The Impact of Prenatal Diagnosis of Selected Central Nervous System Anomalies for Prenatal Counselling Based on Significant Pregnancy Morbidity and Neonatal Outcomes

Ten-year review of neonatal neurosurgical outcomes and cost analysis

Background

Neurosurgical interventions in neonates may contribute to increased neonatal intensive care unit (NICU) stay. The impact of neurosurgical interventions on length of stay (LOS) and cost is not well-documented in the literature. In addition to LOS, other factors may impact overall resource utilization. Our objective was to perform a cost analysis of neonates who underwent neurosurgical procedures.

Methods

A retrospective chart review was performed on NICU patients who underwent ventriculoperitoneal and/or subgaleal shunt placement between January 1, 2010, and April 30, 2021. Postoperative outcomes were analyzed, including LOS, revisions, infections, emergency department (ED) visits following discharge, and readmissions accounting for health care utilization cost.

Results

Sixty-six neonates underwent shunt placement during our study period. Out of our 66 patients, 40% of infants had intraventricular hemorrhage (IVH). About 81% had hydrocephalus. Specific diagnoses for our patient population varied and included: 37.9% of patients had IVH complicated by posthemorrhagic hydrocephalus, 27.3% had Chiari II malformation, 9.1% had a cystic malformation leading to hydrocephalus, 7.5% had solely hydrocephalus or ventriculomegaly, 6.0% had myelomeningocele, 4.5% had Dandy-Walker malformation, 3.0% had aqueductal stenosis, and the remaining 4.5% had varying other pathologies. In our patient population, 11% of patients had an identified or suspected infection within 30 days after surgery. The average LOS was 59 days versus 67 days for patients with a postoperative infection. Number of patients who visited the ED within 30 days of discharge was 21%. Of these ED visits, 57% led to readmission. Complete cost analysis was available for 35 out of 66 patients. The average LOS was 63 days with average cost of admission of $209,703.43. Average cost for readmission was $25,757.02. Average daily cost for neurosurgical patients was $1,672.98 versus $1,298.17 for all NICU patients.

Conclusion

Neonates who underwent neurosurgical procedures had longer LOS as well as higher daily cost. LOS for infants with infections following procedures was increased by 10.6%. Further research is needed to optimize health-care utilization for these high-risk neonates.

Ethical and Legal Dilemmas Around Termination of Pregnancy for Severe Fetal Hydrocephalus, Spina Bifida Aperta and Meningomyelocoella

Introduction:

There are many ethical and moral dilemmas regarding the termination of pregnancy(TOP) with severe fetal anomalies.

Aim:

Our aim is to present a case of severe fetal hydrocephalus (HCP), spina bifida aperta and, meningomyelocoella (MMC).

Case report:

A gynecologist examined a 23-year-old patient with vital pregnancy of 24/25 week of gestation (WG) with the anomaly of the fetus. At the Perinatological Medical Advisory Board, a decision was made that the pregnancy should be continued and monitored bearing in mind that pregnancy exceeded the legal framework for TOP. Medical Advisory Board’s ultrasound examination showed the following: severe hydrocephalus (HCP), spina bifida aperta, hyperehogen intestine, pes equinovarus. Via multidisciplinary consultation it was decided to make a delivery with the elective caesarian section (CS) causing as little trauma to the fetus as possible, with 37 WG completed due to the pelvic presentation and fetal anomalies. The patient gave birth via CS to a live female newborn–birth weight 3920 grams, birth length 56 cm, head circumference 48 cm, and Apgar score 8/8. The head was hydrocephalic with spaced suture. There was thoracolumbar defect of spina bifida aperta and meningomyelocele (MMC) 10x12 cm in size. An urgent surgical procedure - the external ventricular derivation of the liquor, and then the successful resection and plastic meningomyelocele was performed by a team of neuro and plastic surgeons. During the fourth postoperative day due to a suspicion of abscess collection and febrility of the mother a relaparotomy is performed and the abscess collection of Retzius space was found. Due to the fall in blood count, blood transfusion in a total dose of 580 ml was given. The patient was discharged on a home treatment as she had a regular general and local status. After the surgery, the condition of the newborn resulted in deterioration, the progression of HCP and dehiscence of head wounds and the thoracolumbar region, in spite of all the measures taken. At that time a decision was made to provide palliative care and this decision was conveyed to the mother. The child had a prolonged apnoeic episode and was not resuscitated. The child died in hospital after surviving for two months postpartum.

Conclusion:

Indication of TOP based on fetal anomalies could be a medical decision but also a personal moral choice of the mother related to legal rules, socio-cultural values and religious beliefs.

Validation of a semiautomated volumetric approach for fetal neurosonography using 5DCNS+ in clinical data from > 1100 consecutive pregnancies

OBJECTIVE

The aim of this study was to evaluate the validity of a semiautomated volumetric approach (5DCNS+) for the detailed assessment of the fetal brain in a clinical setting.

METHODS

Stored 3D volumes of > 1100 consecutive 2nd and 3rd trimester pregnancies (range 15-36 gestational weeks) were analyzed using a workflow-based volumetric approach 5DCNS+, enabling semiautomated reconstruction of diagnostic planes of the fetal central nervous system (CNS). All 3D data sets were examined for plane accuracy, the need for manual adjustment, and fetal-maternal characteristics affecting successful plane reconstruction. We also examined the potential of these standardized views to give additional information on proper gyration and sulci formation with advancing gestation.

RESULTS

Based on our data, we were able to show that gestational age with an OR of 1.085 (95% CI 1.041-1.132) and maternal BMI with an OR of 1.022 (95% CI 1.041-1.054) only had a slight impact on the number of manual adjustments needed to reconstruct the complete volume, while maternal age and fetal position during acquisition (p = 0.260) did not have a significant effect. For the vast majority (958/1019; 94%) of volumes, using 5DCNS+ resulted in proper reconstruction of all nine diagnostic planes. In less than 1% (89/9171 planes) of volumes, the program failed to give sufficient information. 5DCNS+ was able to show the onset and changing appearance of CNS folding in a detailed and timely manner (lateral/parietooccipital sulcus formation seen in < 65% at 16-17 gestational weeks vs. 94.6% at 19 weeks).

CONCLUSIONS

The 5DCNS+ method provides a reliable algorithm to produce detailed, 3D volume-based assessments of fetal CNS integrity through a standardized reconstruction of the orthogonal diagnostic planes. The method further gives valid and reproducible information regarding ongoing cortical development retrieved from these volume sets that might aid in earlier in utero recognition of subtle structural CNS anomalies.