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Guilbaud L, Carreras E, Garel C, Maiz N, Dhombres F, Deprest J, Jouannic JM. Proposal for standardized prenatal assessment of fetal open dysraphisms by the European reference network for Intellectual disability, TeleHealth, Autism and Congenital Anomalies (ITHACA) and eUROGEN. Prenat Diagn 2024; 44:1073-1087. [PMID: 38898590 DOI: 10.1002/pd.6618] [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: 01/24/2024] [Revised: 05/14/2024] [Accepted: 05/29/2024] [Indexed: 06/21/2024]
Abstract
Open dysraphisms, that is, myelomeningocele and myeloschisis, are rare diseases associated with a risk of severe disability, including lower limb motor and sensory deficiency, sphincter deficiency, and potential intellectual deficiency. Open dysraphism is diagnosed in Europe in 93.5% of cases. In case of suspicion of fetal open dysraphism, a detailed fetal morphologic assessment is required to confirm the diagnosis and exclude associated structural anomalies, as well as genetic assessment. In case of isolated fetal open dysraphism, assessment of prognosis is based on fetal imaging including the level of the lesion, the presence or not of a sac, the presence and nature of intra cranial anomalies, and the anatomical and functional evaluation of the lower extremities. Based on these biomarkers, a personalized prognosis as well as comprehensive information about prenatal management alternatives will allow parents to decide on further management options. Standardization of prenatal assessment is essential to compare outcomes with benchmark data and make assessment of surgical innovation possible. Herein, we propose a protocol for the standardized ultrasound assessment of fetuses with isolated open dysraphism.
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Affiliation(s)
- Lucie Guilbaud
- Fetal Medicine Department, Armand Trousseau University Hospital, Spin@ Reference Center, Sorbonne University, Paris, France
| | - Elena Carreras
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Catherine Garel
- Pediatric Radiology Department, Armand Trousseau University Hospital, Sorbonne University, Paris, France
| | - Nerea Maiz
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ferdinand Dhombres
- Fetal Medicine Department, Armand Trousseau University Hospital, Spin@ Reference Center, Sorbonne University, Paris, France
| | - Jan Deprest
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Institute of Women's Health, University College London, London, UK
| | - Jean-Marie Jouannic
- Fetal Medicine Department, Armand Trousseau University Hospital, Spin@ Reference Center, Sorbonne University, Paris, France
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Talamonti G. Reflections upon the intrauterine repair of myelomeningocele. Childs Nerv Syst 2024; 40:1571-1575. [PMID: 38514517 DOI: 10.1007/s00381-024-06365-0] [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: 02/19/2024] [Accepted: 03/12/2024] [Indexed: 03/23/2024]
Abstract
The intrauterine repair of myelomeningocele presents certain advantages and has gained widespread acceptance. It significantly reduces the incidence of Chiari-2 anomalies and hydrocephalus, and it is thought to enhance the neurologic outcome. Nevertheless, several issues remain unsettled and there are no negligible disadvantages. After working with patients with myelomeningocele for 30 years, I thought about how we currently treat them. There are ethical, organizational, neurological, obstetrical, and postnatal aspects worth discussing.
