Fetal Myelomeningocele Research Articles

Open Intrauterine Fetal Myelomeningocele Repair: Changes in the Surgical Procedure and Perinatal Complications during the First 8 Years of Experience at a Single Center

Introduction: Open fetal myelomeningocele (fMMC) repair is nowadays a therapeutic option in selected cases. We aimed to evaluate changes in maternal and fetal outcome after fMMC repair during the first 8 years of experience at a tertiary referral fetal medicine center in Switzerland. ­Materials and Methods: Between 2010 and 2018, fMMC repair and delivery of the neonate via planned cesarean section was performed in 67 cases. Cases were retrospectively stratified into 2 groups: a “training phase” (TP) with supervision from an external surgeon during 11 operations (2010–2014, 15 cases) followed by an “experienced phase” (EP, 2014–2018, 52 cases); each phase lasted about 4 years. Both phases were compared with regard to various maternal and fetal outcome parameters. Results: Analyses did not reveal differences between TP and EP in major outcome parameters such as gestational age at delivery, chorionic membrane separation, or the incidence of placental abruption. Although more complex surgical techniques were applied in EP (e.g., dermal closure using a rotational flap), surgery time was not different from TP. At the same time, surgical complications such as oligohydramnios (27 vs. 8%, p = 0.046) with MRI-confirmed leakage (13 vs. 4%, nonsignificant) and subchorionic hematoma (20 vs. 2%, p = 0.009) were less common in EP than TP. Conclusions: This study shows that the level of competence at our center with regard to major perinatal outcome parameters was already high in the first years of fMMC repair. However, more complex surgical techniques and significantly less minor complications were observed during the most recent years.

Postoperative imaging following fetal open myelomeningocele repair: The clinical utility of magnetic resonance imaging and sonographic amniotic fluid volumes in detecting suspected hysterotomy scar dehiscence.

Hysterotomy scar disruption, ranging from myometrial thinning to complete dehiscence, is a well-established complication of open-hysterotomy fetal myelomeningocele (MMC) repair. This study sought to (a) determine the feasibility of postoperative magnetic resonance imaging (MRI) in detecting signs of hysterotomy scar disruption and (b) identify the sonographic and clinical signs suggestive of subacute scar dehiscence, including decreasing amniotic fluid index (AFI) and uterine contractions, respectively. A unique index case of suspected hysterotomy dehiscence following MMC repair prompted a retrospective review of 31 total open-hysterotomy fetal MMC repairs performed at our center, including 21 cases found to have intact hysterotomy scarring and 10 cases of non intact scarring detected at subsequent cesarean delivery. In each case, routine post operative MRI, performed 6 weeks after the MMC repair, was reviewed to evaluate the thickness of the hysterotomy site. Cases were also reviewed for sonographic and clinical patterns preceding delivery, including changes in AFI and the presence or absence of uterine contractions. Of the 31 total reviewed cases, 21 cases were found to have intact hysterotomy scar sites at the time of cesarean delivery. Among the intact cases, the net change in AFI from the time of MRI to delivery ranged from -45% to 47%, with a mean increase in fluid levels of 8% over an average of 5.6 weeks. The other 11 cases, including the index case, were found to have signs of scar disruption at delivery, including seven with thinned scar sites and four with grossly dehiscent sites. Amongst non-intact cases, AFI predominately decreased, with a net change ranging from -56% to 9% for a mean change of -24% over an average of 5.4 weeks. Regular uterine contractions close to the time of delivery occurred in 82% of the non intact cases. Hysterotomy scar disruption can rarely be detected by MRI following MMC repair. Decreasing AFI and contractions may serve as early warning signs of scar dehiscence and should be taken into consideration for obstetric management.

Fetal myelomeningocele repair

Myelomeningocele is a congenital malformation that causes a spectrum of morbidity. With the standard of care now being in utero repair, the spectrum of morbidity has changed. The purpose of this article is to review the diagnosis, workup and treatment options of fetal myelomeningocele. We also review the obstetrical, neurological, gastrointestinal, urinary, and orthopedic outcomes of the in utero myelomeningocele repair.

