation and continues throughout gestation. Researchers discussed the benefits of in-utero closure prior to the publication of the prospective randomized multicenter Management of Myelomeningocele Study (MOMS trial). Compared to postnatal repair with maternal complications and prematurity as trade-offs, prenatal repair reduced shunting, reversed hindbrain herniation, and improved neurological function. This article discusses the diagnosis, evaluation, long-term follow-up, surgical options, and innovative treatment for fetal myelomeningocele.
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Affiliation(s)
| | - Sophie Liu
- Department of Neuroscience, University of Johns Hopkins, Baltimore, MD, USA
| | - Abeer Dagra
- University of Florida, College of Medicine, Gainesville, FL, USA
| | - Ramya Reddy
- University of Florida, College of Medicine, Gainesville, FL, USA
| | - Akshay Reddy
- University of Florida, College of Medicine, Gainesville, FL, USA
| | | | - Majid Khan
- University of Nevada, Reno School of Medicine, Reno, NV, USA
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10
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Sasaoka AKS, Moron AF, Araujo Júnior E, Sañudo A, Barbosa MM, Milani HJF, Sarmento SGP, Cavalheiro S. Ultrasound evaluation of uterine scar thickness after open fetal surgery for myelomeningocele. Childs Nerv Syst 2023; 39:655-661. [PMID: 35939128 DOI: 10.1007/s00381-022-05642-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 08/02/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE This study aimed to analyse the evolution of uterine scar thickness after open fetal surgery for myelomeningocele (MMC) by ultrasonography, and to establish a cut-off point for uterine scar thickness associated with high-risk of uterine rupture. METHODS A prospective longitudinal study was conducted with 77 pregnant women who underwent open fetal surgery for MMC between 24 and 27 weeks of gestation. After fetal surgery, ultrasound follow-up was performed once a week, and the scar on the uterine wall was evaluated and its thickness was measured by transabdominal ultrasound. At least five measurements of the uterine scar thickness were performed during pregnancy. A receiver operating characteristics (ROC) curve was constructed to obtain a cut-off point for the thickness of the scar capable of detecting the absence of thinning. Kaplan-Meier curves were constructed to evaluate the probability of thinning during pregnancy follow-up. RESULTS The mean ± standard deviation of maternal age (years), gestational age at surgery (weeks), gestational age at delivery (weeks), and birth weight (g) were 30.6 ± 4.5, 26.1 ± 0.8, 34.3 ± 1.2 and 2287.4 ± 334.4, respectively. Thinning was observed in 23 patients (29.9%). Pregnant women with no thinning had an average of 17.1 ± 5.2 min longer surgery time than pregnant women with thinning. A decrease of 1.0 mm in the thickness of the uterine scar was associated with an increased likelihood of thinning by 1.81-fold (95% confidence interval [CI]: 1.32-2.47; p < 0.001). The area below the ROC curve was 0.899 (95% CI: 0.806-0.954; p < 0.001), and the cut-off point was ≤ 3.0 mm, which simultaneously presented greater sensitivity and specificity. After 63 days of surgery, the probability of uterine scarring was 50% (95% CI: 58-69). CONCLUSION A cut-off point of ≤ 3.0 mm in the thickness of the uterine scar after open fetal surgery for MMC may be used during ultrasonography monitoring for decision-making regarding the risk of uterine rupture and indication of caesarean section.
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Affiliation(s)
- Alexandre Kim Sangalan Sasaoka
- Department of Obstetrics, Paulista School of Medicina - Federal University of São Paulo (EPM-UNIFESP), Rua Belchior de Azevedo, 156 apto. 111 Torre Vitoria, São Paulo, SP, 05089-030, Brazil
| | - Antonio Fernandes Moron
- Department of Obstetrics, Paulista School of Medicina - Federal University of São Paulo (EPM-UNIFESP), Rua Belchior de Azevedo, 156 apto. 111 Torre Vitoria, São Paulo, SP, 05089-030, Brazil
- Paulista Center of Fetal Medicine, São Paulo, SP, Brazil
- Santa Joana Maternity and Hospital, São Paulo, SP, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicina - Federal University of São Paulo (EPM-UNIFESP), Rua Belchior de Azevedo, 156 apto. 111 Torre Vitoria, São Paulo, SP, 05089-030, Brazil.
| | - Adriana Sañudo
- Department of Preventive Medicine, Paulista School of Medicina - Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Mauricio Mendes Barbosa
- Paulista Center of Fetal Medicine, São Paulo, SP, Brazil
- Santa Joana Maternity and Hospital, São Paulo, SP, Brazil
| | - Herbene José Figuinha Milani
- Department of Obstetrics, Paulista School of Medicina - Federal University of São Paulo (EPM-UNIFESP), Rua Belchior de Azevedo, 156 apto. 111 Torre Vitoria, São Paulo, SP, 05089-030, Brazil
- Paulista Center of Fetal Medicine, São Paulo, SP, Brazil
- Santa Joana Maternity and Hospital, São Paulo, SP, Brazil
| | | | - Sergio Cavalheiro
- Paulista Center of Fetal Medicine, São Paulo, SP, Brazil
- Santa Joana Maternity and Hospital, São Paulo, SP, Brazil
- Department of Neurology and Neurosurgery, Paulista School of Medicina - Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
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11
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Kunpalin Y, Vergote S, Joyeux L, Telli O, David AL, Belfort M, De Coppi P, Deprest J. Local host response of commercially available dural patches for fetal repair of spina bifida aperta in rabbit model. Prenat Diagn 2023; 43:370-381. [PMID: 36650109 DOI: 10.1002/pd.6315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 12/05/2022] [Accepted: 01/11/2023] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Fetal surgery for spina bifida aperta (SBA) by open hysterotomy typically repairs anatomical native tissue in layers. Increasingly, fetoscopic repair is performed using a dural patch followed by skin closure. We studied the host response to selected commercially available patches currently being used in a fetal rabbit model for spina bifida repair. METHODS SBA was surgically induced at 23-24 days of gestation (term = 31 days). Fetal rabbits were assigned to unrepaired (SBA group), or immediate repair with Duragen™ or Durepair™. Non-operated littermates served as normal controls. At term, spinal cords underwent immunohistochemical staining including Nissl and glial fibrillary acidic protein. We hypothesized that spinal cord coverage with a dural patch and skin closure would preserve motor neuron density within the non-inferiority limit of 201.65 cells/mm2 and reduce inflammation compared to unrepaired SBA fetuses. RESULTS Motor neuron density assessed by Nissl staining was conserved both by Duragen (n = 6, 89.5; 95% CI -158.3 to -20.6) and Durepair (n = 6, 37.0; 95% CI -132.6 to -58.5), whereas density of GFAP-positive cells to quantify inflammation was lower than in unrepaired SBA-fetuses (SBA 2366.0 ± 669.7 cells/mm2 vs. Duragen 1274.0 ± 157.2 cells/mm2 ; p = 0.0002, Durepair 1069.0 ± 270.7 cells/mm2 ; p < 0.0001). CONCLUSIONS Covering the rabbit spinal cord with either Duragen or Durepair followed by skin closure preserves motor neuron density and reduces the inflammatory response.
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Affiliation(s)
- Yada Kunpalin
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, MyFetUZ Fetal Research Center, KU Leuven, Leuven, Belgium.,Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Simen Vergote
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, MyFetUZ Fetal Research Center, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Luc Joyeux
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Onur Telli
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, MyFetUZ Fetal Research Center, KU Leuven, Leuven, Belgium
| | - Anna L David
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, MyFetUZ Fetal Research Center, KU Leuven, Leuven, Belgium.,Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Michael Belfort
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Paolo De Coppi
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, MyFetUZ Fetal Research Center, KU Leuven, Leuven, Belgium.,Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, MyFetUZ Fetal Research Center, KU Leuven, Leuven, Belgium.,Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Great Ormond Street Institute of Child Health, University College London, London, UK
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12
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Advances in Fetal Surgical Repair of Open Spina Bifida. Obstet Gynecol 2023; 141:505-521. [PMID: 36735401 DOI: 10.1097/aog.0000000000005074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 10/03/2022] [Indexed: 02/04/2023]
Abstract
Spina bifida remains a common congenital anomaly of the central nervous system despite national fortification of foods with folic acid, with a prevalence of 2-4 per 10,000 live births. Prenatal screening for the early detection of this condition provides patients with the opportunity to consider various management options during pregnancy. Prenatal repair of open spina bifida, traditionally performed by the open maternal-fetal surgical approach through hysterotomy, has been shown to improve outcomes for the child, including decreased need for cerebrospinal fluid diversion surgery and improved lower neuromotor function. However, the open maternal-fetal surgical approach is associated with relatively increased risk for the patient and the overall pregnancy, as well as future pregnancies. Recent advances in minimally invasive prenatal repair of open spina bifida through fetoscopy have shown similar benefits for the child but relatively improved outcomes for the pregnant patient and future childbearing.
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13
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Olutoye OO, Joyeux L, King A, Belfort MA, Lee TC, Keswani SG. Minimally Invasive Fetal Surgery and the Next Frontier. Neoreviews 2023; 24:e67-e83. [PMID: 36720693 DOI: 10.1542/neo.24-2-e67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Most patients with congenital anomalies do not require prenatal intervention. Furthermore, many congenital anomalies requiring surgical intervention are treated adequately after birth. However, there is a subset of patients with congenital anomalies who will die before birth, shortly after birth, or experience severe postnatal complications without fetal surgery. Fetal surgery is unique in that an operation is performed on the fetus as well as the pregnant woman who does not receive any direct benefit from the surgery but rather lends herself to risks, such as hemorrhage, abruption, and preterm labor. The maternal risks involved with fetal surgery have limited the extent to which fetal interventions may be performed but have, in turn, led to technical innovations that have significantly advanced the field. This review will examine congenital abnormalities that can be treated with minimally invasive fetal surgery and introduce the next frontier of prenatal management of fetal surgical pathology.