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Affiliation(s)
- Giuseppe Talamonti
- Dep. of Neurosurgery, ASST Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
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Athiel Y, Jouannic JM, Mauffré V, Dehan C, Adam C, Blot S, Lallemant P, De Saint Denis T, Larghero J, Nasone J, Guilbaud L. Allogenic umbilical cord-derived mesenchymal stromal cells improve motor function in prenatal surgical repair of myelomeningocele: An ovine model study. BJOG 2024; 131:759-767. [PMID: 37492999 DOI: 10.1111/1471-0528.17624] [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: 03/30/2023] [Revised: 07/05/2023] [Accepted: 07/11/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVE To investigate the effects of an adjuvant allogenic umbilical cord mesenchymal stromal cell (UC-MSC) patch applied during fetal surgery on motor and sphincter function in the ovine MMC model. DESIGN MMC defects were surgically created at 75 days of gestation and repaired 14 days later. POPULATION Ovine MMC model: fetal lambs. METHODS We compared lambs that received a UC-MSC patch with a control group of lambs that received an acellular patch. MAIN OUTCOME MEASURES Clinical neurological assessment was performed at 2 and 24 hours of life and included determination of the Sheep Locomotor Rating scale (SLR), which has been validated in the ovine MMC model. Electrophysical examinations, spine scans and histological analyses were also performed. RESULTS Of the 13 operated lambs, nine were born alive: five had of these had received a UC-MSC patch and four an acellular patch. At 24 hours of life, lambs in the UC-MSC group had a significantly higher score (14 versus 5, P = 0.04). Amyotrophy was significantly more common in the control group (75% versus 0%, P = 0.02). All the lambs in the control group and none of those in the UC-MSC group were incontinent. No significant differences were observed between the UC-MSC and control groups in terms of the presence of spontaneous EMG activity, nerve conduction or spinal evoked potentials. In the microscopic examination, lambs in the UC-MSC group had less fibrosis between the spinal cord and the dermis (mean thickness, 453 versus 3921 μm, P = 0.03) and around the spinal cord (mean thickness, 47 versus 158 μm, P < 0.001). Examination of the spinal cord in the area of the MMC defect showed a higher large neuron density in the UC-MSC group (14.5 versus 5.6 neurons/mm2, P < 0.001). No tumours were observed. CONCLUSIONS Fetal repair of MMC using UC-MSC patches improves motor and sphincter function as well as spinal preservation and reduction of fibrosis.
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Affiliation(s)
- Yoann Athiel
- Université Paris Cité, INSERM, U976 et Centre d'Investigation Clinique en Biothérapies CIC-BT CBT501, INSERM, Paris, France
- Service de médecine fœtale, APHP, Hôpital Trousseau, DMU ORIGYNE, Sorbonne Université, Paris, France
| | - Jean-Marie Jouannic
- Université Paris Cité, INSERM, U976 et Centre d'Investigation Clinique en Biothérapies CIC-BT CBT501, INSERM, Paris, France
- Service de médecine fœtale, APHP, Hôpital Trousseau, DMU ORIGYNE, Sorbonne Université, Paris, France
- Working Group Spina Bifida and Other Dysraphisms, European Reference Network ITHACA, Paris, France
| | - Vincent Mauffré
- Université Paris-Saclay, UVSQ, INRAE, BREED, Jouy-en-Josas, France
- École Nationale Vétérinaire d'Alfort, BREED, Maison-Alfort, France
| | - Coralie Dehan
- Université Paris-Saclay, UVSQ, INRAE, BREED, Jouy-en-Josas, France
- École Nationale Vétérinaire d'Alfort, BREED, Maison-Alfort, France
| | - Clovis Adam
- Service d'anatomopathologie, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | - Stéphane Blot
