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Mikulski MF, Well A, Beckerman Z, Fraser CD, Bebbington MW, Moise KJ. Open and endoscopic fetal myelomeningocele surgeries display similar in-hospital safety profiles in a large, multi-institutional database. Am J Obstet Gynecol MFM 2023; 5:100854. [PMID: 36587805 DOI: 10.1016/j.ajogmf.2022.100854] [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: 11/28/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Open intrauterine fetal myelomeningocele repair has demonstrated decreased ventriculoperitoneal shunting and improved motor outcomes despite maternal and fetal risks. Few data directly compare the safety of open vs endoscopic approaches. OBJECTIVE This study aimed to analyze in-hospital maternal and fetal outcomes of pregnant patients undergoing open vs endoscopic fetal myelomeningocele repair using a large, multi-center database. STUDY DESIGN This was a review of the Pediatric Health Information System database from October 1, 2015, to December 31, 2021. All patients who underwent open or endoscopic fetal myelomeningocele repair according to the International Classification of Diseases, Tenth Revision, were identified. Demographics, gestational age, and outcomes were analyzed. Descriptive and univariate statistics were used. RESULTS A total of 378 pregnant patients underwent fetal myelomeningocele repair. The approach was endoscopic in 143 cases (37.8%) and open in 235 cases (62.2%). Overall postprocedural outcomes included no maternal in-hospital mortalities or intensive care unit admissions, a median length of stay of 4 days (interquartile range, 4-5), 14 cases (3.7%) of surgical and postoperative complications, 6 cases (1.6%) of intrauterine infections, 12 cases (3.2%) of obstetrical complications (including preterm premature rupture of membranes), 3 cases (0.8%) of intrauterine fetal demise, and 16 cases (4.2%) of preterm delivery. Compared with an open approach, the endoscopic approach occurred at a later gestational age (25 weeks [interquartile range, 24-25] vs 24 weeks [interquartile range, 24-25]; P<.001) and had an increased rate of intrauterine infection (6 [4.2%] cases vs 0 [0%] case; P=.002). There was no difference between approaches in the rates of surgical complications, obstetrical complications, intrauterine fetal demise, or preterm deliveries. CONCLUSION Compared with an open approach, endoscopic fetal myelomeningocele repair displays a comparable rate of fetal complications, including intrauterine fetal demise and preterm delivery, and a similar in-hospital maternal safety profile despite an association with increased intrauterine infection.
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Affiliation(s)
- Matthew F Mikulski
- Departments of Surgery and Perioperative Care (Drs Mikulski, Well, Beckerman, and Fraser).
| | - Andrew Well
- Departments of Surgery and Perioperative Care (Drs Mikulski, Well, Beckerman, and Fraser)
| | - Ziv Beckerman
- Departments of Surgery and Perioperative Care (Drs Mikulski, Well, Beckerman, and Fraser); Department of Surgery, Duke University School of Medicine, Durham NC (Dr Beckerman)
| | - Charles D Fraser
- Departments of Surgery and Perioperative Care (Drs Mikulski, Well, Beckerman, and Fraser)
| | - Michael W Bebbington
- Women's Health (Drs Bebbington and Moise), The University of Texas at Austin Dell Medical School, Austin, TX
| | - Kenneth J Moise
- Women's Health (Drs Bebbington and Moise), The University of Texas at Austin Dell Medical School, Austin, TX
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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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Sival DA, Patuszka A, Koszutski T, Heep A, Verbeek RJ. Neurologic Outcome Comparison between Fetal Open-, Endoscopic- and Neonatal-Intervention Techniques in Spina Bifida Aperta. Diagnostics (Basel) 2023; 13:diagnostics13020251. [PMID: 36673061 PMCID: PMC9858470 DOI: 10.3390/diagnostics13020251] [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: 11/09/2022] [Revised: 12/13/2022] [Accepted: 01/06/2023] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION In spina bifida aperta (SBA), fetal closure of the myelomeningocele (MMC) can have a neuroprotective effect and improve outcomes. In Europe, surgical MMC closure is offered by fetal-open (OSBAR), fetal-endoscopic (FSBAR), and neonatal (NSBAR) surgical techniques. Pediatric neurologists facing the challenging task of counseling the parents may therefore seek objective outcome comparisons. Until now, such data are hardly available. In SBA, we aimed to compare neurologic outcomes between OSBAR, FSBAR, and NSBAR intervention techniques. METHODS We determined intervention-related complications, neuromuscular integrity, and neurologic outcome parameters after OSBAR (n = 17) and FSBAR (n = 13) interventions by age- and lesion-matched comparisons with NSBAR-controls. Neurological outcome parameters concerned: shunt dependency, segmental alterations in muscle ultrasound density (reflecting neuromuscular integrity), segmental motor-, sensory- and reflex conditions, and the likelihood of intervention-related gain in ambulation. RESULTS Compared with NSBAR-controls, fetal intervention is associated with improved neuromuscular tissue integrity, segmental neurological outcomes, reduced shunt dependency, and a higher chance of acquiring ambulation in ≈20% of the operated children. Children with MMC-lesions with a cranial border at L3 revealed the most likely intervention-related motor function gain. The outcome comparison between OSBAR versus FSBAR interventions revealed no significant differences. CONCLUSION In SBA, OSBAR- and FSBAR-techniques achieved similar neuroprotective results. A randomized controlled trial is helpful in revealing and compare ongoing effects by surgical learning curves.
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Affiliation(s)
- Deborah A. Sival
- Department of Pediatric Neurology, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
- Correspondence: ; Tel.: +31-50-3611085; Fax: +31-50-3611787
| | - Agnieszka Patuszka
- Department of Gynaecology, Obstetrics and Oncological Gynaecology, School of Medicine with Division of Dentistry in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland
| | - Tomasz Koszutski
- Department of Pediatric Surgery and Urology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-055 Katowice, Poland
| | - Axel Heep
- Department of Pediatrics and Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, 26129 Oldenburg, Germany
| | - Renate J. Verbeek
- Department of Pediatric Neurology, Emma Children’s Hospital, Amsterdam University Medical Centre, 1105 AZ Amsterdam, The Netherlands
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Kohl T. Lifesaving Treatments for the Tiniest Patients-A Narrative Description of Old and New Minimally Invasive Approaches in the Arena of Fetal Surgery. CHILDREN (BASEL, SWITZERLAND) 2022; 10:67. [PMID: 36670618 PMCID: PMC9856479 DOI: 10.3390/children10010067] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 12/14/2022] [Accepted: 12/21/2022] [Indexed: 12/31/2022]
Abstract
Fetal surgery has become a lifesaving reality for hundreds of fetuses each year. The development of a formidable spectrum of safe and effective minimally invasive techniques for fetal interventions since the early 1990s until today has led to an increasing acceptance of novel procedures by both patients and health care providers. From his vast personal experience of more than 20 years as one of the pioneers at the forefront of clinical minimally invasive fetal surgery, the author describes and comments on old and new minimally invasive approaches, highlighting their lifesaving or quality-of-life-improving potential. He provides easy-to-use practical information on how to perform partial amniotic carbon dioxide insufflation (PACI), how to assess lung function in fetuses with pulmonary hypoplasia, how to deal with giant CPAMS, how to insert shunts into fetuses with LUTO and hydrothorax when conventional devices are not available, and how to resuscitate a fetus during fetal cardiac intervention. Furthermore, the author proposes a curriculum for future fetal surgeons, solicits for the centralization of patients, for adequate maternal counseling, for adequate pain management and adequate hygienic conditions during interventions, and last but not least for starting the process of academic recognition of the matured field as an independent specialty. These steps will allow more affected expectant women and their unborn children to gain access to modern minimally invasive fetal surgery and therapy. The opportunity to treat more patients at dedicated centers will also result in more opportunities for the research of rare diseases and conditions, promising even better pre- and postnatal care in the future.
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Affiliation(s)
- Thomas Kohl
- German Center for Fetal Surgery & Minimally-Invasive Therapy (DZFT), Mannheim University Hospital (UMM), Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
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Fetoscopic Myelomeningocele Repair with Complete Release of the Tethered Spinal Cord Using a Three-Port Technique: Twelve-Month Follow-Up-A Case Report. Diagnostics (Basel) 2022; 12:diagnostics12122978. [PMID: 36552985 PMCID: PMC9776674 DOI: 10.3390/diagnostics12122978] [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: 10/06/2022] [Revised: 11/15/2022] [Accepted: 11/18/2022] [Indexed: 11/29/2022] Open
Abstract
Open spina bifida is one of the most common congenital defects of the central nervous system. Open fetal surgery, which is one of the available therapeutic options, remains the gold standard for prenatal repairs. Fetoscopic closure may lower the number of maternal complications associated with open fetal surgery. Regardless of the approach, the outcome may be compromised by the development of tethered spinal cord (TSC) syndrome. At 24.2 weeks of gestation, a primipara was admitted due to fetal myelomeningocele and was deemed eligible for fetoscopic repair. Fetal surgery was performed at 25.0 weeks of gestation. It was the first complete untethering of the spinal cord and anatomic reconstruction (dura mater, spinal erectors, skin) achieved during a fetoscopic repair of spina bifida. Cesarean section due to placental abruption was performed at 31.1 weeks of gestation. VP shunting, with no need for revision, was performed at 5 weeks postdelivery due to progressing ventriculomegaly. No clinical or radiological signs of secondary tethering were observed. Neurological examination at 11 months postdelivery revealed cranial nerves without any signs of damage, axial hypotonia, decreased muscle tone in the lower extremities, and absent pathological reflexes. Motor development was slightly retarded. Complete untethering of the neural structures should always be performed, regardless of the surgical approach, as it is the only course of action that lowers the risk for developing secondary TSC.