Nationwide survey of fetal myelomeningocele in Japan: Background for fetal surgery

Fetal surgery for myelomeningocele (MMC) has yet not been performed in Japan, and the clinical background of fetal MMC in Japan remains poorly described. We examined the prenatal characteristics and perinatal outcomes of fetal MMC to prepare for the introduction of fetal surgery. A nationwide questionnaire survey was conducted with regard to fetuses with MMC between January 2012 and December 2014 at perinatal centers in Japan. In 50 tertiary centers, 188 cases of MMC were identified, of which 126 (67%) were isolated cases. Only half of the cases involved referral to tertiary centers with a diagnosis of MMC. The median time point for a prenatal diagnosis was 26weeks' gestation (range, 12-38weeks); in 54% of cases the diagnosis occurred after 26 gestational weeks, which is over the limit for fetal surgery for MMC. Furthermore, in 22% of cases the diagnosis was made before 22 gestational weeks, and in three-quarters of these cases termination of pregnancy was selected. No fetal or neonatal deaths were observed in the isolated MMC group. MMC repair, ventriculoperitoneal shunt and clean intermittent catheterization were required after birth in 100%, 73% and 55% of isolated MMC cases, respectively. In total, 96% of the tertiary centers cared for <5 cases of fetal MMC per year. Gestational age at MMC diagnosis was late mid-gestation, therefore earlier detection is essential when considering fetal treatment of MMC in Japan. Although the survival rate was excellent, in three-quarters of isolated MMC cases ventriculoperitoneal shunt was required. Early detection and centralization of MMC cases at specialized centers should be considered.

Evaluation and Disposition of Fetal Myelomeningocele Repair Candidates: A Large Referral Center Experience

Background: Fetal myelomeningocele (fMMC) repair yields superior outcomes to postnatal repair and is increasingly offered at select fetal centers. Objectives: To report the fMMC referral process from initial referral to evaluation and surgical intervention in a large fetal referral center. Methods: We conducted a retrospective cohort study of patients referred to Texas Children’s Fetal Center for fMMC between September 2013 and January 2018, reviewing the process from referral to final disposition. The stepwise evaluation included a phone interview followed by multidisciplinary consultation at our fetal center. We modified the Management of Myelomeningocele Study inclusion and exclusion criteria to allow a maternal body mass index of 35–40 on an individual basis. Results: A total of 204 referrals were contacted for a phone interview; 175 (86%) pursued outpatient evaluation, and 80 (46%) of them qualified for repair. Among the eligible patients, 37 (46%) underwent fetoscopic repair, 20 (25%) underwent open repair, and 17 (21%) declined prenatal surgery. Of the 89 noneligible patients (53%) excluded upon outpatient evaluation, 64 (72%) were excluded for fetal and 17 (19%) for maternal reasons. No hindbrain herniation (16%) and maternal BMI and/or hypertension (5%) were the most common reasons for fetal and maternal exclusion, respectively. A total of 31% of our referral population underwent fetal surgery. Conclusions: A small percentage of fMMC referrals ultimately undergo prenatal surgery. Stepwise evaluation and multidisciplinary teams are key to the success of large referral programs.

Development of a Fetal Surgery Program to Improve Neonatal Outcomes

In 2017, our pediatric hospital developed a fetal surgery program offering in utero procedures to repair complex congenital anomalies. The service provides comprehensive care for the maternal-fetal dyad, in one location. Fetal surgery allows for treatment of specific fetal conditions that were once considered life threatening or only treatable after birth. Emerging evidence demonstrates that treatment of certain fetal conditions increases a baby’s chances of survival and improved health. Leadership and frontline staff collaborated with specialists and surgeons to develop guidelines and protocols in the implementation of this program. Our hospital was one of the first pediatric facilities in the United States to offer inpatient obstetric care for women who experience complex fetal diagnoses. An interprofessional response to fetal complications was well established within the center. The provision of fetal surgery options was a continuance of the center’s approach of comprehensive care for the maternal-fetal dyad. Extensive program development included the following: addition of a fetal surgeon; creation of nurse coordinator roles to provide support, education, and comprehensive follow-up care for patients; exhaustive literature reviews; development of process flow diagrams to delineate roles and responsibilities; and didactic and operative skills training for staff, including simulations, mandatory preprocedure huddles, and formalized procedure debriefing. Our team has now successfully performed more than 90 fetal surgeries, such as open fetal myelomeningocele (fMMC) repair, open fetal teratoma resection, fetoscopic laser treatment for twin-to-twin complications, and complex ex utero intrapartum treatment procedures. The center has completed 14 open fMMC repairs, with early outcomes data demonstrating a 15% postbirth shunt placement rate. These are encouraging data compared with the MOMS trial, which indicated a 40% shunt placement rate in those with prenatal repair and an 82% shunt placement rate with postnatal repair. For our center, the average gestational age at the time of repair was 25.4 weeks and the average gestational age at birth was 35.2 weeks. Program development challenges included logistics planning, resource allocation, and staff trepidation. Challenges were overcome through teamwork, research, and an unflagging focus on evidence-based, best-practice models. Inclusion of frontline nursing staff was critical to the success of this innovative program.