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Affiliation(s)
- Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Luc Joyeux
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Michael A Belfort
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
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14
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Siahaan AMP, Susanto M, Lumbanraja SN, Ritonga DH. Long-term neurological cognitive, behavioral, functional, and quality of life outcomes after fetal myelomeningocele closure: a systematic review. Clin Exp Pediatr 2023; 66:38-45. [PMID: 36470279 PMCID: PMC9815938 DOI: 10.3345/cep.2022.01102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/07/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Myelomeningocele is a lifelong condition that features several comorbidities, such as hydrocephalus, scoliosis, club foot, and lower limb sensory and motor disabilities. Its management has progressed over time, ranging from supportive care to early postnatal closure to prenatal closure of the defect. Recent research discovered that fetal myelomeningocele closure (fMMC) provided superior neurological outcomes to those of postnatal closure. When performed at 12 months of age, fMMC can avert or delay the need for a ventriculoperitoneal shunt and reversed the hindbrain herniation. Moreover, fMMC reportedly enhanced motor function and mental development at 30 months of age. However, its long-term outcomes remain dubious. PURPOSE This systematic review aimed to determine the long-term neurological cognitive, behavioral, functional, and quality of life (QoL) outcomes after fMMC. METHODS The PubMed, Directory of Open Access Journals, EBSCO, and Cochrane databases were extensively searched for articles published in 2007-2022. Meta-analyses, clinical trials, and randomized controlled trials with at least 5 years of follow-up were given priority. RESULTS A total of 11 studies were included. Most studies revealed enhanced long-term cognitive, behavioral, functional, and QoL outcomes after fMMC. CONCLUSION Our results suggest that fMMC substantially enhanced patients' long-term neurological cognitive, behavioral, functional, and QoL outcomes.
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Affiliation(s)
| | - Martin Susanto
- Department of Neurosurgery, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | - Sarma Nursani Lumbanraja
- Department of Obstetrics & Gynecology, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | - Dwi Herawati Ritonga
- Division of Pediatrics, H Amri Tambunan General Hospital, Lubuk Pakam, Indonesia
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15
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Sadlecki P, Walentowicz-Sadlecka M. Prenatal diagnosis of fetal defects and its implications on the delivery mode. Open Med (Wars) 2023; 18:20230704. [PMID: 37197356 PMCID: PMC10183726 DOI: 10.1515/med-2023-0704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/28/2023] [Accepted: 04/10/2023] [Indexed: 05/19/2023] Open
Abstract
Congenital malformations are defined as single or multiple defects of the morphogenesis of organs or body parts, identifiable during intrauterine life or at birth. With recent advances in prenatal detection of congenital malformations, many of these disorders can be identified early on a routine fetal ultrasound. The aim of the present systematic review is to systematize the current knowledge about the mode of delivery in pregnancies complicated by fetal anomalies. The databases Medline and Ebsco were searched from 2002 to 2022. The inclusion criteria were prenatally diagnosed fetal malformation, singleton pregnancy, and known delivery mode. After the first round of research, 546 studies were found. For further analysis, studies with full text available concerning human single pregnancy with known neonatal outcomes were considered. Publications were divided into six groups: congenital heart defects, neural tube defects, gastroschisis, fetal tumors, microcephaly, and lung and thorax malformations. Eighteen articles with a descripted delivery mode and neonatal outcome were chosen for further analysis. In most pregnancies complicated by the presence of fetal anomalies, spontaneous vaginal delivery should be a primary option, as it is associated with lower maternal morbidity and mortality. Cesarean delivery is generally indicated if a fetal anomaly is associated with the risk of dystocia, bleeding, or disruption of a protective sac; examples of such anomalies include giant omphaloceles, severe hydrocephalus, and large myelomeningocele and teratomas. Fetal anatomy ultrasound should be carried out early, leaving enough time to familiarize parents with all available options, including pregnancy termination, if an anomaly is detected.
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Affiliation(s)
- Pawel Sadlecki
- Department of Obstetrics and Gynecology, Regional Polyclinical HospitalGrudziadz, Poland
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16
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Moldenhauer JS, Johnson A, Van Mieghem T. International Society for Prenatal Diagnosis 2022 DEBATE: There should be formal accreditation and ongoing quality assurance/review for units offering fetal therapy that includes public reporting of outcomes. Prenat Diagn 2022; 43:411-420. [PMID: 36522853 DOI: 10.1002/pd.6286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/07/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022]
Abstract
The field of fetal therapy has so far escaped from formal accreditation and quality control. Despite that, current published evidence shows that outcomes of interventions in younger fetal therapy centers are similar to what is achieved in more experienced centers and outcomes of interventions have improved over time. The question however remains what is not being published and what should be the standard of care, given the lack of level 1 evidence from randomized controlled trials for many interventions. Formal collaborative networks such as NAFTnet and others allow for anonymized benchmarking of center outcomes, without publicly shaming (and financially punishing) underperforming centers. Large registries also allow for tracking of rare complications and may result in improved patient outcomes over time. Core outcome sets, which could serve as a basis for outcome reporting, are available for some conditions, but certainly not for all, resulting in communication difficulties between centers. Formal accreditation, quality control, and outcome reporting are hard to implement, expensive, and may result in decreasing access to care by pushing smaller centers out of the market. Despite the existing difficulties, international societies have committed to quality improvement, and fetal therapy programs are strongly recommended to participate in voluntary outcome tracking.
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Affiliation(s)
| | - Anthony Johnson
- The Fetal Center Department of Obstetrics and Gynecology and Reproductive Sciences Division of Fetal Intervention McGovern Medical School at The University of Texas Health Science Center Houston Texas USA
| | - Tim Van Mieghem
- Department of Obstetrics and Gynaecology Fetal Medicine Unit and Ontario Fetal Centre Mount Sinai Hospital and University of Toronto Toronto Ontario Canada
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17
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Shlobin NA, Yerkes EB, Swaroop VT, Lam S, McLone DG, Bowman RM. Multidisciplinary spina bifida clinic: the Chicago experience. Childs Nerv Syst 2022; 38:1675-1681. [PMID: 35870009 DOI: 10.1007/s00381-022-05594-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/23/2022] [Indexed: 11/03/2022]
Abstract
Open spina bifida (open SB) is the most complex congenital abnormality of the central nervous system compatible with long-term survival. Multidisciplinary care is required to address the effect of this disease on the neurological, musculoskeletal, genitourinary, and gastrointestinal systems, as well as the complex psychosocial impact on the developing child. Individuals with SB benefit from the involvement of neurosurgeons, orthopedic surgeons, urologists, physical medicine and rehabilitation specialists, pediatricians, psychologists, physical/occupational/speech therapists, social workers, nurse coordinators, and other personnel. Multidisciplinary clinics are the gold standard for coordinated, optimal medical and surgical care. Ann and Robert H. Lurie Children's Hospital, formerly known as Children's Memorial Hospital, was one of the first hospitals in the USA to manage patients with this complex disease in a multidisciplinary manner. We describe the longitudinal experience of the multidisciplinary Spina Bifida Center at our institution and highlight the advances that have arisen from this care model over time. This clinic serves as an exemplar of organized, effective, and patient-centered approach to the comprehensive care of people living with open SB.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Elizabeth B Yerkes
- Department of Urology, Division of Pediatric Urology, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Vineeta T Swaroop
- Department of Orthopedic Surgery, Division of Pediatric Orthopedic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sandi Lam
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David G McLone
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robin M Bowman
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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18
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Affiliation(s)
- Bermans J Iskandar
- From the Department of Neurological Surgery, University of Wisconsin-Madison, Madison (B.J.I.); and the Departments of Molecular and Human Genetics, Molecular and Cellular Biology, and Medicine, Baylor College of Medicine, Houston (R.H.F.)
| | - Richard H Finnell
- From the Department of Neurological Surgery, University of Wisconsin-Madison, Madison (B.J.I.); and the Departments of Molecular and Human Genetics, Molecular and Cellular Biology, and Medicine, Baylor College of Medicine, Houston (R.H.F.)
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19
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Chmait RH, Monson MA, Pham HQ, Chu JK, Speybroeck AVAN, Chon AH, Kontopoulos EV, Quintero RA. Percutaneous/mini-laparotomy fetoscopic repair of open spina bifida: a novel surgical technique. Am J Obstet Gynecol 2022; 227:375-383. [PMID: 35752302 DOI: 10.1016/j.ajog.2022.05.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 05/15/2022] [Accepted: 05/16/2022] [Indexed: 11/29/2022]
Abstract
Open spina bifida (OSB) is the most common congenital anomaly of the central nervous system compatible with life. Prenatal repair of open spina bifida via open maternal-fetal surgery has been shown to improve postnatal neurological outcomes, including reducing the need for ventriculoperitoneal shunting and improving lower neuromotor function. Fetoscopic repair of OSB minimizes the maternal risks while providing similar neurosurgical outcomes to the fetus. Two fetoscopic techniques are currently in use: (1) the laparotomy-assisted approach, and (2) the percutaneous approach. The laparotomy-assisted fetoscopic technique appears to be associated with less risk of preterm birth compared to the percutaneous approach. However, the percutaneous approach avoids laparotomy and uterine exteriorization, and is associated with less anesthesia risk and improved maternal post-surgical recovery. The purpose of this paper is to describe our experience with a novel surgical approach, which we call percutaneous/mini-laparotomy fetoscopy (PML), in which access to the uterus for one of the ports is done via a mini-laparotomy, while the other ports are inserted percutaneously. This technique draws on the benefits of both the laparotomy-assisted and the percutaneous techniques, while minimizing their drawbacks. This surgical approach may prove invaluable in the prenatal repair of open spina bifida as well as other complex fetal surgical procedures.
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Affiliation(s)
- Ramen H Chmait
- Los Angeles Fetal Surgery, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA; The USFetus Research Consortium, Miami, FL-Los Angeles, CA
| | - Martha A Monson
- Los Angeles Fetal Surgery, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, UT; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
| | - Huyen Q Pham
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Jason K Chu
- Department of Neurosurgery, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Alexander VAN Speybroeck
- Department of General Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Andrew H Chon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR
| | - Eftichia V Kontopoulos
- The Fetal Institute, Miami, FL; The USFetus Research Consortium, Miami, FL-Los Angeles, CA; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Wertheim School of Medicine, Florida International University, Miami, FL
| | - Ruben A Quintero
- The Fetal Institute, Miami, FL; The USFetus Research Consortium, Miami, FL-Los Angeles, CA; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Wertheim School of Medicine, Florida International University, Miami, FL
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20
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Sanín Blair JE, Sepulveda W, Etchegaray A, Ventura W, Corral E, Gutierrez-Marin J, Espinoza J. Uterine rupture in subsequent pregnancies following in utero spina bifida closure without stapled hysterotomy. Am J Obstet Gynecol 2022; 226:741-743. [PMID: 35065019 DOI: 10.1016/j.ajog.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/12/2022] [Accepted: 01/13/2022] [Indexed: 11/17/2022]
Affiliation(s)
- José E Sanín Blair
- Maternal-Fetal Medicine and Fetal Surgery, Department of Obstetrics and Gynecology, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Waldo Sepulveda
- FETALMED-Centro de Diagnostico Materno-Fetal, Santiago, Chile
| | - Adolfo Etchegaray
- Fetal Medicine Unit, Department of Obstetrics, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | - Walter Ventura
- Fetal Medicine Unit, Department of Obstetrics and Perinatology, Instituto Nacional Materno Perinatal, Lima, Peru
| | - Edgardo Corral
- Department of Obstetrics and Gynecology, Regional Hospital, Rancagua, Chile
| | - Jorge Gutierrez-Marin
- Maternal-Fetal Medicine and Fetal Surgery, Department of Obstetrics and Gynecology, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Jimmy Espinoza
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, 6651 Main St., Ste. 420, Houston, TX 77030.