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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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Corroenne R, Yepez M, Pyarali M, Fox K, Mastrobattista JM, Mack LM, Lee W, Whitehead WE, Castillo HA, Castillo J, Mehollin-Ray AR, Espinoza J, Shamshirsaz AA, Nassr AA, Belfort MA, Sanz Cortes M. Longitudinal evaluation of motor function in patients who underwent prenatal or postnatal neural tube defect repair. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:221-229. [PMID: 32730648 DOI: 10.1002/uog.22165] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 06/10/2020] [Accepted: 07/03/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To compare the evolution of motor function from mid-gestation to 12 months of age between prenatally and postnatally repaired cases of open neural tube defect (ONTD). METHODS This was a retrospective cohort study of all fetuses that underwent prenatal (fetoscopic or open hysterotomy) or postnatal ONTD repair at a single institution between November 2011 and December 2018. The anatomical level of the lesion was defined as the upper bony spinal defect at initial magnetic resonance imaging assessment. Prenatal motor function of the lower extremities was evaluated by ultrasound according to the metameric level of the neurological lesion, based on the methodology of Carreras et al. Fetal motor function was assessed at referral, at 6 weeks after surgery in prenatally repaired cases or 6 weeks after referral in postnatally repaired cases (6-week follow-up) and at the last scan before delivery. In addition, motor function was assessed by a detailed neurological examination at birth and 12 months of age. First sacral (S1) neurological level of the lesion was considered as intact motor function. For statistical comparisons, we attributed numerical scores to each neurological level and motor function was expressed as median (range) neurological level. Motor function (as numerical score) and the proportion of cases with intact motor function and with motor function two or more levels better than expected based on the anatomical level of the lesion were compared between the prenatal- and postnatal-repair groups. Fetal motor function was compared to the anatomical level of the lesion at referral and a better motor function was defined when it was two or more levels better than the anatomical level of the lesion. To assess the evolution of motor function, we compared motor function at referral with that at each follow-up assessment using paired t-tests. RESULTS We included 127 patients with ONTD, of whom 93 underwent prenatal (51 fetoscopic and 42 open hysterotomy) and 34 postnatal repair. At the time of referral, cases in the prenatal- and postnatal-repair groups presented with a similar anatomical level of lesion (L3 (T9-S1) vs L3 (T7-S1); P = 0.52), similar motor function (S1 (L1-S1) vs S1 (L1-S1); P = 0.52) and a similar proportion of cases with intact motor function (81% vs 79%; P = 0.88) and with motor function two or more levels better than expected based on the anatomical level of the lesion (62% vs 74%; P = 0.24). When compared with prenatally repaired cases, postnatally repaired cases showed worse motor function at birth (S1 (L1-S1) vs L4 (L1-S1); P < 0.01) and at 12 months of age (S1 (L1-S1) vs L4 (L1-S1); P < 0.01). In the prenatal-repair group, motor function remained stable from the time of referral to 12 months of age (P = 0.26). Furthermore, the proportion of patients with intact motor function at referral (81% (75/93)) was similar to that at the 6-week follow-up (74% (64/87)), at the last scan before birth (74% (42/57)), at birth (68% (63/93)) and at 12 months of age (67% (39/58)) in the prenatal-repair group. In the postnatal-repair group, worse motor function, starting from the third trimester to 12 months of age, was observed. The proportion of patients with intact motor function at referral (79% (27/34)) was similar to that at 6-week follow-up (80% (12/15); P = 0.92), but was lower at the last assessment before birth (25% (2/8); P < 0.01), at birth (24% (8/34); P < 0.01) and at 12 months of age (28% (7/25); P < 0.01). Similar findings were noted when assessing the evolution of the proportion of cases with motor function two or more levels better than expected based on the anatomical level of the lesion in each group. CONCLUSIONS Infants with ONTD that underwent postnatal repair had worse motor function at birth and at 12 months of age than at mid-gestation and when compared with infants that underwent prenatal ONTD repair. Prenatal motor function assessment by ultrasound is an adequate tool to identify those infants who should have a good clinical motor function after delivery. Information obtained by fetal motor function assessment can have an important role for patient counseling and case selection for surgery. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R Corroenne
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - M Yepez
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - M Pyarali
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - K Fox
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - J M Mastrobattista
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - L M Mack
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - W Lee
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - W E Whitehead
- Department of Neurosurgery, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - H A Castillo
- Department of Developmental Pediatrics, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - J Castillo
- Department of Developmental Pediatrics, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - A R Mehollin-Ray
- E. B. Singleton Department of Pediatric Radiology, Texas Children's Hospital & Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - A A Shamshirsaz
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - A A Nassr
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - M A Belfort
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - M Sanz Cortes
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
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Corroenne R, Sanz Cortes M, Johnson RM, Whitehead WE, Donepudi R, Mehollin-Ray AR, Huisman TAGM, Espinoza J, Nassr AA, Belfort MA, Shamshirsaz AA. Impact of the cystic neural tube defects on fetal motor function in prenatal myelomeningocele repairs: A retrospective cohort study. Prenat Diagn 2021; 41:965-971. [PMID: 34145612 DOI: 10.1002/pd.5992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 05/31/2021] [Accepted: 06/03/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the impact of the lesion type (cystic [myelomeningocele] or flat [myeloschisis]) on the fetal motor function (MF) in cases candidates for prenatal open neural tube defect (ONTD) repair. METHODS Retrospective cohort study of patients with ONTD who underwent prenatal repair at a single institution between 2011 and 2019. The lesion type and the measurements of the length and width of the lesions to calculate the surface of the ellipsoid lesion were performed using MR scans. Prenatal MF of the lower extremities was evaluated by ultrasound following a metameric distribution at the time of referral. Intact MF was defined as the observation of plantar flexion of the ankle. Logistic regression was performed to determine the predictive value of the type of lesion for having an intact MF at the time of referral. RESULTS 103 patients were included at 22.9 (19-25.4) weeks; 65% had cystic and 35% had flat lesions. At the time of referral, there was a higher proportion of cases with an intact MF in the presence of flat lesions (34/36; 94.4%) as compared to cystic lesion (48/67; 71.6%, p < 0.01). When adjusting for gestational age and anatomical level of the lesion, flat ONTD were 3.1 times more likely to be associated by intact motor function (CI%95 [2.1-4.6], p < 0.01) at the time of referral. CONCLUSION Cystic ONTD are more likely to be associated with impaired MF at mid-gestation in candidates for prenatal ONTD repair.
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Affiliation(s)
- Romain Corroenne
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, Texas, USA
| | - Magdalena Sanz Cortes
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, Texas, USA
| | - Rebecca M Johnson
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, Texas, USA
| | - William E Whitehead
- Department of Neurosurgery, Texas Children's Hospital & Baylor College of Medicine, Houston, Texas, USA
| | - Roopali Donepudi
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, Texas, USA
| | - Amy R Mehollin-Ray
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, Texas, USA.,E. B. Singleton Department of Pediatric Radiology, Texas Children's Hospital & Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
| | - Thierry A G M Huisman
- E. B. Singleton Department of Pediatric Radiology, Texas Children's Hospital & Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, Texas, USA
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, Texas, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, Texas, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, Texas, USA
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10
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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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11
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Forde B, Habli M. Unique Considerations: Preterm Prelabor Rupture of Membranes in the Setting of Fetal Surgery and Higher Order Pregnancies. Obstet Gynecol Clin North Am 2021; 47:653-669. [PMID: 33121651 DOI: 10.1016/j.ogc.2020.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Two unique aspects of antenatal care occur in the setting of fetal surgery and multiple gestations. As fetal interventions increase, so do the number of cases of iatrogenic preterm prelabor rupture of membranes (PPROM). Because of the amniotic sac's inability to heal, the risk of PPROM after surgery is directly correlated with the number of interventions, the size of the defect, and the surgery performed. Higher order gestations also carry an increased risk of PPROM. This paper reviews the risks and management of PPROM in the setting of the various prenatal interventions as well as in the setting of multiple gestations.
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Affiliation(s)
- Braxton Forde
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Medical Sciences Building, Room 4555, 231 Albert Sabin Way, Cincinnati, OH 45267-0526, USA.
| | - Mounira Habli
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Good Samaritan Hospital, Cincinnati, OH, USA; Fetal Care Center of Cincinnati, Cincinnati Children's Hospital, Cincinnati, OH, USA
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12
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Diehl D, Belke F, Kohl T, Axt-Fliedner R, Degenhardt J, Khaleeva A, Oehmke F, Faas D, Ehrhardt H, Kolodziej M, Uhl E, Windhorst AC, Neubauer BA. Fully percutaneous fetoscopic repair of myelomeningocele: 30-month follow-up data. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:113-118. [PMID: 32510722 DOI: 10.1002/uog.22116] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 04/27/2020] [Accepted: 05/27/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE This observational study reports on the postnatal mortality and 30-month outcome of children who underwent fully percutaneous fetoscopic repair of myelomeningocele (MMC) at a single center in Giessen, Germany. METHODS Between October 2010 and August 2014, a total of 72 patients underwent fully percutaneous fetoscopic MMC closure at 21 + 0 to 29 + 1 (mean, 23 + 5) weeks' gestation. Of these, 52 (72%) participated in this study; however, 30-month mortality data are available for all 72 children. Children were examined at four timepoints: shortly after birth and at 3 months, 12 months and 30 months of corrected age. The patients underwent age-specific standardized neurological examinations and assessment of leg movements and ambulation at all timepoints. Cognitive and motor development were assessed using the Bayley Scales of Infant Development, second edition (BSID-II), at 30 months. RESULTS All 72 children survived the intrauterine procedure, however, four (5.6%) infants died postnatally (including two of the 52 comprising the study cohort). Of the 52 patients included in the study, 11.5% were delivered before the 30th week of gestation (mean, 33 + 1 weeks) and, of the survivors, 48.1% had ventriculoperitoneal shunt placement. Of the 50 infants that were alive at 30 months, independent ambulation, without orthosis, was feasible for 46%. At 30 months of follow-up, 46% of children presented with a functional level that was at least two segments better than the anatomical level of the lesion. At 30 months, 70% of the children presented with BSID-II psychomotor development index score of ≥ 70 and 80% with BSID-II mental development index score of ≥ 70. CONCLUSION Intrauterine repair of MMC by percutaneous fetoscopy shows largely similar outcomes to those reported for open repair, with respect to mortality, prematurity, shunt-placement rates, motor and mental development and free ambulation. © 2020 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 Diehl
