[Fetal surgery for myelomeningocele: Obstetric evolution and short-term perinatal outcomes of a cohort of 21 cases]

Abstract

Objective: The aim of this study is to describe the surgical technique, obstetrical evolution, and perinatal outcomes of a cohort of fetuses undergoing intrauterine surgery to repair open spina bifida (OSB).

Methods: We performed a prospective analysis of 21 consecutive fetuses with OSB at our institution between 2015 and 2017. The surgical technique was similar to that described in the management of myelomeningocele study (MOMS) (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT00060606) trial, except that the hysterotomy was performed using a bipolar dissector. Postoperative maternal and infant care both were provided at the same institution. There were no losses to follow-up. Surgical and obstetrical complications and perinatal outcomes were analyzed.

Results: Fetal surgery was performed at a mean gestation of 25.8 weeks (24.1-27.6). The mean gestational age at birth was 34.2 weeks (29.2-37.1). The mean surgical time was 138 min (101-187), the duration of surgery trending downward over time; while the average admission length was 7.1 days (4-32). Fifty-two percent (11/21) of the patients experienced preterm premature rupture of membranes. No patient required any postcesarean transfusions. There were no instances of placental abruption, uterine rupture, or maternal death. Uterine scar healing was normal in 95% of the patients. All but one of the 21 fetuses (95%) survived; the one fetal death was due to an amniotic band. The need for postnatal skin closure was 5%, with one of 20 repaired prenatally with a synthetic skin patch. No case (19) repaired with fetal tissues required postnatal skin closure. Seventy percent (14/20) of the infants required no further treatment for hydrocephalus over their first year of life; four patients (20%) required a ventriculoperitoneal shunt, while two others underwent an endoscopic third ventriculostomy (10%). Neonatal motor function was better than the prenatal anatomical level in 45% (9/20), equal in 50% (10/20), and worse in 5% (1/20).

Conclusions: Our data confirm that fetal surgery for OSB is associated with an increased risk of preterm delivery and premature rupture of membranes, but significantly reduces the need for postnatal treatment of hydrocephalus and improves short-term motor outcomes. Our results are similar to those published for the randomized MOMS trial.

Conflict of interest statement

There are no conflicts of interest.

Figures

Figura 1

Exposición uterina

Figura 2

Mapeo placentario

Figura 3

(a) Inicio de Histerotomía puntual con electrobisturi convencional. (b) Ampliación de Histerotomía con disector bipolar

Figura 4

Anestesia fetal

Figura 5

Exposición de la disrafia fetal

Figura 6

Cierre anatómico completo del defecto

Figura 7

Histerorrafia

Gráfico 1

Tiempos quirúrgicos detallados

Figura 8

Banda amniótica umbilical

Figura 9

Cicatriz cutánea incompleta en caso 1 (parche)

Figura 10

Cicatrices cutáneas de los casos 2–13. Caso 4 no incluido por óbito fetal. Nótense descargas laterales en el caso 8

Figura 11

Cicatrices cutáneas casos 14–21

Figura 12

Remisión prenatal de malformación de Chiari II en resonancia fetal (caso 2)

Gráfico 2

Necesidad de tratamiento de hidrocefalia en primer año de vida