Risk Factors for Preterm Birth following Open Fetal Myelomeningocele Repair: Results from a Prospective Cohort

Background: Fetal myelomeningocele (fMMC) repair is a therapeutic option in selected cases. This study aimed to identify risk factors for preterm birth (PTB) following open fMMC repair. Methods: Sixty-seven women underwent fMMC repair and delivered a baby between 2010 and 2018 at our center. Demographic, surgical, and pregnancy complications, including potential risk factors for PTB such as preterm premature rupture of membranes (PPROM), chorioamniotic membrane separation (CMS), and placental abruption were evaluated. Results: Maternal body mass index, maternal age, parity, previous uterine surgery, gestational age at fetal surgery, total surgery duration, surgical subcutaneous hematoma, oligohydramnios, and amniotic fluid leakage were not identified as risk factors for PTB. CMS (p = 0.028, 92 vs. 52%) and PPROM (p = 0.001, 95 vs. 52%) were highly associated with PTB. Placental abruption was found more often in women after fMMC repair than in a general obstetrical population (12 vs. 1%) and ended in premature birth in all cases (p = 0.024, 100 vs. 60%). However, the majority of women delivered at a gestational age >35 weeks. Conclusions: In our study cohort, risk factors for PTB were PPROM, CMS, and placental abruption, whereas surgery duration did not influence outcome. We conclude that the surgery technique should aim to minimize CMS and amniotic fluid leakage.

Antenatal Ultrasound Compared to MRI Evaluation of Fetal Myelomeningocele: A Prenatal and Postnatal Evaluation [28G

INTRODUCTION: Spina bifida affects 0.5-1 in 1000 pregnancies in the United States. Imaging has played a major role in pregnancies complicated by spinal defects. Our goal was to directly compare ultrasounds and MRI obtained antenatally in the diagnosis and localization of fetal myelomeningocele and compare these to the postnatal outcomes of these infants. METHODS: A retrospective analysis of patients referred to the Fetal Care Center at the Cleveland Clinic from 2005-2017. Ultrasounds and MRIs were obtained within the Cleveland Clinic electronic medical record. Infants were followed up at an interdisciplinary myelomeningocele pediatrics clinic. RESULTS: MRI and US varied in correlation with physical exam at time of birth and surgery. While no differences were detected in demographics, pregnancy outcomes or pediatric outcomes, it was noted the majority of patients developed neurogenic bladders irrespective of lesion level. CONCLUSION: MRI is not superior to US in the diagnosis of MMC. Pregnancies complicated by MMC do not vary in morbidity and pediatric outcomes remain similar regardless of level of lesion. This data provides additional information for the counseling of patients when faced with this antenatal diagnosis.

Influence of route of delivery on perinatal outcomes in fetuses with myelomeningocele

The optimal route of delivery of fetuses with myelomeningocele is controversial. The aim of this study is to determine whether route of delivery predisposes to perinatal complications and influences short-term outcomes in patients with myelomeningocele. The authors performed a retrospective review of the medical records of 26 patients with myelomeningocele admitted to the Neonatal Intensive Care Unit in this hospital from 2001 to 2015. They compared perinatal complications and short-term outcomes of elective cesarean section (n = 21) and vaginal delivery (n = 5) groups. There were no ruptured nor infectious myelomeningoceles cases in either group. No statistically significant difference in ambulation status at two years of age was observed between the two groups. The present data suggest that perinatal complications and short-term outcomes were not associated with route of delivery. Vaginal delivery might be the optimal route of delivery for fetal myelomeningocele if there is no obstetric contraindication.