- U955-IMRB, Inserm, École Nationale Vétérinaire d'Alfort, Unité de Neurologie, Maisons-Alfort, France
| | - Pauline Lallemant
- National Reference Center for Rare Disease: Vertebral and Spinal Cord Anomalies (MAVEM Center), AP-HP, Trousseau Hospital, Paris, France
- Sorbonne University, AP-HP, Trousseau Hospital, Paris, France
| | - Timothé De Saint Denis
- Service de Neurochirurgie Pédiatrique, Centre de Référence Chiari, Syringomyélie et Malformations du Rachis et de la Moelle C-MAVEM, et Centre de Référence des Malformations Craniofaciales-CRMR, Paris, France
| | - Jérôme Larghero
- Université Paris Cité, INSERM, U976 et Centre d'Investigation Clinique en Biothérapies CIC-BT CBT501, INSERM, Paris, France
- Unité de Thérapie Cellulaire et Centre MEARY de Thérapie Cellulaire et Génique, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Justine Nasone
- Université Paris Cité, INSERM, U976 et Centre d'Investigation Clinique en Biothérapies CIC-BT CBT501, INSERM, Paris, France
- Unité de Thérapie Cellulaire et Centre MEARY de Thérapie Cellulaire et Génique, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Lucie Guilbaud
- Université Paris Cité, INSERM, U976 et Centre d'Investigation Clinique en Biothérapies CIC-BT CBT501, INSERM, Paris, France
- Service de médecine fœtale, APHP, Hôpital Trousseau, DMU ORIGYNE, Sorbonne Université, Paris, France
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Zepf J, Vonzun L, Rüegg L, Strübing N, Krähenmann F, Meuli M, Mazzone L, Moehrlen U, Ochsenbein-Kölble N. Fetal Spina Bifida Repair in Obese Mothers: Is Maternal and Fetal Safety Compromised? Fetal Diagn Ther 2024; 51:175-183. [PMID: 38190813 PMCID: PMC10994580 DOI: 10.1159/000536071] [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: 08/02/2023] [Accepted: 12/20/2023] [Indexed: 01/10/2024]
Abstract
INTRODUCTION The Management of Myelomeningocele Study (MOMS) eligibility criteria preclude in utero surgery for fetal spina bifida (fSB) when the maternal body mass index (BMI) is ≥35 kg/m2. Some centers still respect this criterion, while others, like ours, do not. This study aimed to assess whether maternal and fetal safety is compromised with higher maternal BMIs. METHODS Data of 192 patients with open fSB repair at our center were retrospectively analyzed. According to their BMI, patients were divided into three groups: group 1 (BMI <30 kg/m2), group 2 (BMI 30-35 kg/m2), and group 3 (BMI >35 kg/m2). Subgroup analysis was performed to assess differences in maternal and fetal outcomes. Additionally, complications were divided into grades 1 to 5 according to their severity and outcome consequences and compared among groups. RESULTS Out of 192 patients, 146 (76.0%) had a BMI <30 kg/m2, 28 (14.6%) had a BMI 30-35 kg/m2, and 18 (9.4%) had a BMI >35 kg/m2. Significant differences occurring more often in either group 2 or 3 compared to group 1 were maternal wound seroma (50% or 56% vs. 32%, p = 0.04), amniotic fluid leakage (14% or 6% vs. 2%, p = 0.01) as well as vaginal bleeding (11% or 35% vs. 9%, p = 0.01). On the contrary, duration of tocolysis with atosiban was shorter in patients with BMI >30 kg/m2 (4 or 5 vs. 6 days, p = 0.01). When comparing severity of maternal or fetal complications, grade 1 intervention-related complications occurred significantly more often in group 3 compared to group 1 or 2 (78% vs. 45% or 57%, p = 0.02). Gestational age at delivery was around 36 weeks in all groups without significant differences. CONCLUSION This investigation did not identify clinically relevant maternal and/or fetal outcome problems related to BMIs >35 kg/m2. Additional studies are however needed to confirm our results.