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21
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Lillegard JB, Eyerly-Webb SA, Watson DA, Bahtiyar MO, Bennett KA, Emery SP, Fisher AJ, Goldstein RB, Goodnight WH, Lim FY, McCullough LB, Moehrlen U, Moldenhauer JS, Moon-Grady AJ, Ruano R, Skupski DW, Treadwell MC, Tsao K, Wagner AJ, Zaretsky MV. Placental Location in Maternal-Fetal Surgery for Myelomeningocele. Fetal Diagn Ther 2021; 49:117-124. [PMID: 34915495 DOI: 10.1159/000521379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/06/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Uterine incision based on placental location in open maternal-fetal surgery (OMFS) has never been evaluated in regards to maternal or fetal outcomes. OBJECTIVE To investigate whether an anterior placenta was associated with increased rates of intraoperative, perioperative, antepartum, obstetric, or neonatal complications in mothers and babies who underwent OMFS for myelomeningocele (fMMC) closure. METHODS Data from the international multi-center prospective registry of patients who underwent OMFS for fMMC closure (fMMC Consortium Registry, 12/15/2010-7/31/2019) was used to compare fetal and maternal outcomes between anterior and posterior placental locations. RESULTS Placental location for 623 patients was evenly distributed between anterior (51%) or posterior (49%). Intraoperative fetal bradycardia (8.3% vs 3.0%, p=0.005) and performance of fetal resuscitation (3.6% vs 1.0%, p=0.034) occurred more frequently in cases with an anterior placenta when compared to those with a posterior placenta. Obstetric outcomes including membrane separation, placental abruption, and spontaneous rupture of membranes were not different among the two groups. However, thinning of the hysterotomy site (27.7% vs 17.7%, p=0.008) occurred more frequently in cases of anterior placenta. Gestational age at delivery (p=0.583) and length of stay in the neonatal intensive care unit (p=0.655) were similar between the two groups. Fetal incision dehiscence and wound revision were not significantly different between groups. Critical clinical outcomes including fetal demise, perinatal death, and neonatal death were all infrequent occurrences and not associated with placental location. CONCLUSIONS Anterior placental location is associated with increased risk of intraoperative fetal resuscitation and increased thinning at the hysterotomy closure site. Individual institutional experiences may have varied but the aggregate data from the fMMC Consortium did not show a significant impact on the gestational age at delivery or maternal or fetal clinical outcomes.
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Affiliation(s)
- Joseph B Lillegard
- Midwest Fetal Care Center, Children's Minnesota, Minneapolis, Minnesota, USA
- Division of General Surgery Research, Mayo Clinic, Rochester, Minnesota, USA
- Pediatric Surgical Associates, Minneapolis, Minnesota, USA
| | | | - David A Watson
- Research Design and Analytics, Children's Minnesota, Minneapolis, Minnesota, USA
| | | | | | | | | | - Ruth B Goldstein
- University of California San Francisco, San Francisco, California, USA
| | - William H Goodnight
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Foong-Yen Lim
- Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | | | | | | | | | - Rodrigo Ruano
- University of Texas Health Science Center, Houston, Texas, USA
| | | | | | - KuoJen Tsao
- University of Texas Health Science Center, Houston, Texas, USA
| | - Amy J Wagner
- Children's Hospital of Wisconsin Fetal Concerns Center, Milwaukee, Wisconsin, USA
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22
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Sanz Cortes M, Chmait RH, Lapa DA, Belfort MA, Carreras E, Miller JL, Brawura Biskupski Samaha R, Sepulveda Gonzalez G, Gielchinsky Y, Yamamoto M, Persico N, Santorum M, Otaño L, Nicolaou E, Yinon Y, Faig-Leite F, Brandt R, Whitehead W, Maiz N, Baschat A, Kosinski P, Nieto-Sanjuanero A, Chu J, Kershenovich A, Nicolaides KH. Experience of 300 cases of prenatal fetoscopic open spina bifida repair: report of the International Fetoscopic Neural Tube Defect Repair Consortium. Am J Obstet Gynecol 2021; 225:678.e1-678.e11. [PMID: 34089698 DOI: 10.1016/j.ajog.2021.05.044] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 05/28/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The multicenter randomized controlled trial Management of Myelomeningocele Study demonstrated that prenatal repair of open spina bifida by hysterotomy, compared with postnatal repair, decreases the need for ventriculoperitoneal shunting and increases the chances of independent ambulation. However, the hysterotomy approach is associated with risks that are inherent to the uterine incision. Fetal surgeons from around the world embarked on fetoscopic open spina bifida repair aiming to reduce maternal and fetal/neonatal risks while preserving the neurologic benefits of in utero surgery to the child. OBJECTIVE This study aimed to report the main obstetrical, perinatal, and neurosurgical outcomes in the first 12 months of life of children undergoing prenatal fetoscopic repair of open spina bifida included in an international registry and to compare these with the results reported in the Management of Myelomeningocele Study and in a subsequent large cohort of patients who received an open fetal surgery repair. STUDY DESIGN All known centers performing fetoscopic spina bifida repair were contacted and invited to participate in a Fetoscopic Myelomeningocele Repair Consortium and enroll their patients in a registry. Patient data entered into this fetoscopic registry were analyzed for this report. Fisher exact test was performed for comparison of categorical variables in the registry with both the Management of Myelomeningocele Study and a post-Management of Myelomeningocele Study cohort. Binary logistic regression analyses were used to assess the registry data for predictors of preterm birth at <30 weeks' gestation, preterm premature rupture of membranes, and need for postnatal cerebrospinal fluid diversion in the fetoscopic registry. RESULTS There were 300 patients in the fetoscopic registry, 78 in the Management of Myelomeningocele Study, and 100 in the post-Management of Myelomeningocele Study cohort. The 3 data sets showed similar anatomic levels of the spinal lesion, mean gestational age at delivery, distribution of motor function compared with upper anatomic level of the lesion in the neonates, and perinatal death. In the Management of Myelomeningocele Study (26.16±1.6 weeks) and post-Management of Myelomeningocele Study cohort (23.3 [20.2-25.6] weeks), compared with the fetoscopic registry group (23.6±1.4 weeks), the gestational age at surgery was lower (comparing fetoscopic repair group with the Management of Myelomeningocele Study; P<.01). After open fetal surgery, all patients were delivered by cesarean delivery, whereas in the fetoscopic registry approximately one-third were delivered vaginally (P<.01). At cesarean delivery, areas of dehiscence or thinning in the scar were observed in 34% of cases in the Management of Myelomeningocele Study, in 49% in the post-Management of Myelomeningocele Study cohort, and in 0% in the fetoscopic registry (P<.01 for both comparisons). At 12 months of age, there was no significant difference in the number of patients requiring treatment for hydrocephalus between those in the fetoscopic registry and the Management of Myelomeningocele Study. CONCLUSION Prenatal and postnatal outcomes up to 12 months of age after prenatal fetoscopic and open fetal surgery repair of open spina bifida are similar. Fetoscopic repair allows for having a vaginal delivery and eliminates the risk of uterine scar dehiscence, therefore protecting subsequent pregnancies of unnecessary maternal and fetal risks.
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23
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Jouannic JM, Guilbaud L, Maurice P, Maisonneuve E, de Saint Denis T, du Peuty C, Zerah M. [The ethics of fetal myelomeningocele surgery]. ACTA ACUST UNITED AC 2021; 50:189-193. [PMID: 34656790 DOI: 10.1016/j.gofs.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Indexed: 10/20/2022]
Abstract
Fetal myelomeningocele surgery was introduced in France in 2014. Developments in prenatal diagnosis of neural tube defects have accompanied the development of prenatal diagnosis. This fetal surgery represents one of the three possible care paths for pregnant women faced with this prenatal diagnosis. The ethical issues of this fetal surgery are discussed and in particular regarding prenatal counselling and patient autonomy of choice.