- Department of Pediatric Neurology, University Hospital Giessen-Marburg, Giessen, Germany
| | - F Belke
- Department of Pediatric Neurology, University Hospital Giessen-Marburg, Giessen, Germany
| | - T Kohl
- Department of Gynecology and Obstetrics, Justus-Liebig-University Giessen, Giessen, Germany
- German Center for Fetal Surgery & Minimally Invasive Therapy (DZFT), University of Mannheim (UMM), Mannheim, Germany
| | - R Axt-Fliedner
- Department of Gynecology and Obstetrics, Justus-Liebig-University Giessen, Giessen, Germany
| | - J Degenhardt
- Department of Gynecology and Obstetrics, Justus-Liebig-University Giessen, Giessen, Germany
| | - A Khaleeva
- Department of Gynecology and Obstetrics, Justus-Liebig-University Giessen, Giessen, Germany
| | - F Oehmke
- Department of Gynecology and Obstetrics, Justus-Liebig-University Giessen, Giessen, Germany
| | - D Faas
- Department of Pediatrics and Neonatology, Justus-Liebig-University Giessen, Giessen, Germany
| | - H Ehrhardt
- Department of Pediatrics and Neonatology, Justus-Liebig-University Giessen, Giessen, Germany
| | - M Kolodziej
- Department of Neurosurgery, Justus-Liebig-University Giessen, Giessen, Germany
| | - E Uhl
- Department of Neurosurgery, Justus-Liebig-University Giessen, Giessen, Germany
| | - A C Windhorst
- Institute of Medical Informatics, Justus-Liebig-University Giessen, Giessen, Germany
| | - B A Neubauer
- Department of Pediatric Neurology, University Hospital Giessen-Marburg, Giessen, Germany
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13
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Corroenne R, Yepez M, Barth J, Pan E, Whitehead WE, Espinoza J, Shamshirsaz AA, Nassr AA, Belfort MA, Sanz Cortes M. Chorioamniotic membrane separation following fetal myelomeningocele repair: incidence, risk factors and impact on perinatal outcome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:684-693. [PMID: 31841246 DOI: 10.1002/uog.21947] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/02/2019] [Accepted: 12/04/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Prenatal myelomeningocele (MMC) repair has been shown to provide significant benefits to the infant, decreasing the postnatal need for ventriculoperitoneal shunt and improving motor outcome. Chorioamniotic membrane separation (CAS) is a potential complication following prenatal MMC repair and may increase the risk of preterm prelabor rupture of membranes (PPROM) and preterm birth. The objectives of this study were: (1) to evaluate the incidence of CAS after prenatal MMC repair; (2) to determine risk factors associated with its occurrence; and (3) to assess its association with adverse perinatal outcomes. METHODS This was a retrospective cohort study of patients who underwent fetal MMC repair between November 2011 and December 2018. Surgery was performed using either a fetoscopic (laparotomy or exteriorized uterus) approach or an open-hysterotomy approach. Eligibility criteria were those reported in the Management of Myelomeningocele Study. If CAS was detected on ultrasound (US), its severity was graded as 'mild' if amnion detachment involved < 25% of the uterine cavity, 'moderate' if it involved 25-50% and 'severe' if it involved > 50%. Evolution of CAS was classified as stable, increasing or decreasing based on the difference in severity grading between the time at first diagnosis and the last US scan before delivery. Logistic regression analysis was performed to identify pre- or perisurgical factors associated with the development of CAS and to determine the risk of adverse perinatal outcome associated with CAS. RESULTS In total, 91 cases were included. Fetoscopic or open-hysterotomy repair of MMC was performed in 52/91 (57.1%) and 39/91 (42.9%) cases, at a median gestational age (GA) of 25.0 weeks (range, 22.9-26.0 weeks) and 25.0 weeks (range, 21.3-25.9 weeks), respectively. CAS was diagnosed in 31/91 (34.1%) patients, at a median GA of 28.1 weeks (range, 24.4-37.6 weeks). Anterior placenta was identified as a risk factor for the postoperative development of CAS (odds ratio (OR), 3.72 (95% CI, 1.46-9.5); P < 0.01). This risk was dependent on the repair technique. An anterior placenta significantly increased the risk of CAS after fetoscopic repair (OR, 3.94 (95% CI, 1.14-13.6); P = 0.03) but not after open repair (OR, 2.8 (95% CI, 0.6-12.5); P = 0.16). There was no significant difference in the rate of CAS after fetoscopic repair (21/52 (40.4%)) vs open-hysterotomy repair (10/39 (25.6%)) (P = 0.14), nor were there any differences in GA at diagnosis of CAS, interval between surgery and diagnosis, distribution of CAS severity or progression of CAS between the two groups. CAS increased the risk of PPROM (50% in those with vs 12% in those without CAS) (OR, 7.6 (95% CI, 2.5-21.9); P < 0.01) and preterm delivery (70% vs 38%) (OR, 3.2 (95% CI, 1.3-8.1); P < 0.01). Fetoscopically repaired cases with CAS had a higher rate of PPROM (12/20 (60.0%) vs 2/31 (6.5%); P < 0.01) and preterm delivery (13/20 (65.0%) vs 5/31 (16.1%); P < 0.01) than those that did not develop CAS, while the differences were not significant in cases with open-hysterotomy repair. Early detection of CAS (before 30 weeks' gestation) was a risk factor for preterm delivery (90% before 30 weeks vs 36% at or after 30 weeks) (OR, 15.7 (95% CI, 2.3-106.3); P < 0.01). There was no association between PPROM or preterm delivery and the severity or progression of CAS. CONCLUSIONS The presence of an anterior placenta was the only factor that increased the risk for CAS after fetoscopic MMC repair. Detection of CAS after fetoscopic MMC repair significantly increases the risk for PPROM and preterm delivery. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Corroenne
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - M Yepez
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - J Barth
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - E Pan
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - W E Whitehead
- Department of Neurosurgery, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - A A Shamshirsaz
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - A A Nassr
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - M A Belfort
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - M Sanz Cortes
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
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14
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Joyeux L, Danzer E, De Bie F, Russo FM, Javaux A, Peralta CFA, De Salles AAF, Pastuszka A, Olejek A, Van Mieghem T, De Coppi P, Moldenhauer J, Whitehead WE, Belfort MA, Lapa DA, Acacio GL, Devlieger R, Hirose S, Farmer DL, Van Calenbergh F, Adzick NS, Johnson MP, Deprest J. Reply. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:634-635. [PMID: 33001498 DOI: 10.1002/uog.23104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- L Joyeux
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Women and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
| | - E Danzer
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - F De Bie
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - F M Russo
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Women and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
| | - A Javaux
- Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - C F A Peralta
- Department of Fetal Medicine, The Heart Hospital, University of São Paulo, São Paulo, Brazil
- Department of Fetal Medicine, Pro Matre Hospital, São Paulo, Brazil
| | - A A F De Salles
- Neuroscience Institute, The Heart Hospital, University of São Paulo, São Paulo, Brazil
| | - A Pastuszka
- Department of Descriptive and Topografic Anatomy, Medical University of Silesia, Katowice, Poland
- Division of Dentistry, School of Medicine, Medical University of Silesia, Zabrze, Poland
| | - A Olejek
- Department of Gynecology, Obstetrics and Gynecologic Oncology, Medical University of Silesia, Bytom, Poland
| | - T Van Mieghem
- Department of Obstetrics and Gynecology, Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada
| | - P De Coppi
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Women and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Specialist Neonatal and Paediatric Surgery Unit, Great Ormond Street Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - J Moldenhauer
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - W E Whitehead
- Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Fetal Center, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - M A Belfort
- Texas Children's Fetal Center, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - D A Lapa
- Fetal Therapy Center, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - G L Acacio
- Department of Obstetrics and Gynecology, Taubate University, São Paulo, Brazil
| | - R Devlieger
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Women and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
| | - S Hirose
- Fetal Care and Treatment Center, UC Davis Children's Hospital, Sacramento, CA, USA
| | - D L Farmer
- Fetal Care and Treatment Center, UC Davis Children's Hospital, Sacramento, CA, USA
| | - F Van Calenbergh
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - N S Adzick
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - M P Johnson
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - J Deprest
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Women and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Institute of Women's Health, University College London Hospitals, London, UK
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15
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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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16
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Verbeek RJ, Mulder PB, Sollie KM, van der Hoeven JH, den Dunnen WFA, Maurits NM, Sival DA. Development of muscle ultrasound density in healthy fetuses and infants. PLoS One 2020; 15:e0235836. [PMID: 32649730 PMCID: PMC7351181 DOI: 10.1371/journal.pone.0235836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 06/23/2020] [Indexed: 11/19/2022] Open
Abstract
Muscle ultrasound density (MUD) is a non-invasive parameter to indicate neuromuscular integrity in both children and adults. In healthy fetuses and infants, physiologic MUD values during development are still lacking. We therefore aimed to determine the physiologic, age-related MUD trend of biceps, quadriceps, tibialis anterior, hamstrings, gluteal and calf muscles, from pre- to the first year of postnatal life. To avoid a bias by pregnancy-related signal disturbances, we expressed fetal MUD as a ratio against bone ultrasound density. We used the full-term prenatal MUD ratio and the newborn postnatal MUD value as reference points, so that MUD development could be quantified from early pre- into postnatal life. Results: During the prenatal period, the total muscle group revealed a developmental MUD trend concerning a fetal increase in MUD-ratio from the 2nd trimester up to the end of the 3rd trimester [median increase: 27% (range 16-45), p < .001]. After birth, MUD-values increased up to the sixth month [median increase: 11% (range -7-27), p = 0.025] and stabilized thereafter. Additionally, there were also individual MUD characteristics per muscle group and developmental stage, such as relatively low MUD values of fetal hamstrings and high values of the paediatric gluteus muscles. These MUD trends are likely to concur with analogous developmentally, maturation-related alterations in the muscle water to peptide content ratios.