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Affiliation(s)
- Julia Zepf
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
| | - Ladina Vonzun
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Ladina Rüegg
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
| | - Nele Strübing
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Franziska Krähenmann
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Martin Meuli
- University of Zurich, Zurich, Switzerland
- Department of Pediatric Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Spina Bifida Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Luca Mazzone
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- Department of Pediatric Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Spina Bifida Center, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Ueli Moehrlen
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- Department of Pediatric Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Spina Bifida Center, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Nicole Ochsenbein-Kölble
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Spina Bifida Study Group Zurich
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- The Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- Department of Pediatric Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Spina Bifida Center, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
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Pontell ME, Yengo-Kahn AM, Taylor E, Kane M, Newton JM, Bennett KA, Wellons JC, Braun SA. Intrauterine closure of myelomeningocele defects with primary linear repair versus bipedicle fasciocutaneous flaps: a post-MOMS cohort study with long-term follow-up. J Neurosurg Pediatr 2023; 31:143-150. [PMID: 36433869 DOI: 10.3171/2022.10.peds22357] [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: 08/17/2022] [Accepted: 10/21/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to determine the effects of in utero bipedicle flaps on maternal-fetal morbidity/mortality, the need for CSF diversion, and long-term functional outcomes. METHODS Eighty-six patients who underwent fetal myelomeningocele repair from 2011 to 2021 at a single institution were reviewed. Primary outcomes included intrauterine fetal demise, postnatal death, postnatal myelomeningocele repair dehiscence, and CSF diversion by final follow-up. RESULTS The cohorts were no different with regard to race, ethnicity, maternal age at fetal surgery, body mass index, gravidity, parity, gestational age at fetal surgery, estimated fetal weight at fetal surgery, or fetal lesion level. Of the 86 patients, 64 underwent primary linear repair and 22 underwent bipedicle flap repair. There were no significant differences in rates of intrauterine fetal demise, postnatal mortality, midline repair site dehiscence, or the need for CSF diversion by final follow-up. Operative times were longer (32.5 vs 18.7 minutes, p < 0.001) and gestational age at delivery was lower (232 vs 241 days, p = 0.01) in the bipedicle flap cohort, but long-term functional outcomes were not different. CONCLUSIONS Analysis of the total cohort affirms the long-term benefits of fetal myelomeningocele repair. In utero bipedicle flaps are safe and can be used for high-tension lesions without increasing perioperative risks to the mother or fetus. In utero flaps preserve the long-term benefits seen with primary linear repair and may expand inclusion criteria for fetal repair, providing life-changing care for more patients.
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Affiliation(s)
| | | | - Emily Taylor
- 3The Fetal Center at Vanderbilt, Vanderbilt University Medical Center, Nashville
| | - Morgan Kane
- 4Pediatric Rehabilitation Services, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
| | - J Michael Newton
- 3The Fetal Center at Vanderbilt, Vanderbilt University Medical Center, Nashville
- 5Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville
| | - Kelly A Bennett
- 3The Fetal Center at Vanderbilt, Vanderbilt University Medical Center, Nashville
- 5Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville
| | - John C Wellons
- 1Departments of Plastic Surgery
- 3The Fetal Center at Vanderbilt, Vanderbilt University Medical Center, Nashville
- 6The Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville; and
- 7Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Stephane A Braun
- 1Departments of Plastic Surgery
- 3The Fetal Center at Vanderbilt, Vanderbilt University Medical Center, Nashville
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Thompson DNP, De Vloo P, Deprest J. Fetal Surgery for Myelomeningocele: Neurosurgical Perspectives. Adv Tech Stand Neurosurg 2023; 47:25-48. [PMID: 37640871 DOI: 10.1007/978-3-031-34981-2_2] [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] [Indexed: 08/31/2023]
Abstract
More than 30 years have elapsed since it was recognised that folic acid supplementation could substantially reduce the risk of open neural tube defects (ONTDs). During that time, many countries have adopted policies of food fortification with demonstrable reduction in the incidence of both cranial and spinal ONTDs. Improved prenatal detection and termination has also resulted in a reduction in the number of affected live births. Nonetheless, in the USA about 1500 children, and in the UK around 500 children are born each year with myelomeningocele (MMC) and so the management of MMC and its complications continues to constitute a significant clinical workload for many paediatric neurosurgical units around the world.Until recently, the options available following antenatal diagnosis of MMC were termination of pregnancy or postnatal repair. As a result of the MOMS trial, prenatal repair has become an additional option in selected cases (Adzick et al., N Engl J Med 364(11):993-1004, 2011). Fetal surgery for myelomeningocele is now offered in more than 30 centres worldwide. The aim of this chapter is to review the experimental basis of prenatal repair of MMC, to critically evaluate the neurosurgical implications of this intervention and to describe the technique of 'open' repair, comparing this with emerging minimally invasive alternatives.