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Affiliation(s)
- J-M Jouannic
- Service de médecine fœtale, Sorbonne Université, AP-HP Sorbonne Université, Hôpital Armand-Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; Centre de référence Maladies Rares C-MAVEM, Hôpital Armand Trousseau, AP-HP Sorbonne Université, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France.
| | - L Guilbaud
- Service de médecine fœtale, Sorbonne Université, AP-HP Sorbonne Université, Hôpital Armand-Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; Centre de référence Maladies Rares C-MAVEM, Hôpital Armand Trousseau, AP-HP Sorbonne Université, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - P Maurice
- Service de médecine fœtale, Sorbonne Université, AP-HP Sorbonne Université, Hôpital Armand-Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; Centre de référence Maladies Rares C-MAVEM, Hôpital Armand Trousseau, AP-HP Sorbonne Université, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - E Maisonneuve
- Service de médecine fœtale, Sorbonne Université, AP-HP Sorbonne Université, Hôpital Armand-Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; Centre de référence Maladies Rares C-MAVEM, Hôpital Armand Trousseau, AP-HP Sorbonne Université, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - T de Saint Denis
- Centre de référence Maladies Rares C-MAVEM, Hôpital Armand Trousseau, AP-HP Sorbonne Université, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; Service de neurochirurgie pédiatrique, Hôpital Necker, Université de Paris, 149, rue du Sèvres, 75015 Paris, France
| | - C du Peuty
- Service de médecine fœtale, Sorbonne Université, AP-HP Sorbonne Université, Hôpital Armand-Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - M Zerah
- Centre de référence Maladies Rares C-MAVEM, Hôpital Armand Trousseau, AP-HP Sorbonne Université, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; Service de neurochirurgie pédiatrique, Hôpital Necker, Université de Paris, 149, rue du Sèvres, 75015 Paris, France
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Sanz Cortes M, Shamshirsaz AA, Ugoji CH, Johnson RM, Espinoza J, Whitehead WE, Belfort MA. Outcomes of subsequent pregnancies after 2-port laparotomy-assisted fetoscopic spina bifida repair. Am J Obstet Gynecol 2021; 225:452-454. [PMID: 34144020 DOI: 10.1016/j.ajog.2021.06.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/10/2021] [Indexed: 11/25/2022]
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25
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Lapa DA, Chmait RH, Gielchinsky Y, Yamamoto M, Persico N, Santorum M, Gil MM, Trigo L, Quintero RA, Nicolaides KH. Percutaneous fetoscopic spina bifida repair: effect on ambulation and need for postnatal cerebrospinal fluid diversion and bladder catheterization. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:582-589. [PMID: 33880811 PMCID: PMC9293198 DOI: 10.1002/uog.23658] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 04/08/2021] [Accepted: 04/08/2021] [Indexed: 06/02/2023]
Abstract
OBJECTIVE A trial comparing prenatal with postnatal open spina bifida (OSB) repair established that prenatal surgery was associated with better postnatal outcome. However, in the trial, fetal surgery was carried out through hysterotomy. Minimally invasive approaches are being developed to mitigate the risks of open maternal-fetal surgery. The objective of this study was to investigate the impact of a novel neurosurgical technique for percutaneous fetoscopic repair of fetal OSB, the skin-over-biocellulose for antenatal fetoscopic repair (SAFER) technique, on long-term postnatal outcome. METHODS This study examined descriptive data for all patients undergoing fetoscopic OSB repair who had available 12- and 30-month follow-up data for assessment of need for cerebrospinal fluid (CSF) diversion and need for bladder catheterization and ambulation, respectively, from eight centers that perform prenatal OSB repair via percutaneous fetoscopy using a biocellulose patch between the neural placode and skin/myofascial flap, without suture of the dura mater (SAFER technique). Univariate and multivariate logistic regression analyses were used to examine the effect of different factors on need for CSF diversion at 12 months and ambulation and need for bladder catheterization at 30 months. Potential cofactors included gestational age at fetal surgery and delivery, preoperative ultrasound findings of anatomical level of the lesion, cerebral lateral ventricular diameter, lesion type and presence of bilateral talipes, as well as postnatal findings of CSF leakage at birth, motor level, presence of bilateral talipes and reversal of hindbrain herniation. RESULTS A total of 170 consecutive patients with fetal OSB were treated prenatally using the SAFER technique. Among these, 103 babies had follow-up at 12 months of age and 59 had follow-up at 30 months of age. At 12 months of age, 53.4% (55/103) of babies did not require ventriculoperitoneal shunt or third ventriculostomy. At 30 months of age, 54.2% (32/59) of children were ambulating independently and 61.0% (36/59) did not require chronic intermittent catheterization of the bladder. Multivariate logistic regression analysis demonstrated that significant prediction of need for CSF diversion was provided by lateral ventricular size and type of lesion (myeloschisis). Significant predictors of ambulatory status were prenatal bilateral talipes and anatomical and functional motor levels of the lesion. There were no significant predictors of need for bladder catheterization. CONCLUSION Children who underwent prenatal OSB repair via the percutaneous fetoscopic SAFER technique achieved long-term neurological outcomes similar to those reported in the literature after hysterotomy-assisted OSB repair. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- D. A. Lapa
- Fetal Therapy Team CoordinatorHospital Infantil SabaraSão PauloBrazil
- Fetal Therapy GroupHospital Israelita Albert EinsteinSão PauloBrazil
| | - R. H. Chmait
- Los Angeles Fetal Surgery, Department of Obstetrics and GynecologyKeck School of Medicine, University of Southern CaliforniaLos AngelesCAUSA
| | - Y. Gielchinsky
- Fetal Therapy, Helen Schneider Hospital for WomenRabin Medical CenterPetah TikvaIsrael
| | | | - N. Persico
- Department of Clinical Sciences and Community HealthUniversity of MilanMilanItaly
- Fetal Medicine and Surgery Service, Fondazione IRCCS Ca' Granda, Ospedale Maggiore PoliclinicoMilanItaly
| | - M. Santorum
- Fetal Medicine Research InstituteKing's College HospitalLondonUK
| | - M. M. Gil
- Department of Obstetrics and GynecologyHospital Universitario de TorrejónMadridSpain
- School of MedicineUniversidad Francisco de VitoriaMadridSpain
| | - L. Trigo
- Fetal Therapy GroupHospital Israelita Albert EinsteinSão PauloBrazil
- BCNatal Fetal Medicine Research CenterBarcelonaSpain
| | | | - K. H. Nicolaides
- Fetal Medicine Research InstituteKing's College HospitalLondonUK
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26
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Miller JL, Groves ML, Ahn ES, Berman DJ, Murphy JD, Rosner MK, Wolfson D, Jelin EB, Korth SA, Keiser AM, Laurie M, Millard SE, Tekes A, Baschat AA. Implementation Process and Evolution of a Laparotomy-Assisted 2-Port Fetoscopic Spina Bifida Closure Program. Fetal Diagn Ther 2021; 48:603-610. [PMID: 34518445 DOI: 10.1159/000518507] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 07/12/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Prenatal closure of open spina bifida via open fetal surgery improves neurologic outcomes for infants in selected pregnancies. Fetoscopic techniques that are minimally invasive to the uterus aim to provide equivalent fetal benefits while minimizing maternal morbidities, but the optimal technique is undetermined. We describe the development, evolution, and feasibility of the laparotomy-assisted 2-port fetoscopic technique for prenatal closure of fetal spina bifida in a newly established program. METHODS We conducted a retrospective cohort study of women consented for laparotomy-assisted fetoscopic closure of isolated fetal spina bifida. Inclusion and exclusion criteria followed the Management of Myelomeningocele Study (MOMS). Team preparation involved observation at the originating center, protocol development, ancillary staff training, and surgical rehearsal using patient-matched models through simulation prior to program implementation. The primary outcome was the ability to complete the repair fetoscopically. Secondary maternal and fetal outcomes to assess performance of the technique were collected prospectively. RESULTS Of 57 women screened, 19 (33%) consented for laparotomy-assisted 2-port fetoscopy between February 2017 and December 2019. Fetoscopic closure was completed in 84% (16/19) cases. Over time, the technique was modified from a single- to a multilayer closure. In utero hindbrain herniation improved in 86% (12/14) of undelivered patients at 6 weeks postoperatively. Spontaneous rupture of membranes occurred in 31% (5/16) of fetoscopic cases. For completed cases, median gestational age at birth was 37 (range 27-39.6) weeks and 50% (8/16) of women delivered at term. Vaginal birth was achieved in 56% (9/16) of patients. One newborn had a cerebrospinal fluid leak that required postnatal surgical repair. CONCLUSION Implementation of a laparotomy-assisted 2-port fetoscopic spina bifida closure program through rigorous preparation and multispecialty team training may accelerate the learning curve and demonstrates favorable obstetric and perinatal outcomes.
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Affiliation(s)
- Jena L Miller
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Mari L Groves
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Edward S Ahn
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - David J Berman
- Division of Obstetric, Gynecologic and Fetal Anesthesiology, Department of Anesthesia and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jamie D Murphy
- Division of Obstetric, Gynecologic and Fetal Anesthesiology, Department of Anesthesia and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Mara K Rosner
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Denise Wolfson
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Eric B Jelin
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sarah A Korth
- Keelty Center for Spina Bifida and Related Conditions, Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Amaris M Keiser
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Melissa Laurie
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sarah E Millard
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Aylin Tekes
- Division of Pediatric Radiology and Pediatric Neuroradiology, Department of Radiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ahmet A Baschat
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
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27
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Two-port, exteriorized uterus, fetoscopic meningomyelocele closure has fewer adverse neonatal outcomes than open hysterotomy closure. Am J Obstet Gynecol 2021; 225:327.e1-327.e9. [PMID: 33957114 DOI: 10.1016/j.ajog.2021.04.252] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/23/2021] [Accepted: 04/28/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND In utero closure of meningomyelocele using an open hysterotomy approach is associated with preterm delivery and adverse neonatal outcomes. OBJECTIVE This study compared the neonatal outcomes in in utero meningomyelocele closure using a 2-port, exteriorized uterus, fetoscopic approach vs the conventional open hysterotomy approach. STUDY DESIGN This retrospective cohort study included all consecutive patients who underwent in utero meningomyelocele closure using open hysterotomy (n=44) or a 2-port, exteriorized uterus, fetoscopic approach (n=46) at a single institution between 2012 and 2020. The 2-port, exteriorized uterus, fetoscopic closure was composed of the following 3 layers: a bovine collagen patch, a myofascial layer, and a skin. The frequency of respiratory distress syndrome and a composite of other adverse neonatal outcomes, including retinopathy of prematurity, periventricular leukomalacia, and perinatal death, were compared between the study groups. Regression analyses were performed to determine any association between the fetoscopic closure and adverse neonatal outcomes, adjusted for several confounders, including gestational age of <37 weeks at delivery. RESULTS The fetoscopic closure was associated with a lower rate of respiratory distress syndrome than the open hysterotomy closure (11.5% [5 of 45] vs 29.5% [13 of 44]; P=.037). The proportion of neonates with a composite of other adverse neonatal outcomes in the fetoscopic group was half of that observed patients in the open hysterotomy group; however, this difference did not reach statistical significance (4.3% [2 of 46] vs 9.1% [4 of 44]; P=.429). Here, regression analysis has demonstrated that fetoscopic meningomyelocele closure was associated with a lower risk of respiratory distress syndrome (adjusted odds ratio, 0.23; 95% confidence interval, 0.06-0.84; P=.026) than open hysterotomy closure. CONCLUSION In utero meningomyelocele closure using a 2-port, exteriorized uterus, fetoscopic approach was associated with a lower risk of respiratory distress syndrome than the conventional open hysterotomy meningomyelocele closure.