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Affiliation(s)
- Renate J. Verbeek
- Department of (Pediatric) Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- * E-mail:
| | - Petra B. Mulder
- Department of Obstetrics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Krystyna M. Sollie
- Department of Obstetrics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Johannes H. van der Hoeven
- Department of (Pediatric) Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Wilfred F. A. den Dunnen
- Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Natalia M. Maurits
- Department of (Pediatric) Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Deborah A. Sival
- Department of Pediatrics, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, The Netherlands
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17
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Joyeux L, De Bie F, Danzer E, Russo FM, Javaux A, Peralta CFA, De Salles AAF, Pastuszka A, Olejek A, Van Mieghem T, De Coppi P, Moldenhauer J, Whitehead WE, Belfort MA, Lapa DA, Acacio GL, Devlieger R, Hirose S, Farmer DL, Van Calenbergh F, Adzick NS, Johnson MP, Deprest J. Learning curves of open and endoscopic fetal spina bifida closure: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:730-739. [PMID: 31273862 DOI: 10.1002/uog.20389] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 06/18/2019] [Accepted: 06/24/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The Management of Myelomeningocele Study (MOMS) trial demonstrated the safety and efficacy of open fetal surgery for spina bifida aperta (SBA). Recently developed alternative techniques may reduce maternal risks without compromising the fetal neuroprotective effects. The aim of this systematic review was to assess the learning curve (LC) of different fetal SBA closure techniques. METHODS MEDLINE, Web of Science, EMBASE, Scopus and Cochrane databases and the gray literature were searched to identify relevant articles on fetal surgery for SBA, without language restriction, published between January 1980 and October 2018. Identified studies were reviewed systematically and those reporting all consecutive procedures and with postnatal follow-up ≥ 12 months were selected. Studies were included only if they reported outcome variables necessary to measure the LC, as defined by fetal safety and efficacy. Two authors independently retrieved data, assessed the quality of the studies and categorized observations into blocks of 30 patients. For meta-analysis, data were pooled using a random-effects model when heterogeneous. To measure the LC, we used two complementary methods. In the group-splitting method, competency was defined when the procedure provided results comparable to those in the MOMS trial for 12 outcome variables representing the immediate surgical outcome, short-term neonatal neuroprotection and long-term neuroprotection at ≥ 12 months of age. Then, when raw patient data were available, we performed cumulative sum analysis based on a composite binary outcome defining successful surgery. The composite outcome combined four clinically relevant variables for safety (absence of extreme preterm delivery < 30 weeks, absence of fetal death ≤ 7 days after surgery) and efficacy (reversal of hindbrain herniation and absence of any neonatal treatment of dehiscence or cerebrospinal fluid leakage at the closure site). RESULTS Of 6024 search results, 17 (0.3%) studies were included, all of which had low, moderate or unclear risk of bias. Fetal SBA closure was performed using standard hysterotomy (11 studies), mini-hysterotomy (one study) or fetoscopy by either exteriorized-uterus single-layer closure (one study), percutaneous single-layer closure (three studies) or percutaneous two-layer closure (one study). Only outcomes for standard hysterotomy could be meta-analyzed. Overall, outcomes improved significantly with experience. Competency was reached after 35 consecutive cases for standard hysterotomy and was predicted to be achieved after ≥ 57 cases for mini-hysterotomy and ≥ 56 for percutaneous two-layer fetoscopy. For percutaneous and exteriorized-uterus single-layer fetoscopy, competency was not reached in the 81 and 28 cases available for analysis, respectively, and LC prediction analysis could not be performed. CONCLUSIONS The number of cases operated is correlated with the outcome of fetal SBA closure, and the number of operated cases required to reach competency ranges from 35 for standard hysterotomy to ≥ 56-57 for minimally invasive modifications. Our observations provide important information for institutions looking to establish a new fetal center, develop a new fetal surgery technique or train their team, and inform referring clinicians, potential patients and third parties. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- L Joyeux
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Women and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
| | - F De Bie
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - E Danzer
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - F M Russo
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Women and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
| | - A Javaux
- Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - C F A Peralta
- Department of Fetal Medicine, The Heart Hospital, University of São Paulo, São Paulo, Brazil
- Department of Fetal Medicine, Pro Matre Hospital, São Paulo, Brazil
| | - A A F De Salles
- Neuroscience Institute, The Heart Hospital, University of São Paulo, São Paulo, Brazil
| | - A Pastuszka
- Department of Descriptive and Topografic Anatomy, Medical University of Silesia, Katowice, Poland
- Division of Dentistry, School of Medicine, Zabrze, Poland
| | - A Olejek
- Department of Gynecology, Obstetrics and Gynecologic Oncology, Medical University of Silesia, Bytom, Poland
| | - T Van Mieghem
- Department of Obstetrics and Gynecology, Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada
| | - P De Coppi
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Women and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Specialist Neonatal and Paediatric Surgery Unit, Great Ormond Street Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - J Moldenhauer
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - W E Whitehead
- Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Fetal Center, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - M A Belfort
- Texas Children's Fetal Center, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - D A Lapa
- Fetal Therapy Center, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - G L Acacio
- Department of Obstetrics and Gynecology, Taubate University, São Paulo, Brazil
| | - R Devlieger
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Women and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
| | - S Hirose
- Fetal Care and Treatment Center, UC Davis Children's Hospital, Sacramento, CA, USA
| | - D L Farmer
- Fetal Care and Treatment Center, UC Davis Children's Hospital, Sacramento, CA, USA
| | - F Van Calenbergh
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - N S Adzick
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - M P Johnson
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - J Deprest
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Women and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Institute of Women's Health, University College London Hospitals, London, UK
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Bradko V, Castillo H, Janardhan S, Dahl B, Gandy K, Castillo J. Towards Guideline-Based Management of Tethered Cord Syndrome in Spina Bifida: A Global Health Paradigm Shift in the Era of Prenatal Surgery. Neurospine 2019; 16:715-727. [PMID: 31284336 PMCID: PMC6944994 DOI: 10.14245/ns.1836342.171] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 04/08/2019] [Accepted: 06/01/2019] [Indexed: 01/04/2023] Open
Abstract
An estimated 60% of the world's population lives in Asia, where the incidence of neural tube defects is high. Aware that tethered cord syndrome (TCS) is an important comorbidity, the purpose of this systematic review was to explore the treatment of TCS among individuals living with spina bifida (SB) in Asia. MEDLINE and Embase databases were searched for relevant studies published from January 2000 to June 2018. Search terms such as 'spinal dysraphism,' 'spinabifida,' 'diastematomyelia,' 'lipomeningocele,' 'lypomyelomeningocele,' 'meningomyelocele,' and 'tethered cord syndrome' were used in diverse combinations. Of the 1,290 articles that were identified in accordance with PRISMA (Preferred Items for Systematic Reviews and Meta-Analyses) guidelines, 15 Asia-based studies met the inclusion criteria. Significant differences in the diagnostic criteria and management of TCS were documented. As the surgical techniques for prenatal closure of the spinal defect continue to evolve, their adoption internationally is likely to continue. In this setting, a clear and evidence-based approach to the definition and management of TCS is essential. The recent publication by the Spina Bifida Association of America of their updated care guidelines may serve as a tool used to promote a systematized approach to diagnosing and treating TCS among individuals with SB in the region, as well as globally.
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Affiliation(s)
- Viachaslau Bradko
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX, USA
- Division of Orthopedic and Scoliosis Surgery, Texas Children’s Hospital, Houston, TX, USA
| | - Heidi Castillo
- Developmental Pediatrics, Department of Pediatrics, Texas Children’s Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Shruthi Janardhan
- Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Benny Dahl
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX, USA
- Division of Orthopedic and Scoliosis Surgery, Texas Children’s Hospital, Houston, TX, USA
| | - Kellen Gandy
- Department of Pediatrics, Staten Island University Hospital, Staten Island, NY, USA
| | - Jonathan Castillo
- Developmental Pediatrics, Department of Pediatrics, Texas Children’s Hospital/Baylor College of Medicine, Houston, TX, USA
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19
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Abstract
The two-hit hypothesis of neural injury in the wake of open neural tube defects suggests an opportunity for preservation of function and potential reversibility of early morphological changes in the fetus diagnosed with myelomeningocele. The Management of Myelomeningocele Study (MOMS) demonstrated reduced need for shunting and improved neurological function in patients treated in utero relative to postnatally, thereby offering level 1 evidence supporting fetal repair. Subsequent studies have offered additional information about urological, orthopedic, radiological, and maternal factors surrounding fetal repair. The quest for robust long-term neurocognitive and motor function data is underway and poised to shape the future of fetal repair. In addition, technical innovations such as fetoscopic surgery aim to minimize maternal morbidity while conferring the beneficial effects observed with open intrauterine intervention.
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20
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Beuriat PA, Poirot I, Hameury F, Demede D, Sweeney KJ, Szathmari A, Di Rocco F, Mottolese C. Low level myelomeningoceles: do they need prenatal surgery? Childs Nerv Syst 2019; 35:957-963. [PMID: 30915531 DOI: 10.1007/s00381-019-04123-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 03/08/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Postnatal closure of a myelomeningocele remains the standard of care in many countries. The prenatal closure has given hope for decreasing the damage to the neural placode and has challenged classic management. However, this technique presents potential sources of complications. Patients with MMC with an anatomical level of L4 and below have a better functional prognosis than higher level malformations. Are they still candidates for prenatal surgery? OBJECTIVE To evaluate outcome of MMC with an anatomical level of L4 and below and discuss, with support of the literature, the indications to perform prenatal closure in this particular group of patients. MATERIALS AND METHODS Twenty-nine children were included in this observational study. The level of the vertebral malformation was sacral in 12 cases (41.4%) or lumbar (level ≤ L4) in 17 cases (58.6%). All the patients was operated postnatally for closure of the MMC with microsurgical technique as soon as possible after clinical evaluation (range 0-97 days). RESULTS Only 11 out of 29 patients (37.9%) needed of a CSF diversion. A Chiari II malformation was present before MMC closure in 17 patients (58.6%) and only in 5 (17%) after. Twenty-six patients (89.7%) were able to walk. Seven (23%) and 16 (55%) of our patients have a normal bladder and bowel control, respectively. All school-aged children attend school. CONCLUSIONS The functional outcome for low-level MMC is good when managed with modern microneurosurgical techniques with a low risk for the patient and the mother. Therefore, we do not suggest prenatal surgery for subgroup of infant with MM.
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Affiliation(s)
- Pierre-Aurelien Beuriat
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Isabelle Poirot
- Department of Pediatric Rehabilitation l'ESCALE, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Frederic Hameury
- Department of Urologic Surgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Delphine Demede
- Department of Urologic Surgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Kieron J Sweeney
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Alexandru Szathmari
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Federico Di Rocco
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France
| | - Carmine Mottolese
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677, Lyon Cedex, France.
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21
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Spinal Dysraphia, Chiari 2 Malformation, Unified Theory, and Advances in Fetoscopic Repair. Neuroimaging Clin N Am 2019; 29:357-366. [PMID: 31256859 DOI: 10.1016/j.nic.2019.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Fetal spina bifida, the most common nonlethal birth defect of the central nervous system, results in substantial neurologic morbidity. The unified theory describes the complex relationship between local spinal lesions and development of Chiari 2 malformation, contributing to hydrocephalus. Prenatal ultrasonography reliably allows diagnosis, but fetal MR imaging is an important complement to identify additional brain abnormalities. Fetal surgery improves neurologic and motor outcomes, but various approaches, either open hysterotomy or minimally invasive to the uterus, carry substantial obstetric risks. Optimization of the fetoscopic approach aims to minimize maternal and obstetric risks, but data regarding longer-term outcomes are awaited.
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22
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Sacco A, Van der Veeken L, Bagshaw E, Ferguson C, Van Mieghem T, David AL, Deprest J. Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta-analysis. Prenat Diagn 2019; 39:251-268. [PMID: 30703262 PMCID: PMC6492015 DOI: 10.1002/pd.5421] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To establish maternal complication rates for fetoscopic or open fetal surgery. METHODS We conducted a systematic literature review for studies of fetoscopic or open fetal surgery performed since 1990, recording maternal complications during fetal surgery, the remainder of pregnancy, delivery, and after the index pregnancy. RESULTS One hundred sixty-six studies were included, reporting outcomes for open fetal (n = 1193 patients) and fetoscopic surgery (n = 9403 patients). No maternal deaths were reported. The risk of any maternal complication in the index pregnancy was 20.9% (95%CI, 15.22-27.13) for open fetal and 6.2% (95%CI, 4.93-7.49) for fetoscopic surgery. For severe maternal complications (grades III to V Clavien-Dindo classification of surgical complications), the risk was 4.5% (95% CI 3.24-5.98) for open fetal and 1.7% (95% CI, 1.19-2.20) for fetoscopic surgery. In subsequent pregnancies, open fetal surgery increased the risk of preterm birth but not uterine dehiscence or rupture. Nearly one quarter of reviewed studies (n = 175, 23.3%) was excluded for failing to report the presence or absence of maternal complications. CONCLUSIONS Maternal complications occur in 6.2% fetoscopic and 20.9% open fetal surgeries, with serious maternal complications in 1.7% fetoscopic and 4.5% open procedures. Reporting of maternal complications is variable. To properly quantify maternal risks, outcomes should be reported consistently across all fetal surgery studies.