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Affiliation(s)
- Dominic N P Thompson
- Department of Pediatric Neurosurgery, Great Ormond Street Hospital for Children NHS Trust, London, UK.
| | | | - Jan Deprest
- Department of Obstetrics and Gynaecology, UZ Leuven, Leuven, Belgium
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Are Cervical Length and Fibronectin Predictors of Preterm Birth after Fetal Spina Bifida Repair? A Single Center Cohort Study. J Clin Med 2022; 12:jcm12010123. [PMID: 36614924 PMCID: PMC9821246 DOI: 10.3390/jcm12010123] [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: 11/21/2022] [Revised: 12/11/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022] Open
Abstract
Background: A remaining risk of fetal spina bifida (fSB) repair is preterm delivery. This study assessed the value of preoperative cervical length (CL), CL dynamics (∆CL) and fetal fibronectin (fFN) tests to predict obstetric complications and length of stay (LOS) around fSB repair. Methods: 134 patients were included in this study. All patients had CL measurement and fFN testing before fSB repair. ∆CL within the first 14 days after intervention and until discharge after fSB repair were compared in groups (∆CL ≥ 10 mm/<10 mm; ≥20 mm/<20 mm). CL before surgery, ∆CL’s, and positive fFN tests were correlated to obstetric complications and LOS. Results: Mean CL before surgery was 41 ± 7 mm. Mean GA at birth was 35.4 ± 2.2 weeks. In the group of ∆CL ≥ 10 mm within the first 14 days after intervention, LOS was significantly longer (p = 0.02). ∆CL ≥ 10 mm until discharge after fSB was associated with a significantly higher rate of GA at birth <34 weeks (p = 0.03). The 3 positive fFN tests before fSB repair showed no correlation with GA at birth. Conclusion: Perioperative ∆CL influences LOS after fetal surgery. ∆CL ≥ 10 mm until discharge after fSB repair has a 3-times higher rate of preterm delivery before 34 weeks. Preoperative fFN testing showed no predictive value for preterm birth after fSB repair and was stopped.
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Athiel Y, Jouannic JM, Guilbaud L. [Surgical experimental protocol of fetal myelomeningocele creation and repair in the ovine model (with video)]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:744-745. [PMID: 35940530 DOI: 10.1016/j.gofs.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/06/2022] [Accepted: 07/27/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Y Athiel
- Service de médecine fœtale, Hôpital Trousseau, Sorbonne Université, APHP, Paris, France; Unité de Thérapie Cellulaire, Biotechnologie des cellules souches, Unité Inserm 976, Paris, France.
| | - J-M Jouannic
- Service de médecine fœtale, Hôpital Trousseau, Sorbonne Université, APHP, Paris, France
| | - L Guilbaud
- Service de médecine fœtale, Hôpital Trousseau, Sorbonne Université, APHP, Paris, France; Unité de Thérapie Cellulaire, Biotechnologie des cellules souches, Unité Inserm 976, Paris, France
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Duci M, Pulvirenti R, Fascetti Leon F, Capolupo I, Veronese P, Gamba P, Tognon C. Anesthesia for fetal operative procedures: A systematic review. FRONTIERS IN PAIN RESEARCH 2022; 3:935427. [PMID: 36246050 PMCID: PMC9554945 DOI: 10.3389/fpain.2022.935427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe anesthetic management of fetal operative procedures (FOP) is a highly debated topic. Literature on fetal pain perception and response to external stimuli is rapidly expanding. Nonetheless, there is no consensus on the fetal consciousness nor on the instruments to measure pain levels. As a result, no guidelines or clinical recommendations on anesthesia modality during FOP are available. This systematic literature review aimed to collect the available knowledge on the most common fetal interventions, and summarize the reported outcomes for each anesthetic approach. Additional aim was to provide an overall evaluation of the most commonly used anesthetic agents.MethodsTwo systematic literature searches were performed in Embase, Medline, Web of Science Core Collection and Cochrane Central Register of Controlled Trials up to December 2021. To best cover the available evidence, one literature search was mostly focused on fetal surgical procedures; while anesthesia during FOP was the main target for the