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Schmitz D, Henn W. The fetus in the age of the genome. Hum Genet 2021; 141:1017-1026. [PMID: 34426855 PMCID: PMC9160108 DOI: 10.1007/s00439-021-02348-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 08/16/2021] [Indexed: 12/15/2022]
Abstract
Due to a number of recent achievements, the field of prenatal medicine is now on the verge of a profound transformation into prenatal genomic medicine. This transformation is expected to not only substantially expand the spectrum of prenatal diagnostic and screening possibilities, but finally also to advance fetal care and the prenatal management of certain fetal diseases and malformations. It will come along with new and profound challenges for the normative framework and clinical care pathways in prenatal (and reproductive) medicine. To adequately address the potential ethically challenging aspects without discarding the obvious benefits, several agents are required to engage in different debates. The permissibility of the sequencing of the whole fetal exome or genome will have to be examined from a philosophical and legal point of view, in particular with regard to conflicts with potential rights of future children. A second requirement is a societal debate on the question of priority setting and justice in relation to prenatal genomic testing. Third, a professional-ethical debate and positioning on the goal of prenatal genomic testing and a consequential re-structuring of clinical care pathways seems to be important. In all these efforts, it might be helpful to envisage the unborn rather not as a fetus, not as a separate moral subject and a second "patient", but in its unique physical connection with the pregnant woman, and to accept the moral quandaries implicitly given in this situation.
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Affiliation(s)
- Dagmar Schmitz
- Institute for History, Theory and Ethics in Medicine, RWTH Aachen University, Wendlingweg 2, 52074, Aachen, Germany.
| | - Wolfram Henn
- Institute of Human Genetics, Saarland University, Homburg/Saar, Germany
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King BC, Hagan J, Corroenne R, Shamshirsaz AA, Espinoza J, Nassr AA, Whitehead W, Belfort MA, Sanz Cortes M. Economic analysis of prenatal fetoscopic vs open-hysterotomy repair of open neural tube defect. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:230-237. [PMID: 32438507 DOI: 10.1002/uog.22089] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/24/2020] [Accepted: 05/07/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Fetal repair of an open neural tube defect (ONTD) by open hysterotomy has been shown to reduce the need for ventriculoperitoneal shunting and improve motor outcomes for infants, but increases the risk of Cesarean section and prematurity. Fetoscopic repair is an alternative approach that may confer similar neurological benefits but allows for vaginal delivery and reduces the incidence of hysterotomy-related complications. We sought to compare the costs of care from fetal surgery until neonatal discharge, as well as the clinical outcomes, associated with each surgical approach. METHODS This was a retrospective cohort study of patients who underwent prenatal ONTD repair, using either the open-hysterotomy or the fetoscopic approach, at a single institution between 2012 and 2018. Clinical outcomes were collected by chart review. A cost-consequence analysis was conducted from the hospital perspective, and included all inpatient and ambulatory hospital and physician costs incurred for the care of mothers and their infants, from the time of maternal admission for fetal ONTD repair up to postnatal maternal and infant discharge. Costs were estimated using cost-to-charge ratios for hospital billing and the Medicare physician fee schedule for physician billing. RESULTS Seventy-eight patients were included in the analysis, of whom 47 underwent fetoscopic repair and 31 underwent open-hysterotomy repair. In the fetoscopic-repair group, compared with the open-repair group, fewer women underwent Cesarean section (53% vs 100%; P < 0.001) and the median gestational age at birth was significantly higher (38.1 weeks (interquartile range (IQR), 35.2-39.1 weeks) vs 35.7 weeks (IQR, 33.9-37.0 weeks); P < 0.001). No case of uterine dehiscence was observed in the fetoscopic-repair group, compared with an incidence of 16% in the open-repair group. After adjusting for baseline characteristics, there was no significant difference in the total cost of care between the fetoscopic-repair and the open-repair groups (median, $76 978 (IQR, $60 312-$115 386) vs $65 103 (IQR, $57 758-$108 103); P = 0.458). CONCLUSIONS Fetoscopic repair of ONTD, when compared with the open-hysterotomy approach, reduces the incidence of Cesarean section and preterm delivery with no significant difference in total costs of care from surgery to infant discharge. This novel approach may represent a cost-effective alternative to improve maternal and neonatal outcomes for this high-risk population. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- B C King
- Section of Neonatology, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - J Hagan
- Section of Neonatology, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - R Corroenne
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - A A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - W Whitehead
- Department of Pediatric Neurosurgery, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - M A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - M Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
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30
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Guilbaud L, Zerah M, Jouannic JM, Quarello E. [The paradoxes of spina bifida in the prenatal period]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2021; 49:569-572. [PMID: 33989830 DOI: 10.1016/j.gofs.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Indexed: 06/12/2023]
Affiliation(s)
- L Guilbaud
- Service de médecine fœtale, Sorbonne université, AP-HP, hôpital Armand-Trousseau, 26, avenue du Docteur Arnold Netter, 75012 Paris, France; Centre de référence maladies rares C-MAVEM, hôpital Armand-Trousseau, 26, avenue du Docteur Arnold Netter, 75012 Paris, France
| | - M Zerah
- Centre de référence maladies rares C-MAVEM, hôpital Armand-Trousseau, 26, avenue du Docteur Arnold Netter, 75012 Paris, France; Service de neurochirurgie pédiatrique, hôpital Necker, Université de Paris, 149, rue du Sèvres, 75015 Paris, France
| | - J-M Jouannic
- Service de médecine fœtale, Sorbonne université, AP-HP, hôpital Armand-Trousseau, 26, avenue du Docteur Arnold Netter, 75012 Paris, France; Centre de référence maladies rares C-MAVEM, hôpital Armand-Trousseau, 26, avenue du Docteur Arnold Netter, 75012 Paris, France
| | - E Quarello
- Institut méditerranéen d'imagerie médicale appliquée à la gynécologie, la grossesse et l'enfance IMAGE(2), 6, rue Rocca, 13008 Marseille, France; Unité de dépistage et de diagnostic prénatal, hôpital Saint-Joseph, 26, boulevard de Louvain, 13285 Marseille cedex, France.
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Fetoscopic compared with open repair of myelomeningocele: a 2-delivery cost-effectiveness analysis. Am J Obstet Gynecol MFM 2021; 3:100434. [PMID: 34217856 DOI: 10.1016/j.ajogmf.2021.100434] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/10/2021] [Accepted: 06/23/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Recent studies have compared maternal and neonatal outcomes associated with fetoscopic surgical approach for repair of myelomeningocele compared with an open approach. OBJECTIVE In this study, we compared the cost-effectiveness of these techniques in the setting of a woman seeking future pregnancies. STUDY DESIGN A decision-analytical model using TreeAge software was designed to compare the costs and outcomes of fetoscopic vs open repair in patients with prenatally diagnosed myelomeningocele. We assumed a theoretical cohort of 500 women with a pregnancy affected by myelomeningocele planning to have a future pregnancy. Our model accounted for costs and quality-adjusted life years of the woman, the neonate with myelomeningocele, and the neonate in a subsequent pregnancy. Neonatal outcomes from the incident pregnancy included motor function >2 levels better than the anatomic level, motor function <2 levels better than the anatomic level, and same motor function as the anatomic level, preterm birth in the index pregnancy, neonatal death in the index pregnancy, and major neurodevelopmental disability as a result of preterm birth in the index pregnancy. Neonatal outcomes in the subsequent pregnancy included stillbirth, preterm birth, and neonatal and major neurodevelopmental disability as a result of preterm birth. Probabilities were derived from the literature, and we used a willingness-to-pay threshold of $100,000 per quality-adjusted life year. RESULTS In the index pregnancy, fetoscopic surgical technique resulted in 140 fewer cases of preterm birth and fewer cases of neurodevelopmental disability and neonatal death. Fetoscopic technique resulted in 130 more cases of functional level >2 levels better than the anatomic level, 35 fewer cases of functional level >2 levels worse than the anatomic level, and 107 fewer cases of function same as the anatomic level. In the subsequent pregnancy, fetoscopic surgery led to 22 fewer cases of delivery complications (uterine dehiscence, uterine rupture, and excessive bleeding), 24 fewer cases of stillbirth, and 22 fewer cases of preterm birth. Although the fetoscopic approach was more costly, it was cost-effective with an incremental cost-effectiveness ratio of $1029 per quality-adjusted life year in our theoretical cohort of 500 patients. Monte Carlo probabilistic sensitivity analysis showed that fetoscopic technique is cost-effective 100% of the time. CONCLUSION In our theoretical cohort, the fetoscopic approach was more costly, but resulted in improved outcomes when a subsequent pregnancy was considered.
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Jha P, Feldstein VA, Revzin MV, Katz DS, Moshiri M. Role of Imaging in Obstetric Interventions: Criteria, Considerations, and Complications. Radiographics 2021; 41:1243-1264. [PMID: 34115536 DOI: 10.1148/rg.2021200163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
US has an established role in the prenatal detection of congenital and developmental disorders. Many pregnant women undergo US at 18-20 weeks of gestation for assessment of fetal anatomy and detection of structural anomalies. With advances in fetoscopy and minimally invasive procedures, in utero fetal interventions can be offered to address some of the detected structural and physiologic fetal abnormalities. Most interventions are reserved for conditions that, if left untreated, often cause in utero death or a substantially compromised neonatal outcome. US is crucial for preprocedural evaluation and planning, real-time procedural guidance, and monitoring and assessment of postprocedural complications. Percutaneous needle-based interventions include in utero transfusion, thoracentesis and placement of a thoracoamniotic shunt, vesicocentesis and placement of a vesicoamniotic shunt, and aortic valvuloplasty. Fetoscopic interventions include myelomeningocele repair and tracheal balloon occlusion for congenital diaphragmatic hernia. In rare cases, open hysterotomy may be required for repair of a myelomeningocele or resection of a sacrococcygeal teratoma. Monochorionic twin pregnancies involve specific complications such as twin-twin transfusion syndrome, which is treated with fetoscopic laser ablation of vascular connections, and twin reversed arterial perfusion sequence, which is treated with radiofrequency ablation. Finally, when extended placental support is necessary at delivery for repair of congenital high airway obstruction or resection of lung masses, ex utero intrapartum treatment can be planned. Radiologists should be aware of the congenital anomalies that are amenable to in utero interventions and, when necessary, consider referral to centers where such treatments are offered. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. ©RSNA, 2021.