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Affiliation(s)
- Adalina Sacco
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Lennart Van der Veeken
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
| | - Emma Bagshaw
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Catherine Ferguson
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Tim Van Mieghem
- Department of Obstetrics and GynaecologyMount Sinai Hospital and University of TorontoTorontoOntarioCanada
| | - Anna L. David
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- National Institute for Health ResearchUniversity College London Hospitals Biomedical Research CentreLondonUK
| | - Jan Deprest
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- Clinical Department Obstetrics and GynaecologyUniversity Hospitals LeuvenLeuvenBelgium
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23
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Abstract
INTRODUCTION Spina bifida is the most common non-lethal congenital birth defect of the central nervous system that causes chronic disability due to the combined effects of local nerve damage and the sequelae of non-communicating hydrocephalus. This abnormality can be identified early in gestation and the damage can be progressive over the course of pregnancy. Advances in fetal treatment have made minimally invasive prenatal surgery a realistic consideration for spina bifida in order to improve the outcome for children affected this condition. EVIDENCE ACQUISITION Prenatal surgery for spina bifida via open fetal surgery with hysterotomy decreases the rate of ventriculoperitoneal shunt placement and improves motor function compared to standard postnatal surgery. Maternal risks of open fetal surgery are primarily related to complications of the hysterotomy including thinning or rupture that begins in the index pregnancy but persists for every future pregnancy. Minimizing maternal risks is the largest impetus to explore and optimize a minimally invasive fetoscopic alternative. Techniques vary from using a complete percutaneous approach to open fetoscopy, which requires laparotomy but is minimally invasive to the uterus. This allows vaginal delivery at term and no scar complications are reported thus far. Fetal short-term neurosurgical outcomes compare favorably with improvement in hindbrain herniation >70% and decreased need for treatment for hydrocephalus between 40-45% after prenatal surgery performed either fetoscopically or through open fetal surgery. EVIDENCE SYNTHESIS Maternal obstetric outcomes are superior for fetoscopic spina bifida repair compared to open fetal surgery and avoids the ongoing risk in future pregnancy. Neonatal and infant benefits appear equivalent. The open fetoscopic approach minimizes the risk of ruptured membranes and subsequent preterm delivery as opposed to a completely percutaneous procedure. International collaboration is ongoing to share experience and assess long term treatment effects. CONCLUSIONS Continued refinement of a minimally invasive strategy for prenatal treatment of spina bifida is necessary to maximize benefits to the child and further minimize maternal risks and preterm birth.
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Affiliation(s)
- Jena L Miller
- Department of Gynecology and Obstetrics, The Johns Hopkins Center for Fetal Therapy, Johns Hopkins University, Baltimore, MD, USA -
| | - Mari L Groves
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Ahmet A Baschat
- Department of Gynecology and Obstetrics, The Johns Hopkins Center for Fetal Therapy, Johns Hopkins University, Baltimore, MD, USA
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24
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Skinner S, Crossley K, Amberg B, Kashyap A, Hooper S, Deprest JA, Hodges R, DeKoninck P. The effects of partial amniotic carbon dioxide insufflation in an ovine model. Prenat Diagn 2018; 38:994-1003. [PMID: 30286262 DOI: 10.1002/pd.5368] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 09/27/2018] [Accepted: 09/27/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVE We aim to assess the effect of partial amniotic carbon dioxide insufflation (PACI) at increasing pressures on fetal acid-base, fetal-placental perfusion, and fetal membrane morphology in an ovine model. METHOD Pregnant ewes and fetuses were instrumented under isoflurane anesthesia at 105 days gestation (term 145 days) to monitor utero-placental blood flow, fetal and maternal blood pressure, heart rate, and blood gas status. One group (n = 6) was exposed to PACI (unheated dry CO2 ), involving 10 mm Hg stepwise increases in insufflation pressure (5 to 25 mm Hg), for 80 minutes followed by 20 minutes of desufflation. Un-insufflated controls (n = 5) were monitored for 100 minutes. At postmortem, fetal membranes were collected for histological analysis. RESULTS PACI at 25 mm Hg caused severe fetal hypercapnia (PaCO2 = 143 ± 5 vs 54 ± 5 mm Hg, P < 0.001), acidosis (pH = 6.85 ± 0.02 vs 7.25 ± 0.02, P < 0.001), hypoxia (SaO2 = 31 ± 4% vs 57 ± 4%, P = 0.01), and reduced uterine artery flow (50 ± 15 vs 196 ± 13 mL/min/kg, P = 0.005) compared with controls. These effects were greater at higher PACI pressures. PACI resulted in leukocyte infiltration in the amnion (1.77 × 10-5 ± 0.61 × 10-5 vs 0.38 × 10-5 ± 0.19 × 10-5 cells/μm2 , P = 0.04) and chorionic membranes (2.94 × 10-5 ± 0.67 × 10-5 vs 0.84 × 10-5 ± 0.42 × 10-5 cells/μm2 , P = 0.01). CONCLUSION Higher PACI pressures results in larger disturbances in fetal acid-base, uterine blood flow, and fetal membrane inflammation in sheep. Differences between human and sheep utero-placental structure should be considered.
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Affiliation(s)
- Sasha Skinner
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia.,Perinatal Services Monash Health, Monash Medical Centre, Clayton, Victoria, Australia
| | - Kelly Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Ben Amberg
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Aidan Kashyap
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Stuart Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Jan A Deprest
- Division of Woman and Child, Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, Cluster Women and Child, Faculty of Medicine, KU Leuven, Leuven, Belgium.,Institute of Women's Health, University College London, London, UK
| | - Ryan Hodges
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia.,Perinatal Services Monash Health, Monash Medical Centre, Clayton, Victoria, Australia
| | - Philip DeKoninck
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia.,Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
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25
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Joyeux L, Danzer E, Flake AW, Deprest J. Fetal surgery for spina bifida aperta. Arch Dis Child Fetal Neonatal Ed 2018; 103:F589-F595. [PMID: 30006470 DOI: 10.1136/archdischild-2018-315143] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 06/20/2018] [Accepted: 06/21/2018] [Indexed: 11/04/2022]
Abstract
Spina bifida aperta (SBA) is one of the most common congenital malformations. It can cause severe lifelong physical and neurodevelopmental disabilities. Experimental and clinical studies have shown that the neurological deficits associated with SBA are not simply caused by incomplete neurulation at the level of the lesion. Additional damage is caused by prolonged exposure of the spinal cord and nerves to the intrauterine environment and a suction gradient due to cerebrospinal fluid leakage, leading to progressive downward displacement of the hindbrain. This natural history can be reversed by prenatal repair. A randomised controlled trial demonstrated that mid-gestational maternal-fetal surgery for SBA decreases the need for ventriculoperitoneal shunting and hindbrain herniation at 12 months and improves neurological motor function at 30 months of age. This came at the price of maternal and fetal risks, the most relevant ones being increased prematurity and a persistent uterine corporeal scar. Recently minimally invasive fetal approaches have been introduced clinically yet they lack extensive experimental or clinical trials. We aim to provide clinicians with the essential information necessary to counsel SBA parents as the basis for considering referral of selected patients to expert fetal surgery centres. We review the reported clinical outcomes and discuss recent developments of potentially less invasive fetal SBA approaches.
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Affiliation(s)
- Luc Joyeux
- Academic Department Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, Faculty of Medicine, Catholic University of Leuven, Leuven, Belgium.,Center for Surgical Technologies, Faculty of Medicine, Catholic University of Leuven, Leuven, Belgium
| | - Enrico Danzer
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Center for Fetal Research, Abramson Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alan W Flake
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Center for Fetal Research, Abramson Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jan Deprest
- Academic Department Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, Faculty of Medicine, Catholic University of Leuven, Leuven, Belgium.,Center for Surgical Technologies, Faculty of Medicine, Catholic University of Leuven, Leuven, Belgium.,Division Woman and Child, Fetal Medicine Unit, Clinical Department of Obstetrics and Gynecology, University Hospital Gasthuisberg, Leuven, Belgium.,Institute of Women's Health, University College London Hospitals, London, UK
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26
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Bardill J, Williams SM, Shabeka U, Niswander L, Park D, Marwan AI. An Injectable Reverse Thermal Gel for Minimally Invasive Coverage of Mouse Myelomeningocele. J Surg Res 2018; 235:227-236. [PMID: 30691800 DOI: 10.1016/j.jss.2018.09.078] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Myelomeningocele (MMC) results in lifelong neurologic and functional deficits. Currently, prenatal repair of MMC closes the defect, resulting in a 50% reduction in postnatal ventriculoperitoneal shunting. However, this invasive fetal surgery is associated with significant morbidities to mother and baby. We have pioneered a novel reverse thermal gel (RTG) to cover MMC defects in a minimally invasive manner. Here, we test in-vitro RTG long-term stability in amniotic fluid and in vivo application in the Grainy head-like 3 (Grhl3) mouse MMC model. MATERIALS AND METHODS RTG stability in amniotic fluid (in-vitro) was monitored for 6 mo and measured using gel permeation chromatography and solution-gel transition temperature (lower critical solution temperature). E16.5 Grhl3 mouse fetuses were injected with the RTG or saline and harvested on E19.5. Tissue was assessed for RTG coverage of the gross defect and inflammatory response by immunohistochemistry for macrophages. RESULTS Polymer backbone molecular weight and lower critical solution temperature remain stable in amniotic fluid after 6 mo. Needle injection over the MMC of Grhl3 fetuses successfully forms a stable gel that covers the entire defect. On harvest, some animals demonstrate >50% RTG coverage. RTG injection is not associated with inflammation. CONCLUSIONS Our results demonstrate that the RTG is a promising candidate for a minimally invasive approach to patch MMC. We are now poised to test our RTG patch in the large preclinical ovine model used to evaluate prenatal repair of MMC.