Subsequent pregnancy outcomes after open maternal-fetal surgery for myelomeningocele

Open maternal-fetal surgery for fetal myelomeningocele results in reduction in neonatal morbidity related to spina bifida but may be associated with fetal, neonatal, and maternal complications in subsequent pregnancies. The objective of this study was to ascertain obstetric risk in subsequent pregnancies after open maternal-fetal surgery for fetal myelomeningocele closure. An international multicenter prospective observational registry created to track and report maternal, obstetric, fetal/neonatal, and subsequent pregnancy outcomes following open maternal-fetal surgery for fetal myelomeningocele was evaluated for subsequent pregnancy outcome variables. Institutional Review Board approval was obtained for the registry. From 693 cases of open maternal-fetal surgery for fetal myelomeningocele closure entered into the registry, 77 subsequent pregnancies in 60 women were identified. The overall live birth rate was 96.2%, with 52 pregnancies delivering beyond 20 weeks gestational age and median gestational age at delivery of 37 (36.3-37.1) weeks. The uterine rupture rate was 9.6% (n= 5), resulting in 2 fetal deaths. Maternal transfusion was required in 4 patients (7.7%). The risk of uterine rupture or dehiscence in subsequent pregnancies with associated fetal morbidity after open maternal-fetal surgery is significant, but is similar to that reported for subsequent pregnancies after classical cesarean deliveries. Future pregnancy considerations should be included in initial counseling for women contemplating open maternal-fetal surgery.

220: Prenatal open vs. two-port exteriorized uterus fetoscopic myelomeningocele repair. Neurosurgical outcomes from a single center

To assess neurosurgical and motor outcomes after an open-hysterotomy or fetoscopic fetal myelomeningocele (MMC) repair. Retrospective cohort study from 2011-2018. 66 patients diagnosed with fetal MMC who underwent a prenatal repair in our center via open-hysterotomy (N=33) or fetoscopic repair (N=33) were included. All patients fulfilled the Management of Myelomeningocele Study (MOMS) inclusion and exclusion criteria. Open-hysterotomy repair technique was performed as reported in MOMS trial. Our standardized fetoscopic repair is a two port, exteriorized uterus technique in CO2, using interrupted sutures for the neurosurgical repair. 13 and 8 of the fetoscopic and open repaired cases respectively, received a dural patch. Neurosurgical outcomes were compared between groups using Student's t-test for independent samples or Mann-Whitney U test if they had normal or non-normal distribution respectively for quantitative data. Chi-square or Fisher's exact test were used to compare qualitative data. Rate of complete hind brain herniation reversal assessed by MRI six weeks after prenatal repair, was similar between both groups [Fetoscopic: 23/32 (71.9%) vs.Open:21/33 (63.6%); p=0.47]. There were no significant differences between the groups in the rates of CSF leak, revision of repair at birth, need for ventriculo-peritoneal shunt placement or need for endoscopic third ventriculostomy (ETV) during the first year of life. Evaluation of functional and anatomical levels of the spinal defect also showed similar rates of improvement. Minimally invasive fetoscopic MMC repair shows comparable neurosurgical and motor outcomes to the open- hysterotomy approach.

Fetal myelomeningocele surgery: Only treating the tip of the iceberg.

Fetal myelomeningocele (fMMC) surgery improves infant outcomes when compared with postnatal surgery. Surgical selection criteria and the option of pregnancy termination, however, limit the number of cases that are eligible for prenatal surgery. We aimed to quantify what proportion of cases could ultimately benefit from fetal therapy. We retrospectively reviewed all cases of fMMC referred to a large tertiary care center over a 10-year period and assessed their eligibility for fetal surgery, pregnancy termination rates, and actual uptake of the surgery. Of 158 cases, 67 (42%) were ineligible for fetal surgery based on surgical exclusion criteria. Eleven fetuses (7%) had chromosomal anomalies, 10 of which (91%) had other anomalies on ultrasound. Thirty-four patients had a combination of maternal and fetal contraindications. Of the remaining 91 eligible cases (58%), 45 (49%) pregnancies were terminated, leaving only 46 (29% of initial 158 cases) as potential candidates for fetal repair. Actual uptake of fetal surgery was 15% (n=14 of 91), but this increased after a national program was started. Only a minority of fMMC cases will ultimately undergo fetal surgery. These numbers support the centralization of care in expert centers.