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Affiliation(s)
- Priyanka Jha
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Vickie A Feldstein
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Margarita V Revzin
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Douglas S Katz
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Mariam Moshiri
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
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Abstract
PURPOSE OF REVIEW To review the advance of maternal--fetal surgery, the research of stem cell transplantation and tissue engineering in prenatal management of fetal meningomyelocele (fMMC). RECENT FINDINGS Advance in the imaging study provides more accurate assessment of fMMC in utero. Prenatal maternal--fetal surgery in fMMC demonstrates favourable postnatal outcome. Minimally invasive fetal surgery minimizes uterine wall disruption. Endoscopic fetal surgery is performed via laparotomy-assisted or entirely percutaneous approach. The postnatal outcome for open and endoscopic fetal surgery shares no difference. Single layer closure during repair of fMMC is preferred to reduce postnatal surgical intervention. All maternal--fetal surgeries impose anesthetic and obstetric risk to pregnant woman. Ruptured of membrane and preterm delivery are common complications. Trans-amniotic stem cell therapy (TRASCET) showed potential tissue regeneration in animal models. Fetal tissue engineering with growth factors and dura substitutes with biosynthetic materials promote spinal cord regeneration. This will overcome the challenge of closure in large fMMC. Planning of the maternal--fetal surgery should adhere to ethical framework to minimize morbidity to both fetus and mother. SUMMARY Combination of endoscopic fetal surgery with TRASCET or tissue engineering will be a new vision to achieve to improve the outcome of prenatal intervention in fMMC.
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Guilbaud L, Maurice P, Lallemant P, De Saint-Denis T, Maisonneuve E, Dhombres F, Friszer S, Di Rocco F, Garel C, Moutard ML, Lachtar MA, Rigouzzo A, Forin V, Zérah M, Jouannic JM. Open fetal surgery for myelomeningocele repair in France. J Gynecol Obstet Hum Reprod 2021; 50:102155. [PMID: 33915336 DOI: 10.1016/j.jogoh.2021.102155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/22/2021] [Accepted: 04/23/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Open fetal myelomeningocele (MMC) surgery is currently the standard of care option for prenatal MMC repair. We described the population referred to our center and reviewed outcome after open fetal MMC repair. MATERIAL AND METHODS All patients referred to our center for MMC were reviewed from July 2014 to June 2020. For all the patients who underwent fetal MMC repair, surgical details, maternal characteristics and data from the neonatal to the three-years-old evaluations were collected. RESULTS Among the 126 patients referred to our center, 49.2% were eligible and 27.4% (n = 17) of them underwent fetal MMC repair. Average gestational age at fetal surgery was 24+6 weeks. There was no case of fetal complication and the only maternal complication was one case of transfusion. We recorded 70% of premature rupture of membranes and 47% of premature labor. Average gestational age at delivery was 34+2 weeks and no patient delivered before 30 weeks. There was no case of uterine scar dehiscence or maternal complication during cesarean section. After birth, 59% of the children had a hindbrain herniation reversal. At 1-year-old, 42% were assigned a functional level of one or more better than expected according to the prenatal anatomic level and 25% required a ventriculoperitoneal shunt. At 3-year-old, all the children attended school and 75% were able to walk with orthotics or independently. CONCLUSION Open fetal surgery enables anatomical repair of the MMC lesion, a potential benefit on cerebral anomalies and motor function, with a low rate of perinatal and maternal complications.
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Affiliation(s)
- Lucie Guilbaud
- Sorbonne University, AP-HP, Trousseau Hospital, DMU ORIGYNE, Department of Fetal Medicine, 26 Avenue du Dr Arnold Netter, 75012 Paris, France; National Reference Center for Rare Disease: Vertebral and Spinal Cord Anomalies (MAVEM Center), AP-HP, Trousseau Hospital, 26 Avenue du Dr Arnold Netter, 75012 Paris, France.
| | - Paul Maurice
- Sorbonne University, AP-HP, Trousseau Hospital, DMU ORIGYNE, Department of Fetal Medicine, 26 Avenue du Dr Arnold Netter, 75012 Paris, France; National Reference Center for Rare Disease: Vertebral and Spinal Cord Anomalies (MAVEM Center), AP-HP, Trousseau Hospital, 26 Avenue du Dr Arnold Netter, 75012 Paris, France
| | - Pauline Lallemant
- National Reference Center for Rare Disease: Vertebral and Spinal Cord Anomalies (MAVEM Center), AP-HP, Trousseau Hospital, 26 Avenue du Dr Arnold Netter, 75012 Paris, France; Sorbonne University, AP-HP, Trousseau Hospital, Department of Physical Medicine and Rehabilitation, 26 Avenue du Dr Arnold Netter, 75012 Paris, France
| | - Timothée De Saint-Denis
- National Reference Center for Rare Disease: Vertebral and Spinal Cord Anomalies (MAVEM Center), AP-HP, Trousseau Hospital, 26 Avenue du Dr Arnold Netter, 75012 Paris, France; Paris University, AP-HP, Necker Enfants Malades Hospital, Department of Pediatric Neurosurgery, 149 Rue de Sèvres, 75015 Paris, France
| | - Emeline Maisonneuve
- Sorbonne University, AP-HP, Trousseau Hospital, DMU ORIGYNE, Department of Fetal Medicine, 26 Avenue du Dr Arnold Netter, 75012 Paris, France; National Reference Center for Rare Disease: Vertebral and Spinal Cord Anomalies (MAVEM Center), AP-HP, Trousseau Hospital, 26 Avenue du Dr Arnold Netter, 75012 Paris, France
| | - Ferdinand Dhombres
- Sorbonne University, AP-HP, Trousseau Hospital, DMU ORIGYNE, Department of Fetal Medicine, 26 Avenue du Dr Arnold Netter, 75012 Paris, France; National Reference Center for Rare Disease: Vertebral and Spinal Cord Anomalies (MAVEM Center), AP-HP, Trousseau Hospital, 26 Avenue du Dr Arnold Netter, 75012 Paris, France
| | - Stéphanie Friszer
- Sorbonne University, AP-HP, Trousseau Hospital, DMU ORIGYNE, Department of Fetal Medicine, 26 Avenue du Dr Arnold Netter, 75012 Paris, France; National Reference Center for Rare Disease: Vertebral and Spinal Cord Anomalies (MAVEM Center), AP-HP, Trousseau Hospital, 26 Avenue du Dr Arnold Netter, 75012 Paris, France
| | - Federico Di Rocco
- Lyon Claude Bernard University, hôpital Femme-Mère-Enfant, Department of Pediatric Neurosurgery, 59 Boulevard Pinel, 69500 Bron, France
| | - Catherine Garel
- National Reference Center for Rare Disease: Vertebral and Spinal Cord Anomalies (MAVEM Center), AP-HP, Trousseau Hospital, 26 Avenue du Dr Arnold Netter, 75012 Paris, France; Sorbonne University, AP-HP, Trousseau Hospital, Department of Pediatric Radiology, 26 Avenue du Dr Arnold Netter, 75012 Paris, France
| | - Marie-Laure Moutard
- National Reference Center for Rare Disease: Vertebral and Spinal Cord Anomalies (MAVEM Center), AP-HP, Trousseau Hospital, 26 Avenue du Dr Arnold Netter, 75012 Paris, France; Sorbonne University, AP-HP, Trousseau Hospital, DMU ORIGYNE, Department of Pediatric Neurology, 26 Avenue du Dr Arnold Netter, 75012 Paris, France
| | - Mohamed-Ali Lachtar
- Sorbonne University, AP-HP, Trousseau Hospital, DMU ORIGYNE, Neonatal Intensive Care Unit, 26 Avenue du Dr Arnold Netter, 75012 Paris, France
| | - Agnès Rigouzzo
- Sorbonne University, AP-HP, Trousseau Hospital, Department of Anesthesiology, 26 Avenue du Dr Arnold Netter, 75012 Paris, France
| | - Véronique Forin
- National Reference Center for Rare Disease: Vertebral and Spinal Cord Anomalies (MAVEM Center), AP-HP, Trousseau Hospital, 26 Avenue du Dr Arnold Netter, 75012 Paris, France; Sorbonne University, AP-HP, Trousseau Hospital, Department of Physical Medicine and Rehabilitation, 26 Avenue du Dr Arnold Netter, 75012 Paris, France
| | - Michel Zérah
- National Reference Center for Rare Disease: Vertebral and Spinal Cord Anomalies (MAVEM Center), AP-HP, Trousseau Hospital, 26 Avenue du Dr Arnold Netter, 75012 Paris, France; Paris University, AP-HP, Necker Enfants Malades Hospital, Department of Pediatric Neurosurgery, 149 Rue de Sèvres, 75015 Paris, France
| | - Jean-Marie Jouannic
- Sorbonne University, AP-HP, Trousseau Hospital, DMU ORIGYNE, Department of Fetal Medicine, 26 Avenue du Dr Arnold Netter, 75012 Paris, France; National Reference Center for Rare Disease: Vertebral and Spinal Cord Anomalies (MAVEM Center), AP-HP, Trousseau Hospital, 26 Avenue du Dr Arnold Netter, 75012 Paris, France
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Wataganara T, Trigo L, Lapa DA. Teaching and training the total percutaneous fetoscopic myelomeningocele repair. J Perinat Med 2021; 49:jpm-2020-0591. [PMID: 33818041 DOI: 10.1515/jpm-2020-0591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/08/2021] [Indexed: 11/15/2022]
Abstract
Skin-over-biocellulose for Antenatal Fetoscopic Repair (SAFER) is a recently developed technique for fully percutaneous fetoscopic repair of myelomeningocele. The formation of a neo-dura mater triggered by the use of a biocellulose patch over the placode obviates the need of primary repair of fetal dura mater, and seems to further improve neurodevelopmental outcome. Insufflation of humidified carbon dioxide into the amniotic cavity requires proper training and a different equipment set from those used in the classic "under-water" fetoscopy. To shorten the learning curve of novice teams, we have developed a structured training course encompassing three critical steps: (1) visiting the proctor center, (2) selection of the first case, and (3) on-site training of the surgical team. Upon the site arrival, there will be: (1) theoretical lecture for all specialists involved in the fetal care, (2) simulation training, and (3) surgical proctoring. Proctor team can take over the surgery if the local team cannot complete. This training course has been successfully used in five different countries: Israel, Chile, Italy, USA and England and all local teams are already performing surgeries solo without any failures or maternal morbidity. Teaching new procedures in fetal medicine is challenging, because of the small number of candidate cases, and the direct relation of good outcomes and the number of cases operated. This proposed training modules may be adopted by other teams that want to embark on this type of novel minimally invasive treatment.