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Affiliation(s)
- James Bardill
- Department of Bioengineering, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado; Division of Pediatric Surgery, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Sarah M Williams
- Division of Pediatric Surgery, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Uladzimir Shabeka
- Division of Pediatric Surgery, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | - Lee Niswander
- Department of Molecular, Cellular and Developmental Biology, University of Colorado Boulder, Boulder, Colorado
| | - Daewon Park
- Department of Bioengineering, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado.
| | - Ahmed I Marwan
- Department of Bioengineering, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado; Division of Pediatric Surgery, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado.
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Canaz H, Alatas I, Saracoglu A, Ozel K, Gedikbasi A. Open Fetal Surgery in Turkey. Fetal Diagn Ther 2018; 45:135-136. [PMID: 30300900 DOI: 10.1159/000492818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Huseyin Canaz
- Department of Neurosurgery, Istanbul Bilim University, Istanbul,
| | - Ibrahim Alatas
- Department of Neurosurgery, Istanbul Bilim University, Istanbul, Turkey
| | - Ayten Saracoglu
- Department of Anesthesiology, Marmara University, Istanbul, Turkey
| | - Kerem Ozel
- Department of Pediatric Surgery, Medeniyet University, Istanbul, Turkey
| | - Ali Gedikbasi
- Department of Perinatology, Kanuni Sultan Suleyman Hospital, Istanbul, Turkey
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Shanmuganathan M, Sival DA, Eastwood KA, Morris K, Cartmill J, Heep A, Bohosiewicz J, Pastuszka A, Hunter A, Ali A, McConnell R, Crimmins D, Malone F, Bailie C, Deprest J, McKillop C, Alfirevic Z, McAuliffe F, Ong S. Prenatal surgery for spina bifida: a therapeutic dilemma. Proceedings of the SHINE conference, Belfast. Ir J Med Sci 2017; 187:713-718. [DOI: 10.1007/s11845-017-1709-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 10/24/2017] [Indexed: 11/27/2022]
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Prenatal surgery for myelomeningocele: review of the literature and future directions. Childs Nerv Syst 2017; 33:1149-1155. [PMID: 28516217 DOI: 10.1007/s00381-017-3440-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 04/28/2017] [Indexed: 10/19/2022]
Abstract
Open spina bifida or myelomeningocele (MMC) is one of the most common serious congenital malformations. Historically, this condition has been treated with closure of the MMC defect shortly after birth. The goal of postnatal closure is to cover the exposed spinal cord and prevent infection. However, postnatal surgery does not reverse or prevent the neurologic injury seen in MMC, reverse hindbrain herniation, or prevent hydrocephalus. The neurologic defects result from primary incomplete neurulation and secondary chronic prenatal damage to the exposed neural elements through mechanical and chemical trauma. In a hope to reduce the numerous surgical procedures, medical complications, and lifelong disabilities associated with MMC, the proposal of prenatal closure was put forth more than two decades ago. After promising results in animal models and some clinical series, a randomized controlled trial, the Management of Myelomeningocele Study (MOMS), was conducted. The MOMS trial demonstrated that closure during the prenatal period could be performed relatively safely and can result in significant benefit to the child. Specifically, prenatal closure results in improved motor function, reduced hindbrain herniation, and reduced need for a cerebral spinal fluid diversion. Long-term outcomes of the patients in the MOMS trial continues in the MOMS 2 study as these children grow. Additionally, investigations are underway on modifications to the open fetal MMC closure techniques.
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Fetoscopic patch coverage of experimental myelomenigocele using a two-port access in fetal sheep. Childs Nerv Syst 2017; 33:1177-1184. [PMID: 28550526 DOI: 10.1007/s00381-017-3461-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 05/14/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE This study aims to assess the feasibility and the effectiveness of a fetoscopic myelomeningocele (MMC) coverage using a sealed inert patch through a two-port access, in the sheep model. METHODS Forty-four fetuses underwent surgical creation of a MMC defect at day 75 and were divided into four groups according to the MMC repair technique, performed at day 90. Group 1 remained untreated. Group 2 had an open surgery using suture of the defect. Groups 3 and 4 underwent defect coverage using a Gore®-polytetrafluoroethylene patch secured with surgical adhesive (Bioglue®), with an open approach (group 3) and a fetoscopic one (group 4). Lambs were killed at term, and histological examinations were performed. RESULTS Fetoscopic patch coverage was achieved in all the lambs of group 4. All the fetuses of group 2 had a complete closure of the defect whereas only 38% in group 3 and 14% in group 4. Fetal loss rate seems to be lower in group 4 than in groups 2 and 3. CONCLUSION Fetoscopic coverage of MMC defect can be performed using a sealed patch through a two-port access, but the patch and glue correction may not be the ideal technique to repair fetal MMC.
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Abstract
Therapeutic fetal surgical procedures are predicated upon the ability to make an accurate fetal diagnosis. The earliest open fetal surgical procedures were introduced in the 1960s to treat Rh isoimmunisation. They were introduced when it became possible to predict impending fetal demise. Open procedures were abandoned when percutaneous approaches proved superior. The introduction of fetal ultrasound allowed the diagnosis of other congenital anomalies, some being amenable to fetal interventions. Open fetal surgical procedures were initially utilised, with significant maternal morbidity. For some anomalies, percutaneous approaches became favoured. In general, all of these procedures involved significant risks to the mother, to save a baby that was likely to die before or shortly after birth without fetal intervention. Fetal repair for myelomeningocele was a "sea change" in approach. The same maternal risks were taken to improve the quality of life of the affected fetus, not save its life. The completion of the "MOMs Trial" has occasioned a "tsunami" of centres in North America applying this approach. Others are attempting percutaneous repairs, with mixed results. This paper reviews the history of fetal surgery, focusing on the themes of the tension between accurate diagnosis and prognosis and open versus "minimally invasive" approaches.
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Affiliation(s)
- H Kitagawa
- Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.
| | - K C Pringle
- Paediatric Surgery, Department of Obstetrics and Gynaecology, University of Otago, Wellington, P.O. Box 7343, Wellington South, 6242, Wellington, New Zealand
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Belfort M, Deprest J, Hecher K. Current controversies in prenatal diagnosis 1: in utero therapy for spina bifida is ready for endoscopic repair. Prenat Diagn 2016; 36:1161-1166. [DOI: 10.1002/pd.4972] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 11/05/2016] [Accepted: 11/16/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Michael Belfort
- Department Obstetrics and Gynecology; Baylor College of Medicine, Texas Medical Center; Houston TX USA
| | - Jan Deprest
- Department of Obstetrics and Gynecology; University Hospitals Leuven and Development and Regeneration, Biomedical Sciences; Leuven Belgium
- Research Department of Maternal Fetal Medicine, Institute for Women's Health; University College London; London UK
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine; University Medical Center; Hamburg Germany
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Pedreira DAL, Reece EA, Chmait RH, Kontopoulos EV, Quintero RA. Fetoscopic repair of spina bifida: safer and better? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:141-147. [PMID: 27273812 PMCID: PMC5113790 DOI: 10.1002/uog.15987] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 05/31/2016] [Accepted: 06/02/2016] [Indexed: 05/31/2023]
Affiliation(s)
- D A L Pedreira
- Fetal Therapy Program, Albert Einstein Hospital, São Paulo, Brazil
| | - E A Reece
- Office of the Dean and Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - R H Chmait
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - E V Kontopoulos
- Department of Obstetrics and Gynecology, University of Missouri, Kansas City, MO, USA
- Elizabeth J. Ferrell Fetal Health Center, Fetal Therapy, Children's Mercy Hospital, Kansas City, MO, USA
| | - R A Quintero
- Elizabeth J. Ferrell Fetal Health Center, Fetal Therapy, Children's Mercy Hospital, Kansas City, MO, USA
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Myelomeningocele - a single institute analysis of the years 2007 to 2015. Childs Nerv Syst 2016; 32:1281-7. [PMID: 27086130 DOI: 10.1007/s00381-016-3079-1] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/04/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND After the introduction of folate supplementation, the number of open spinal dysraphism was successfully reduced over time. In 2007, the department for pediatric neurosurgery was established in the children's hospital. Since then, newborns with myelomeningocele (MMC), the most common form of open neural tube defects (NTD), are treated here. The aim of this study is to present the concepts applied to and experiences resulting from treatment of MMC. METHODS Records of all newborns with MMC treated surgically during the period January 2007 to August 2015 in our institution were analyzed. Children, who were previously operated in utero were excluded. The type of neural tube defect, its location, associated comorbidities, and ambulation were recorded. RESULTS Forty-eight children (25 males, 23 females) with spinal dysraphism were included in the analysis. In nearly 90 % of the cases, the repair of the MMC was done on the day of delivery. The follow-up period ranges from 9 weeks to 8 9/12 years (loss of follow-up in 2 cases). In 19 %, the defect remained undetected during gestation and in one case, carbamazepine was taken despite pregnancy. In 36 children (75 %), we found a Chiari malformation type II (CMII) associated with myelomeningocele. 85.4 % suffered from hydrocephalus and implantation of a shunt was necessary. In cases of bladder impairment, an intermittent catheterization was the most common management (83.3 %); no bladder augmentation was required. Twelve children required orthopedic surgery. Twenty-three of 33 patients (70 %) are ambulatory w/wo orthoses and devices. The 13 children who are younger than 2 years were considered separately to assess the motor activity safely. CONCLUSIONS Our data show that neural tube defects to this day can remain undetected despite medical care during pregnancy. The most common associated diseases with MMC are Chiari II malformations and hydrocephalus. In the seven cases of simultaneous repair of MMC with shunt implantation, no additional complications were encountered. An interdisciplinary approach was allowed in a high percentage independence and social continence.
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Joyeux L, Engels AC, Russo FM, Jimenez J, Van Mieghem T, De Coppi P, Van Calenbergh F, Deprest J. Fetoscopic versus Open Repair for Spina Bifida Aperta: A Systematic Review of Outcomes. Fetal Diagn Ther 2016; 39:161-71. [DOI: 10.1159/000443498] [Citation(s) in RCA: 136] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 12/10/2015] [Indexed: 11/19/2022]
Abstract
Objective: To compare outcomes of fetoscopic spina bifida aperta repair (FSBAR) with the results of the open approach (OSBAR) as in the Management Of Myelomeningocele Study (MOMS). Methods: This was a systematic comparison of reports on FSBAR with data from the MOMS (n = 78). Inclusion criteria were studies of spina bifida aperta patients who underwent FSBAR and were followed for ≥12 months. Primary outcome was perinatal mortality. Secondary outcomes included operative, maternal, fetal, neonatal and infant outcomes. Results: Out of 16 reports, we included 5 from 2 centers. Due to bias and heterogeneity, analysis was restricted to two overlapping case series (n = 51 and 71). In those, FSBAR was technically different from OSBAR, had comparable perinatal mortality (7.8 vs. 2.6%, p = 0.212) and shunt rate at 12 months (45 vs. 40%, p = 0.619), longer operation time (223 vs. 105 min, p < 0.001), higher preterm prelabor membrane rupture rate (84 vs. 46%, p < 0.001), earlier gestational age at birth (32.9 vs. 34.1 weeks, p = 0.03), higher postnatal reoperation rate (28 vs. 2.56%, p < 0.001) and absence of uterine thinning or dehiscence (0 vs. 36%, p < 0.001). Functional outcomes were not available. Conclusion: FSBAR utilizes a different neurosurgical technique, takes longer to complete, induces more prematurity, requires additional postnatal procedures, yet has a comparable shunt rate and is not associated with uterine thinning or dehiscence. Long-term functional data are awaited.