second search. The following fetal procedures were included: fetal transfusion, laser ablation of placental anastomosis, twin-reversed arterial perfusion treatment, fetoscopic endoluminal tracheal occlusion, thoraco-amniotic shunt, vesico-amniotic shunt, myelomeningocele repair, resection of sacrococcygeal teratoma, ligation of amniotic bands, balloon valvuloplasty/septoplasty, ex-utero intrapartum treatment, and ovarian cyst resection/aspiration. Yielded articles were screened against the same inclusion criteria. Studies reporting anesthesia details and procedures’ outcomes were considered. Descriptive statistical analysis was performed and findings were reported in a narrative manner.ResultsThe literature searches yielded 1,679 articles, with 429 being selected for full-text evaluation. A total of 168 articles were included. Overall, no significant differences were found among procedures performed under maternal anesthesia or maternal-fetal anesthesia. Procedures requiring invasive fetal manipulation resulted to be more effective when performed under maternal anesthesia only. Based on the available data, a wide range of anesthetic agents are currently deployed and no consistency has been found neither between centers nor procedures.ConclusionsThis systematic review shows great variance in the anesthetic management during FOP. Further studies, systematically reporting intraoperative fetal monitoring and fetal hormonal responses to external stimuli, are necessary to identify the best anesthetic approach. Additional investigations on pain pathways and fetal pain perception are advisable.
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Affiliation(s)
- Miriam Duci
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Rebecca Pulvirenti
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Francesco Fascetti Leon
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
- Correspondence: Francesco Fascetti Leon
| | - Irma Capolupo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Paola Veronese
- Maternal-fetal Medicine Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Piergiorgio Gamba
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Costanza Tognon
- Anesthesiology Pediatric Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
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Athiel Y, Nasone J, Arakelian L, Faivre L, Dugas A, Jouannic JM, Larghero J, Guilbaud L. Biodistribution of allogenic umbilical cord-derived mesenchymal stromal cells after fetal repair of myelomeningocele in an ovine model. Stem Cell Res Ther 2022; 13:300. [PMID: 35841029 PMCID: PMC9284777 DOI: 10.1186/s13287-022-02991-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 06/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background Myelomeningocele (MMC) is a spinal cord congenital defect that leads to paraplegia, sphincter disorders and potential neurocognitive disabilities. Prenatal surgery of MMC provides a significant benefit compared to surgery at birth. Mesenchymal stromal cell (MSC) therapy as an adjuvant treatment for prenatal surgery showed promising results in animal experiments which could be considered for clinical use in human fetuses. Despite numerous reassuring studies on the safety of MSCs administration in humans, no study focused on MSCs biodistribution after a local MSCs graft on the fetal spinal cord. Aim The purpose of our study was to assess the biodistribution of umbilical cord-derived mesenchymal stromal cells (UC-MSCs) at birth in lambs who had a prenatal myelomeningocele repair using a fibrin patch seeded with allogenic UC-MSCs. Methods After isolation, UC-MSCs were tagged using a green fluorescent protein (GFP)-containing lentiviral vector. MMC defects were surgically created at 75 days of gestation and repaired 15 days later using UC-MSCs patch. Lambs were delivered at 142 days and sacrificed. DNA extraction was performed among biopsies of the different organs and q-PCR analysis was used to detect the expression of GFP (GFP DNA coding sequence). Results In our 6 surviving lambs grafted with UC-MSCs, GFP lentivirus genomic DNA was not detected in the organs. Conclusion These reassuring data will support translational application in humans, especially since the first human clinical trial using mesenchymal stromal cells for in-utero treatment of MMC started recently in U.S.A.