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Affiliation(s)
- Tuangsit Wataganara
- Division of Maternal Fetal Medicine, Department of Obstetrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Lucas Trigo
- Hospital Israelita Albert Einstein, Fetal Therapy Program, São Paulo, SP, Brazil
| | - Denise Araujo Lapa
- Hospital Israelita Albert Einstein, Fetal Therapy Program, São Paulo, SP, Brazil
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Verweij EJ, de Vries MC, Oldekamp EJ, Eggink AJ, Oepkes D, Slaghekke F, Spoor JKH, Deprest JA, Miller JL, Baschat AA, DeKoninck PLJ. Fetoscopic myelomeningocoele closure: Is the scientific evidence enough to challenge the gold standard for prenatal surgery? Prenat Diagn 2021; 41:949-956. [PMID: 33778976 PMCID: PMC8360048 DOI: 10.1002/pd.5940] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 12/18/2022]
Abstract
Since the completion of the Management of Myelomeningocoele Study, maternal-fetal surgery for spina bifida has become a valid option for expecting parents. More recently, multiple groups are exploring a minimally invasive approach and recent outcomes have addressed many of the initial concerns with this approach. Based on a previously published framework, we attempt to delineate the developmental stage of the surgical techniques. Furthermore, we discuss the barriers of performing randomized controlled trials comparing two surgical interventions and suggest that data collection through registries is an alternative method to gather high-grade evidence.
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Affiliation(s)
- E Joanne Verweij
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Martine C de Vries
- Department of Medical Ethics & Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Esther J Oldekamp
- Department of Medical Ethics & Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Alex J Eggink
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jochem K H Spoor
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan A Deprest
- Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Jena L Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ahmet A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Lappen JR, Pettker CM, Louis JM, Louis JM. Society for Maternal-Fetal Medicine Consult Series #54: Assessing the risk of maternal morbidity and mortality. Am J Obstet Gynecol 2021; 224:B2-B15. [PMID: 33309560 DOI: 10.1016/j.ajog.2020.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The rates of maternal morbidity and mortality in the United States demand a comprehensive approach to assessing pregnancy-related risks. Numerous medical and nonmedical factors contribute to maternal morbidity and mortality. Reducing the number of women who experience pregnancy morbidity requires identifying which women are at greatest risk and initiating appropriate interventions early in the reproductive life course. The purpose of this Consult is to educate all healthcare practitioners about factors contributing to a high-risk pregnancy, strategies to assess maternal health risks due to pregnancy, and the importance of risk assessment across the reproductive spectrum in reducing maternal morbidity and mortality.
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Affiliation(s)
| | | | | | - Judette M Louis
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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Hautier S, Kermorvant E, Khen-Dunlop N, de Wailly D, Beauquier B, Corroenne R, Milani G, Bonnet D, James S, Vinit N, Blanc T, Aigrain Y, Colmant C, Salomon L, Ville Y, Stirnemann J. [Prenatal path of care following the diagnosis of a malformation for which a novel prenatal therapy is available]. ACTA ACUST UNITED AC 2020; 49:172-179. [PMID: 33166705 DOI: 10.1016/j.gofs.2020.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Fetal therapy is part of the available care offer for several severe malformations. The place of these emergent prenatal interventions in the prenatal path of care is poorly known. The objective of this study is to describe the decision-making process of patients facing the option of an emergent in utero intervention. METHODS We have conducted a retrospective monocentric descriptive study in the department of maternal-fetal medicine of Necker Hospital. We collected data regarding eligibility or not for fetal surgery and the pregnancy outcomes of patients referred for myelomeningocele, diaphragmatic hernia, aortic stenosis and low obstructive uropathies. RESULTS All indications combined, 70% of patients opted for fetal surgery. This rate was lower in the case of myelomeningocele with 21% consent, than in the other pathologies: 69% for diaphragmatic hernias, 90% for aortic stenoses and 76% for uropathy. When fetal intervention was declined, the vast majority of patients opted for termination of pregnancy: 86%. In 14% of the considering fetal surgery, the patient was referred too far. CONCLUSION The acceptance rate for fetal surgeries depends on condition. It offers an additional option and is an alternative for couples for which termination of pregnancy (TOP) is not an option. Timely referral to an expert center allows to discuss the place of a fetal intervention and not to deprive couples of this possibility.
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Affiliation(s)
- S Hautier
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - E Kermorvant
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - N Khen-Dunlop
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - D de Wailly
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - B Beauquier
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - R Corroenne
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - G Milani
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - D Bonnet
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - S James
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - N Vinit
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - T Blanc
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - Y Aigrain
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - C Colmant
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - L Salomon
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - Y Ville
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - J Stirnemann
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France.
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Licci M, Guzman R, Soleman J. Maternal and obstetric complications in fetal surgery for prenatal myelomeningocele repair: a systematic review. Neurosurg Focus 2020; 47:E11. [PMID: 31574465 DOI: 10.3171/2019.7.focus19470] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 07/22/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Comparing prenatal and postnatal surgical repair techniques for myelomeningocele (MMC), in utero fetal surgery has increasingly gained acceptance and is considered by many specialized centers the first choice of treatment. Despite its benefits, as demonstrated in the Management of Myelomeningocele Study (MOMS), including reduced need for CSF shunting in neonates and improved motor outcomes at 30 months, there is still an ongoing debate on fetal and maternal risks associated with the procedure. Prenatal open hysterotomy, fetoscopic MMC repair techniques, and subsequent delivery by cesarean section are associated with maternal complications. The aim of this systematic review is to assess the available literature on maternal and obstetric complication rates and perinatal maternal outcomes related to fetal MMC repair. METHODS The authors identified references for inclusion in this review by searching PubMed and MEDLINE, with restrictions to English language, case series, case reports, clinical trials, controlled clinical trials, meta-analyses, randomized controlled trials, reviews, and systematic reviews. The rate of maternal and obstetric complications was analyzed based on studies focusing on this issue and presenting clear results on the matter. RESULTS Of 1264 articles screened, 36 were included in this systemic review, whereof 11 were eligible for data analysis and comparison. The average overall rate of maternal and obstetric complications corresponds to 78.6%. The majority of the described events are obstetric complications, varying from chorioamniotic membrane separation in 65.6% of cases, oligohydramnios in 13.0% of cases, placental abruption in 5.0% of cases, spontaneous or preterm premature membrane rupture in 42.0% of cases, and early preterm delivery in 11.3% of cases due to uterine dehiscence, occurring in 0.9% of cases. The most common medical complications are development of pulmonary edema occurring in 2.8%, gestational diabetes in 3.7%, gestational hypertension/preeclampsia in 3.7%, and need for blood transfusions in 3.2% of cases. Limitations of the review arise from the lack of data in the current literature, with maternal and obstetric complications being underreported. CONCLUSIONS Although the efforts of further advancement of intrauterine prenatal MMC repair aim to increase neonatal outcomes, maternal health hazard will continue to be an issue of crucial importance and further studies are required.
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Affiliation(s)
- Maria Licci
- 1Department of Neurosurgery, University Hospital of Basel.,2Division of Pediatric Neurosurgery, Children's University Hospital of Basel; and
| | - Raphael Guzman
- 1Department of Neurosurgery, University Hospital of Basel.,2Division of Pediatric Neurosurgery, Children's University Hospital of Basel; and.,3Faculty of Medicine, University of Basel, Switzerland
| | - Jehuda Soleman
- 1Department of Neurosurgery, University Hospital of Basel.,2Division of Pediatric Neurosurgery, Children's University Hospital of Basel; and.,3Faculty of Medicine, University of Basel, Switzerland
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40
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Gotha L, Pruthi V, Abbasi N, Kulkarni AV, Church P, Drake JM, Carvalho JCA, Diambomba Y, Thakur V, Ryan G, Van Mieghem T. Fetal spina bifida: What we tell the parents. Prenat Diagn 2020; 40:1499-1507. [PMID: 32692418 DOI: 10.1002/pd.5802] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 06/08/2020] [Accepted: 07/19/2020] [Indexed: 12/20/2022]
Abstract
Worldwide, about 150 000 infants are born with spina bifida yearly, making this condition one of the most common fetal central nervous system anomalies compatible with life. Over the last decade, major changes have been introduced in the prenatal diagnosis and management of spina bifida. In this review, we provide a brief summary of the current management of fetal spina bifida and present essential information that should be provided to expecting parents when their fetus has been diagnosed with spina bifida. This information is focused around common parental questions, as encountered in our typical clinical practice, to facilitate knowledge translation.
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Affiliation(s)
- Lara Gotha
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Vagisha Pruthi
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada.,Ontario Fetal Centre, Toronto, Canada
| | - Nimrah Abbasi
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada.,Ontario Fetal Centre, Toronto, Canada
| | - Abhaya V Kulkarni
- Ontario Fetal Centre, Toronto, Canada.,Division of Neurosurgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Paige Church
- Department of Pediatrics, Sunnybrook Health Sciences Centre, Holland-Bloorview Kids Rehabilitation Hospital and University of Toronto, Toronto, Canada
| | - James M Drake
- Ontario Fetal Centre, Toronto, Canada.,Division of Neurosurgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Jose C A Carvalho
- Ontario Fetal Centre, Toronto, Canada.,Department of Anesthesia, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Yenge Diambomba
- Ontario Fetal Centre, Toronto, Canada.,Department of Pediatrics, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Varsha Thakur
- Ontario Fetal Centre, Toronto, Canada.,Department of Cardiology, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Greg Ryan
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada.,Ontario Fetal Centre, Toronto, Canada
| | - Tim Van Mieghem
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada.,Ontario Fetal Centre, Toronto, Canada
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41
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Narang K, Elrefaei A, Wyatt MA, Warner LL, Abrao Trad AT, Segura LG, Bendel-Stenzel E, Ahn ES, Arendt KW, Qureshi MY, Ruano R. Fetal Surgery in the Era of SARS-CoV-2 Pandemic: A Single-Institution Review. Mayo Clin Proc Innov Qual Outcomes 2020; 4:717-724. [PMID: 32839753 PMCID: PMC7437475 DOI: 10.1016/j.mayocpiqo.2020.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To cope with the changing health care services in the era of SARS-CoV-2 pandemic. We share the institutional framework for the management of anomalous fetuses requiring fetal intervention at Mayo Clinic, Rochester, Minnesota. To assess the success of our program during this time, we compare intraoperative outcomes of fetal interventions performed during the pandemic with the previous year. Patients We implemented our testing protocol on patients undergoing fetal intervention at our institution between March 1, and May 15, 2020, and we compared it with same period a year before. A total of 17 pregnant patients with anomalous fetuses who met criteria for fetal intervention were included: 8 from 2019 and 9 from 2020. Methods Our testing protocol was designed based on our institutional perinatal guidelines, surgical requirements from the infection prevention and control (IPAC) committee, and input from our fetal surgery team, with focus on urgency of procedure and maternal SARS-CoV-2 screening status. We compared the indications, types of procedures, maternal age, gestational age at procedure, type of anesthesia used, and duration of procedure for cases performed at our institution between March 1, 2020, and May 15, 2020, and for the same period in 2019. Results There were no statistically significant differences among the number of cases, indications, types of procedures, maternal age, gestational age, types of anesthesia, and duration of procedures (P values were all >.05) between the pre–SARS-CoV-2 pandemic in 2019 and the SARS-CoV-2 pandemic in 2020. Conclusions Adoption of new institutional protocols during SARS-CoV-2 pandemic, with appropriate screening and case selection, allows provision of necessary fetal intervention with maximal benefit to mother, fetus, and health care provider.