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Carreras E, Maroto A, Illescas T, Meléndez M, Arévalo S, Peiró JL, García-Fontecha CG, Belfort M, Cuxart A. Prenatal ultrasound evaluation of segmental level of neurological lesion in fetuses with myelomeningocele: development of a new technique. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:162-167. [PMID: 26306897 DOI: 10.1002/uog.15732] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 07/18/2015] [Accepted: 08/20/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To report our preliminary experience in the use of prenatal ultrasound examination to assess lower-limb movements in fetuses with myelomeningocele. We aimed to determine the accuracy of this method to establish the segmental level of neurological lesion, as this is the best known predictor of the future ability to walk. METHODS This was a preliminary, observational study including fetuses with myelomeningocele operated on prenatally. The patterns of movements present and absent in the affected fetuses' lower limbs were evaluated systematically by ultrasound examination. According to the known nerve function associated with each muscle group, the segmental level of neurological lesion was established before birth. The agreement for the segmental levels assigned, between the prenatal ultrasound technique and the classical neurological clinical examination after birth (gold standard), was tested using the weighed kappa (wκ) index. RESULTS Seventy-one fetuses with myelomeningocele were evaluated at the Hospital Universitari Vall d'Hebron. After counseling, the parents opted for prenatal surgery (26 cases), termination of pregnancy (43 cases) or postnatal repair (two cases). Five patients did not fulfil the inclusion criteria for prenatal surgery and three were excluded after birth. In the 18 fetuses that underwent surgery and were analyzed, the agreement between prenatal and postnatal segmental levels assigned was 91.7% for the right limb (wκ = 0.80) and 88.9% for the left limb (wκ = 0.73). CONCLUSIONS The agreement found between prenatal and postnatal assignment of level of lesion in this preliminary study suggests that neurological sonographic evaluation is feasible before birth. This may provide accurate individualized information about the motor function and future ambulation prognosis of fetuses with myelomeningocele.
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Affiliation(s)
- E Carreras
- Maternal-Fetal Medicine, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - A Maroto
- Maternal-Fetal Medicine, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - T Illescas
- Maternal-Fetal Medicine, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M Meléndez
- Physical Medicine and Rehabilitation, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - S Arévalo
- Maternal-Fetal Medicine, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - J L Peiró
- Paediatric Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - C G García-Fontecha
- Paediatric Orthopaedic Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M Belfort
- Maternal-Fetal Medicine, Texas Children's Hospital, Houston, TX, USA
| | - A Cuxart
- Physical Medicine and Rehabilitation, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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Klein JL, Lemmon ME, Northington FJ, Boltshauser E, Huisman TAGM, Poretti A. Clinical and neuroimaging features as diagnostic guides in neonatal neurology diseases with cerebellar involvement. CEREBELLUM & ATAXIAS 2016; 3:1. [PMID: 26770813 PMCID: PMC4712469 DOI: 10.1186/s40673-016-0039-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 12/10/2015] [Indexed: 02/07/2023]
Abstract
Cerebellar abnormalities are encountered in a high number of neurological diseases that present in the neonatal period. These disorders can be categorized broadly as inherited (e.g. malformations, inborn errors of metabolism) or acquired (e.g. hemorrhages, infections, stroke). In some disorders such as Dandy-Walker malformation or Joubert syndrome, the main abnormalities are located within the cerebellum and brainstem. In other disorders such as Krabbe disease or sulfite oxidase deficiency, the main abnormalities are found within the supratentorial brain, but the cerebellar involvement may be helpful for diagnostic purposes. In In this article, we review neurological disorders with onset in the neonatal period and cerebellar involvement with a focus on how characterization of cerebellar involvement can facilitate accurate diagnosis and improved accuracy of neuro-functional prognosis.
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Affiliation(s)
- Jessica L Klein
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD USA ; Neurosciences Intensive Care Nursery Program, The Johns Hopkins University School of Medicine, Baltimore, MD USA ; Department of Pediatrics, Medical University of South Carolina, Charleston, SC USA
| | - Monica E Lemmon
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD USA ; Neurosciences Intensive Care Nursery Program, The Johns Hopkins University School of Medicine, Baltimore, MD USA ; Division of Pediatric Neurology, Department of Pediatrics, Duke University School of Medicine, Durham, NC USA
| | - Frances J Northington
- Neurosciences Intensive Care Nursery Program, The Johns Hopkins University School of Medicine, Baltimore, MD USA ; Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Eugen Boltshauser
- Division of Pediatric Neurology, University Children's Hospital, Zurich, Switzerland
| | - Thierry A G M Huisman
- Neurosciences Intensive Care Nursery Program, The Johns Hopkins University School of Medicine, Baltimore, MD USA ; Section of Pediatric Neuroradiology, Division of Pediatric Radiology, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Sheikh Zayed Tower, Room 4174, 1800 Orleans Street, Baltimore, MD USA
| | - Andrea Poretti
- Neurosciences Intensive Care Nursery Program, The Johns Hopkins University School of Medicine, Baltimore, MD USA ; Division of Pediatric Neurology, University Children's Hospital, Zurich, Switzerland ; Section of Pediatric Neuroradiology, Division of Pediatric Radiology, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Sheikh Zayed Tower, Room 4174, 1800 Orleans Street, Baltimore, MD USA
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Verbeek RJ, Sentner CP, Smit GPA, Maurits NM, Derks TGJ, van der Hoeven JH, Sival DA. Muscle Ultrasound in Patients with Glycogen Storage Disease Types I and III. ULTRASOUND IN MEDICINE & BIOLOGY 2016; 42:133-142. [PMID: 26437929 DOI: 10.1016/j.ultrasmedbio.2015.08.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 07/04/2015] [Accepted: 08/18/2015] [Indexed: 06/05/2023]
Abstract
In glycogen storage diseases (GSDs), improved longevity has resulted in the need for neuromuscular surveillance. In 12 children and 14 adults with the "hepatic" (GSD-I) and "myopathic" (GSD-III) phenotypes, we cross-sectionally assessed muscle ultrasound density (MUD) and muscle force. Children with both "hepatic" and "myopathic" GSD phenotypes had elevated MUD values (MUD Z-scores: GSD-I > 2.5 SD vs. GSD-III > 1 SD, p < 0.05) and muscle weakness (GSD-I muscle force; p < 0.05) of myopathic distribution. In "hepatic" GSD-I adults, MUD stabilized (GSD-I adults vs. GSD-I children, not significant), concurring with moderate muscle weakness (GSD-I adults vs. healthy matched pairs, p < 0.05). In "myopathic" GSD-III adults, MUD increased with age (MUD-GSD III vs. age: r = 0.71-0.83, GSD-III adults > GSD-III children, p < 0.05), concurring with pronounced muscle weakness (GSD-III adults vs. GSD-I adults, p < 0.05) of myopathic distribution. Children with "hepatic" and "myopathic" GSD phenotypes were both found to have myopathy. Myopathy stabilizes in "hepatic" GSD-I adults, whereas it progresses in "myopathic" GSD-III adults. Muscle ultrasonography provides an excellent, non-invasive tool for neuromuscular surveillance per GSD phenotype.
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Affiliation(s)
- Renate J Verbeek
- Department of Neurology, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, The Netherlands
| | - Christiaan P Sentner
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, The Netherlands
| | - G Peter A Smit
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, The Netherlands
| | - Natasha M Maurits
- Department of Neurology, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, The Netherlands
| | - Terry G J Derks
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, The Netherlands
| | - Johannes H van der Hoeven
- Department of Neurology, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, The Netherlands
| | - Deborah A Sival
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, The Netherlands.
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Pedreira DA, Zanon N, Nishikuni K, Moreira de Sá RA, Acacio GL, Chmait RH, Kontopoulos EV, Quintero RA. Endoscopic surgery for the antenatal treatment of myelomeningocele: the CECAM trial. Am J Obstet Gynecol 2016; 214:111.e1-111.e11. [PMID: 26386383 DOI: 10.1016/j.ajog.2015.09.065] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Revised: 08/06/2015] [Accepted: 09/09/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND A recent randomized clinical trial named Management of Myelomeningocele Study (MOMS trial) showed that prenatal correction of open spina bifida (OSB) via open fetal surgery was associated with improved infant neurological outcomes relative to postnatal repair, but at the expense of increased maternal morbidity. OBJECTIVE We sought to report the final results of our phase I trial (Cirurgia Endoscópica para Correção Antenatal da Meningomielocele [CECAM]) on the feasibility, safety, potential benefits, and side effects of the fetoscopic treatment of OSB using our unique surgical technique. STUDY DESIGN Ten consecutive pregnancies with lumbosacral OSB were enrolled in the study. Surgeries were performed percutaneously under general anesthesia with 3 ports and partial carbon dioxide insufflation. After appropriate surgical positioning of the fetus, the neuroplacode was released with scissors and the skin was undermined to place a biocellulose patch over the lesion. The skin was closed over the patch using a single running stitch. Preoperative, postoperative, and postnatal magnetic resonance imaging were performed to assess hindbrain herniation. Neurodevelopmental evaluation was performed before discharge and at 3, 6, and 12 months. All cases were delivered by cesarean delivery, at which time the uterus was assessed for evidence of thinning or dehiscence. RESULTS The median gestational age at the time of surgery was 27 weeks (range 25-28 weeks). Endoscopic repair was completed in 8 of 10 fetuses. Two cases were unsuccessful due to loss of uterine access. The mean gestational age at birth was 32.4 weeks with a mean latency of 5.6 weeks between surgery and delivery (range 2-8 weeks). There was 1 fetal and 1 neonatal demise, and 1 unsuccessful case underwent postnatal repair. Of the 7 infants available for analysis, complete reversal of hindbrain herniation occurred in 6 of 7 babies. Three babies required ventriculoperitoneal shunting or third ventriculostomy. Functional motor level was the same or better than the anatomical level in 6 of 7 cases. There was no significant maternal morbidity and no evidence of myometrial thinning or dehiscence. However, surgeries were complicated by premature rupture of membrane and prematurity. CONCLUSION Our study suggests that the antenatal treatment of OSB using a fetoscopic approach and our unique surgical technique can result in a watertight seal, reversal of the hindbrain herniation, and better than expected motor function. Our technique differs substantially from the classic repair of OSB used in prior open fetal surgery and fetoscopic studies, in which the dura mater is dissected and the defect is closed in multiple layers. Instead, we use a biocellulose patch placed over the lesion and simple closure of the skin. As such, our technique is an alternative to the current paradigms in the antenatal treatment of OSB. Our clinical outcomes are in line with the results of our extensive prior animal work. Maternal benefits of our approach and technique include minimal morbidity and no myometrial legacy. Current limitations of the approach include potential loss of access, premature rupture of membranes, and attendant prematurity. Phase II trials are needed to prevent these complications and to further assess the risks and benefits of our distinct surgical approach and technique.