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Affiliation(s)
- Yoann Athiel
- Stem Cell Biotechnologies, U976 et Centre d'Investigation Clinique en Biothérapies CIC-BT CBT501, INSERM, Paris, France.,Department of Fetal Medicine, APHP, Trousseau Hospital, DMU ORIGYNE, Sorbonne University, Paris, France
| | - Justine Nasone
- Stem Cell Biotechnologies, U976 et Centre d'Investigation Clinique en Biothérapies CIC-BT CBT501, INSERM, Paris, France.,Unité de Thérapie Cellulaire et Centre MEARY de Thérapie Cellulaire et Génique, Saint Louis Hospital, Université Paris Cité, Paris, France
| | - Lousineh Arakelian
- Stem Cell Biotechnologies, U976 et Centre d'Investigation Clinique en Biothérapies CIC-BT CBT501, INSERM, Paris, France
| | - Lionel Faivre
- Stem Cell Biotechnologies, U976 et Centre d'Investigation Clinique en Biothérapies CIC-BT CBT501, INSERM, Paris, France.,Unité de Thérapie Cellulaire et Centre MEARY de Thérapie Cellulaire et Génique, Saint Louis Hospital, Université Paris Cité, Paris, France
| | - Anaïs Dugas
- Stem Cell Biotechnologies, U976 et Centre d'Investigation Clinique en Biothérapies CIC-BT CBT501, INSERM, Paris, France.,Department of Fetal Medicine, APHP, Trousseau Hospital, DMU ORIGYNE, Sorbonne University, Paris, France
| | - Jean-Marie Jouannic
- Stem Cell Biotechnologies, U976 et Centre d'Investigation Clinique en Biothérapies CIC-BT CBT501, INSERM, Paris, France.,Department of Fetal Medicine, APHP, Trousseau Hospital, DMU ORIGYNE, Sorbonne University, Paris, France
| | - Jérôme Larghero
- Stem Cell Biotechnologies, U976 et Centre d'Investigation Clinique en Biothérapies CIC-BT CBT501, INSERM, Paris, France.,Unité de Thérapie Cellulaire et Centre MEARY de Thérapie Cellulaire et Génique, Saint Louis Hospital, Université Paris Cité, Paris, France
| | - Lucie Guilbaud
- Stem Cell Biotechnologies, U976 et Centre d'Investigation Clinique en Biothérapies CIC-BT CBT501, INSERM, Paris, France. .,Department of Fetal Medicine, APHP, Trousseau Hospital, DMU ORIGYNE, Sorbonne University, Paris, France.
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In utero treatment of myelomeningocele with allogenic umbilical cord-derived mesenchymal stromal cells in an ovine model. Curr Res Transl Med 2021; 70:103314. [PMID: 34731725 DOI: 10.1016/j.retram.2021.103314] [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: 07/11/2021] [Revised: 09/24/2021] [Accepted: 10/01/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE OF THE STUDY The purpose of our study was to investigate the effects of ovine umbilical cord-derived mesenchymal stromal cells (UC-MSCs) seeded in a fibrin patch as an adjuvant therapy for fetal myelomeningocele repair in the ovine model. MATERIALS AND METHODS MMC defects were surgically created at 75 days of gestation and repaired 15 days later with UC-MSCs patch or an acellular patch. At birth, motor function, tail movements, and voiding abilities were recorded. Histological and immunohistochemical analysis included study of MMC defect's healing, spinal cord, UC-MSCs survival, and screening for tumors. RESULTS Six lambs were born alive in each group. There was no difference between the two groups on the median sheep locomotor rating score but all lambs in the control group had a score between lower than 3 compared to 50% in UC-MSCs group. There were more lambs with tail movements and voiding ability in UC-MSCs group (83% vs 0% and 50% vs 0%, respectively). gray matter area and large neurons density were higher in UC-MSCs group (2.5 vs 0.8 mm2 and 19.3 vs 1.6 neurons/mm2 of gray matter, respectively). Fibrosis thickness at the myelomeningocele scar level was reduced in UC-MSCs group (1269 µm vs 2624 µm). No tumors were observed. CONCLUSION Fetal repair of myelomeningocele using allogenic UC-MSCs patch provides a moderate improvement in neurological functions, gray matter and neuronal preservation and prevented from fibrosis development at the myelomeningocele scar level.
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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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