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Key Words
- ACOG, American College of Obstetrics and Gynecology
- AFPS, American Foundation for Patient Safety
- AGP, aerosol-generating procedures
- ASA, American Society of Anesthesiology
- CDH, congenital diaphragmatic hernia
- COVID-19, coronavirus-2019
- FETO, fetoscopic endoluminal tracheal occlusion
- GA, general anesthesia
- IFMSS, International Fetal Medicine and Surgery Society
- LUTO, lower urinary tract obstruction
- MAC, monitored anesthesia care
- NAFTNet, North American Fetal Therapy Network
- SMFM, Society for Maternal and Fetal Medicine
- TAPS, twin anemia polycythemia sequence
- TTTS, twin-to-twin transfusion syndrome
- WHO, World Health Organization
- qRT-PCR, quantitative real time polymerase chain reaction
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Affiliation(s)
- Kavita Narang
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN
| | - Amro Elrefaei
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN
| | - Michelle A Wyatt
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN
| | - Lindsay L Warner
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Ayssa Teles Abrao Trad
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN
| | - Leal G Segura
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Ellen Bendel-Stenzel
- Division of Neonatology, Department of Pediatrics and Adolescent medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Edward S Ahn
- Division of Neurosurgery, Department of Pediatrics and Adolescent medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Katherine W Arendt
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN
| | - M Yasir Qureshi
- Pediatric Cardiology Division, Department of Pediatrics and Adolescent medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Rodrigo Ruano
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN
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42
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Weiner HL, Adelson PD, Brockmeyer DL, Maher CO, Gupta N, Smyth MD, Jea A, Blount JP, Riva-Cambrin J, Lam SK, Ahn ES, Albert GW, Leonard JR. Prenatal counseling for myelomeningocele in the era of fetal surgery: a shared decision-making approach. J Neurosurg Pediatr 2020; 25:640-647. [PMID: 32109872 PMCID: PMC7164397 DOI: 10.3171/2019.12.peds19449] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 12/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Management of Myelomeningocele Study demonstrated that fetal surgery, as compared to postnatal repair, decreases the rate of hydrocephalus and improves expected motor function. However, fetal surgery is associated with significant maternal and neonatal risks including uterine wall dehiscence, prematurity, and fetal or neonatal death. The goal of this study was to provide information about counseling expectant mothers regarding myelomeningocele in the era of fetal surgery. METHODS The authors conducted an extensive review of topics pertinent to counseling in the setting of myelomeningocele and introduce a new model for shared decision-making to aid practitioners during counseling. RESULTS Expectant mothers must decide in a timely manner among several potential options, namely termination of pregnancy, postnatal surgery, or fetal surgery. Multiple factors influence the decision, including maternal health, fetal heath, financial resources, social support, risk aversion, access to care, family planning, and values. In many cases, it is a difficult decision that benefits from the guidance of a pediatric neurosurgeon. CONCLUSIONS The authors review critical issues of prenatal counseling for myelomeningocele and discuss the process of shared decision-making as a framework to aid expectant mothers in choosing the treatment option best for them.
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Affiliation(s)
- Howard L. Weiner
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - P. David Adelson
- Department of Neurosurgery, Barrow Neurological Institute at Phoenix Children’s Hospital, University of Arizona College of Medicine, Phoenix, Arizona
| | - Douglas L. Brockmeyer
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah
| | - Cormac O. Maher
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan
| | - Nalin Gupta
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, UCSF Benioff Children’s Hospital, University of California, San Francisco, California
| | - Matthew D. Smyth
- Department of Neurological Surgery, Division of Pediatric Neurological Surgery, St. Louis Children’s Hospital, Washington University School of Medicine in St. Louis, Missouri
| | - Andrew Jea
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jeffrey P. Blount
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Children’s of Alabama, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Alberta, Canada
| | - Sandi K. Lam
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Edward S. Ahn
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Children’s Center, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Gregory W. Albert
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Arkansas Children’s Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and
| | - Jeffrey R. Leonard
- Department of Neurological Surgery, Section of Neurosurgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, Ohio
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Mazzone L, Moehrlen U, Ochsenbein-Kölble N, Pontiggia L, Biedermann T, Reichmann E, Meuli M. Bioengineering and in utero transplantation of fetal skin in the sheep model: A crucial step towards clinical application in human fetal spina bifida repair. J Tissue Eng Regen Med 2019; 14:58-65. [PMID: 31595702 DOI: 10.1002/term.2963] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 08/02/2019] [Accepted: 09/05/2019] [Indexed: 11/09/2022]
Abstract
An intricate problem during open human fetal surgery for spina bifida regards back skin closure, particularly in those cases where the skin defect is much too large for primary closure. We hypothesize that tissue engineering of fetal skin might provide an adequate autologous skin substitute for in utero application in such situations. Eight sheep fetuses of four time-mated ewes underwent fetoscopic skin biopsy at 65 days of gestation. Fibroblasts and keratinocytes isolated from the biopsy were used to create fetal dermo-epidermal skin substitutes. These were transplanted on the fetuses by open fetal surgery at 90 days of gestation on skin defects (excisional wounds) created during the same procedure. Pregnancy was allowed to continue until euthanasia at 120 days of gestation. The graft area was analyzed macroscopically and microscopically. The transplanted fetal dermo-epidermal skin substitutes was well discernable in situ in three of the four fetuses available for analysis. Histology confirmed healed grafts with a close to natural histological skin architecture four weeks after in utero transplantation. This experimental study generates evidence that laboratory grown autologous fetal skin analogues can successfully be transplanted in utero. These results have clinical implications as an analogous procedure might be applied in human fetuses undergoing prenatal repair to facilitate primary skin closure. Finally, this study may also fertilize the field of fetal tissue engineering in general, particularly when more interventional, minimally invasive, and open fetal surgical procedures become available.
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Affiliation(s)
- Luca Mazzone
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Zurich Center for Fetal Diagnosis and Treatment, Zurich, Switzerland.,Tissue Biology Research Unit, Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ueli Moehrlen
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Zurich Center for Fetal Diagnosis and Treatment, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Nicole Ochsenbein-Kölble
- Zurich Center for Fetal Diagnosis and Treatment, Zurich, Switzerland.,Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Luca Pontiggia
- Tissue Biology Research Unit, Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Thomas Biedermann
- Tissue Biology Research Unit, Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ernst Reichmann
- Tissue Biology Research Unit, Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Martin Meuli
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Zurich Center for Fetal Diagnosis and Treatment, Zurich, Switzerland.,Tissue Biology Research Unit, Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
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44
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Chmait RH, Kontopoulos EV, Quintero RA. Uterine legacy of open maternal-fetal surgery: preterm uterine rupture. Am J Obstet Gynecol 2019; 221:535. [PMID: 31351066 DOI: 10.1016/j.ajog.2019.07.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/18/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Ramen H Chmait
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA; The USFetus Research Consortium.
| | - Eftichia V Kontopoulos
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL; The USFetus Research Consortium
| | - Rubén A Quintero
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL; The USFetus Research Consortium
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45
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Abstract
Myelomeningocele is a congenital malformation that causes a spectrum of morbidity. With the standard of care now being in utero repair, the spectrum of morbidity has changed. The purpose of this article is to review the diagnosis, workup and treatment options of fetal myelomeningocele. We also review the obstetrical, neurological, gastrointestinal, urinary, and orthopedic outcomes of the in utero myelomeningocele repair.
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Affiliation(s)
- Kaeli J Yamashiro
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA 95817, USA.
| | - Laura A Galganski
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA 95817, USA
| | - Shinjiro Hirose
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA 95817, USA
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46
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Abstract
Ex Utero Intrapartum Treatment (EXIT) is a technique developed to safely and efficiently establish cardiopulmonary support at delivery while maintaining placental bypass. Indications for the EXIT approach are expanding and currently include EXIT-to-airway, EXIT-to-resection, EXIT-to-extracorporeal membrane oxygenation (ECMO), and EXIT-to-separation of conjoined twins. The EXIT technique involves planned partial delivery of the fetus via hysterotomy while maintaining uterine relaxation and placental support, allowing for the establishment of neonatal cardiopulmonary stability in a controlled manner. Fetal interventions performed during EXIT can include endotracheal intubation, tracheostomy, mass excision, removal of a temporary tracheal occlusive device, ECMO cannulation, and others. The most important aspect of an EXIT procedure is the formation of a multi-disciplinary team with broad expertise in fetal intervention to collaborate throughout the pre, intra, and post-partum periods. This chapter reviews the prenatal workup, decision making, surgical indications, and operative considerations associated with EXIT procedures.
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Affiliation(s)
- Christina M Bence
- Children's Hospital of Wisconsin, Medical College of Wisconsin, 999 N. 92nd Street, Suite 320, Milwaukee, WI 53226, USA
| | - Amy J Wagner
- Children's Hospital of Wisconsin, Medical College of Wisconsin, 999 N. 92nd Street, Suite 320, Milwaukee, WI 53226, USA.
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