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Bevilacqua NS, Pedreira DAL. Fetoscopy for meningomyelocele repair: past, present and future. EINSTEIN-SAO PAULO 2015; 13:283-9. [PMID: 26154549 PMCID: PMC4943825 DOI: 10.1590/s1679-45082015rw3032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 03/13/2015] [Indexed: 01/18/2023] Open
Abstract
Meningomyelocele is a malformation with high prevalence, and one of its main comorbidities is Arnold-Chiari malformation type II. The intrauterine repair of this defect has been studied to reduce the progressive spinal cord damage during gestation. The purpose of the present review was to describe the evolution of fetal surgery for meningomyelocele repair. Searches on PubMed database were conducted including articles published in the last 10 years. Twenty-seven articles were selected, 16 experimental studies and 11 studies in humans. A recent study demonstrated that the fetal correction results in better prognosis of neurological and psychomotor development, but open surgery, which has being used widely, has considerable maternal risks. Studies in animal and human models show that the endoscopic approach is feasible and leads to lower maternal morbidity rates. Two endoscopic techniques are currently under assessment - one in Germany and another in Brazil, and we believe that the endoscopic approach will be the future technique for prenatal repair of this defect.
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Woitek R, Prayer D, Weber M, Amann G, Seidl R, Bettelheim D, Schöpf V, Brugger PC, Furtner J, Asenbaum U, Kasprian G. Fetal diffusion tensor quantification of brainstem pathology in Chiari II malformation. Eur Radiol 2015; 26:1274-83. [DOI: 10.1007/s00330-015-3939-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 07/15/2015] [Accepted: 07/21/2015] [Indexed: 11/29/2022]
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Garabedian C, Jouannic JM, Benachi A, Sénat MV, Favre R, Houfflin-Debarge V. Thérapie fœtale et fœtoscopie : une réalité clinique en 2015. ACTA ACUST UNITED AC 2015; 44:597-604. [DOI: 10.1016/j.jgyn.2015.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 05/11/2015] [Accepted: 06/03/2015] [Indexed: 10/23/2022]
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Kohl T. Percutaneous minimally invasive fetoscopic surgery for spina bifida aperta. Part I: surgical technique and perioperative outcome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:515-524. [PMID: 24891102 DOI: 10.1002/uog.13430] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 05/08/2014] [Accepted: 05/27/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To analyze the current technical approach of percutaneous minimal-access fetoscopic closure of spina bifida aperta (SBA) and provide an overview of its development in ovine and human fetuses. METHODS Minimal-access percutaneous fetoscopic closure of SBA was performed at the German Center for Fetal Surgery & Minimal-access Therapy (DZFT) in 51 human fetuses at 21.0-29.1 weeks of gestation (mean age, 23.7 weeks). Various parameters of surgical relevance for the success and safety of the procedure and the early perioperative outcome were analyzed retrospectively. In addition, information from the early clinical cases was examined to determine how this shaped development of the approach. RESULTS Percutaneous minimal-access fetoscopic closure of SBA was performed with a high rate of technical success, regardless of placental or fetal position. All fetuses survived surgery, but there was one very early preterm delivery 1 week after the procedure and this neonate died immediately, from early postoperative chorioamnionitis. Of the 50 surviving fetuses, 44 (88%) were delivered at or beyond 30 weeks and 25 (50%) at or beyond 34 weeks of gestation. There was one neonatal death from an uinsuspected case of trisomy 13 and two infant deaths from Chiari-II malformation. CONCLUSIONS Following an adequate learning curve, minimal-access fetoscopic surgery for fetal spina bifida can be performed with a high rate of technical success, regardless of placental position.
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Affiliation(s)
- T Kohl
- German Center for Fetal Surgery & Minimally Invasive Therapy (DZFT), University of Giessen-Marburg, Giessen, Germany
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Flake A. Percutaneous minimal-access fetoscopic surgery for myelomeningocele - not so minimal! ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:499-500. [PMID: 25363896 DOI: 10.1002/uog.14673] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- A Flake
- Department of General, Thoracic and Fetal Surgery, Center for Fetal Diagnosis and Therapy, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Degenhardt J, Schürg R, Winarno A, Oehmke F, Khaleeva A, Kawecki A, Enzensberger C, Tinneberg HR, Faas D, Ehrhardt H, Axt-Fliedner R, Kohl T. Percutaneous minimal-access fetoscopic surgery for spina bifida aperta. Part II: maternal management and outcome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:525-531. [PMID: 24753062 DOI: 10.1002/uog.13389] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 03/11/2014] [Accepted: 04/09/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To assess maternal morbidity and outcome in women undergoing minimal-access fetoscopic surgery for spina bifida aperta. METHODS This was a retrospective study of 51 women undergoing minimal-access fetoscopic surgery to improve postnatal neurological outcome of spina bifida aperta, at a mean gestational age of 24 weeks, at our center between July 2010 and June 2013. We analyzed various perioperative complications of surgery, namely: maternal and fetal death, need for maternal blood transfusion, placental abruption, pulmonary edema, spontaneous labor, oligohydramnios, chorioamnionitis, chorioamniotic membrane separation, duration of hospitalization, amniotic fluid leakage, gestational age at delivery and status of hysterotomy site. RESULTS In none of the 51 women was there maternal demise, spontaneous labor, placental abruption or a need for maternal blood transfusion in the perioperative period. Chorioamniotic membrane separation occurred in one patient, mild pulmonary edema occurred in one and oligohydramnios occurred in seven. All fetuses survived surgery, but there was one very early preterm delivery 1 week after the procedure and this neonate died immediately, from early postoperative chorioamnionitis. Amniotic fluid leakage occurred in 43 patients, at a mean gestational age of 29.7 (range, 22.6-37.3) weeks; two of these patients developed chorioamnionitis. Duration of maternal hospitalization after surgery was 7.2 (range, 4-12) days. Mean gestational age at delivery was 33 (range, 24.6-38.1) weeks. All abdominal and uterine trocar insertion sites healed well. CONCLUSION Minimal-access fetoscopic surgery for spina bifida aperta is apparently safe for most maternal patients. Despite the common occurrence of amniotic leakage, the majority of women deliver beyond 32 weeks of gestation.
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Affiliation(s)
- J Degenhardt
- Department of Obstetrics & Gynecology, University of Giessen-Marburg, Giessen, Germany
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Ovaere C, Eggink A, Richter J, Cohen-Overbeek TE, Van Calenbergh F, Jansen K, Oepkes D, Devlieger R, De Catte L, Deprest JA. Prenatal Diagnosis and Patient Preferences in Patients with Neural Tube Defects around the Advent of Fetal Surgery in Belgium and Holland. Fetal Diagn Ther 2014; 37:226-34. [DOI: 10.1159/000365214] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 06/11/2014] [Indexed: 11/19/2022]
Abstract
Introduction: We review the characteristics and prenatal choices of patients recently evaluated for neural tube defects (NTD) at two tertiary units. The prenatal diagnosis of NTD allows parents to consider all prenatal options. In selected cases of spina bifida aperta this also includes fetal surgery, which we started offering after combined ‘in-house' and ‘exported' training. Material and Methods: This is a retrospective review of prospectively collected data on NTD diagnosed over the last 8 years and recent fetal surgery referrals. Results: A total of 167 patients were referred for assessment at a median of 19 weeks. Cranial lesions were diagnosed significantly earlier than spinal lesions. Of the open spinal lesions, 77% were isolated. Of these, 22% were managed expectantly and 1 (1%) had fetal surgery. There was no correlation between parental decisions on prenatal management with disease-specific severity markers. We had 14 fetal surgery referrals, all but 1 from beyond our typical referral area; 6 of the assessed patients were operated on, 4 were expectantly managed and 4 requested termination of pregnancy (TOP). These pregnancy outcomes were in the expected range. Discussion: Open spina bifida is mainly diagnosed in the second trimester and 76% of subjects request TOP, irrespective of the severity indicators. The number of local patients considering fetal surgery is low.
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Heuer GG, Adzick NS, Sutton LN. Fetal Myelomeningocele Closure: Technical Considerations. Fetal Diagn Ther 2014; 37:166-71. [DOI: 10.1159/000363182] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 04/16/2014] [Indexed: 11/19/2022]
Abstract
Myelomeningocele (MMC) is one of the most common serious congenital malformations. Typically this condition has been treated with closure of the MMC defect shortly after birth. In general, surgery for MMC aims to provide a multilayered closure to provide protection to the neural elements, prevent leakage of spinal fluid and reduce infection risks. A randomized controlled trial, the Management of Myelomeningocele Study (MOMS), has shown that closure during the fetal period can be performed relatively safely and can result in significant benefit to the child. Whereas the surgical technique of prenatal closure of an MMC defect is similar to a postnatal closure, there are some important technical differences. The goal of this paper is to describe the technique of fetal closure of MMC defects, highlight the unique steps that are needed for this surgery and delineate some potential pitfalls.
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Watanabe M, Kim AG, Flake AW. Tissue Engineering Strategies for Fetal Myelomeningocele Repair in Animal Models. Fetal Diagn Ther 2014; 37:197-205. [DOI: 10.1159/000362931] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Myelomeningocele (MMC), the most severe form of spina bifida, is a common and devastating malformation. Over two decades of experimental work in animal models have led to the development and clinical application of open fetal surgery for the repair of the MMC defect. This approach offers improved neurofunctional outcomes and is now a clinical option for the management of prenatally diagnosed MMC in selected patients. However, there are still opportunities for further improvement in the prenatal treatment of MMC. A less invasive approach would allow for an application earlier in gestation, with a reduction in maternal and fetal risks and the potential for reduced neurological injury. Tissue engineering offers a realistic and appealing alternative approach for the prenatal treatment of MMC. This review discusses the rationale for tissue engineering in MMC, addresses recent experimental progress and describes potential future directions.
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