Maternal Complications following Open Fetal Myelomeningocele Repair at the Zurich Center for Fetal Diagnosis and Therapy

Introduction: Despite undoubtable benefits of open fetal myelomeningocele (fMMC) repair, there are considerable maternal risks. The aim of this study was to evaluate and systematically categorize maternal complications after open fMMC repair. Methods: We analyzed data of 40 fMMC repairs performed at the Zurich Center for Fetal Diagnosis and Therapy. Maternal complications were classified according to a 5-level grading system based on a classification of surgical complications proposed by Clavien and Dindo. Results: We observed no grade 5 complication (death of a patient). Five (12.5%) women demonstrated severe grade 4 complications: 1 case of uterine rupture in a nullipara at 36 gestational weeks (GW), a third-degree atrioventricular block which needed short mechanical resuscitation, a bilateral lung embolism requiring intensive care unit (ICU) management due to low-output syndrome, and chorioamnionitis and urosepsis both requiring ICU management at 31 GW. Twenty-six (65%) women had minor (grade 1–3) complications. Conclusions: Only one grade 4 complication (uterine rupture, 2.5%) was a clear-cut direct consequence of fetal surgery. The other four grade 4 complications (10%) occurred in the context of, but cannot unequivocally be attributed to, fetal surgery, since they may occur also in other circumstances. The classification system used is a tenable step towards stringent documentation of maternal complications.

Prenatal Sonographic Head Circumference and Cerebral Ventricle Width Measurements Before and After Open Fetal Myelomeningocele Repair - Prediction of Shunting During the First Year of Life.

The aim of this study was to describe the sonographic evolution of fetal head circumference (HC) and width of the posterior horn of the lateral ventricle (Vp) after open fetal myelomeningocele (fMMC) repair and to assess whether pre- or postoperative measurements are helpful to predict the need for shunting during the first year of life. All 30 children older than one year by January 2017 who previously had fMMC repair at the Zurich Center for Fetal Diagnosis and Therapy were included. Sonographic evolution of fetal HC and Vp before and after fMMC repair was assessed and compared between the non-shunted (N = 16) and the shunted group (N = 14). ROC curves were generated for the fetal HC Z-score and Vp in order to show their predictive accuracy for the need for shunting until 1year of age. HC was not an independent factor for predicting shunting. However, the need for shunting was directly dependent on the preoperative Vp as well as the Vp before delivery. A Vp > 10 mm at evaluation for fMMC repair or > 15 mm before delivery identifies 100 % of the infants needing shunt placement at a false-positive rate of 44 % and 25 %, respectively. All fetuses with a Vp > 15 mm at first evaluation received a shunt. Fetuses demonstrating a Vp of > 15 mm before in utero MMC repair are extremely likely to develop hydrocephalus requiring a shunt during the first year of life. This compelling piece of evidence must be appropriately integrated into prenatal counseling.

Fetal Myelomeningocele: Antenatal Characteristics and Pregnancy Outcomes [19R

INTRODUCTION: Spina bifida is the most common fetal anomaly of the central nervous system, which affect 1:1000 live births in the United States. Myelomeningocele is the most common presentation of spina bifida, representing half of these cases. Given the meningeal membrane sac may contain spinal cord, cerebrospinal fluid and nerve roots, this defect results in significant morbidity to infants and major life-long disabilities. In this study we aimed to identify maternal and fetal characteristics associated with expectant management or termination of pregnancy in the setting of antenatally diagnosed Myelomeningocele. METHODS: A retrospective cohort analysis was performed with patients who had presented to the Cleveland Clinic Fetal Care Center between 2005-2017. Live births then followed up at the pediatric Myelomeningocele clinic within our institution. RESULTS: Our data showed 40% of patients with antenatally diagnosed Myelomeningocele elected for second trimester terminations vs. 60% who chose to continue either by cesarean section or vaginal delivery. Based off ultrasound findings, there were no significant differences among these two groups. Maternal body mass index was significantly higher in those who continued pregnancies (p&lt;0.05). In addition, the fetal diagnostic methods chosen by patients was significantly different. Those who elected to terminate were more likely to pursue amniocentesis instead of MRI characterization of the fetus (p&lt;0.02). CONCLUSION: Taken together, we conclude, in the setting of antenatally diagnosed Myelomeningocele, patients often rely less on the associated ultrasonographic findings and depend more on maternal characteristics as well as fetal diagnostics in determining whether to continue or terminate pregnancy in the second trimester.

Early Administration of Magnesium Sulfate during Open Fetal Myelomeningocele Repair Reduces the Dose of Inhalational Anesthesia

Introduction: Optimal uterine relaxation is achieved through higher minimum alveolar concentration (MAC) of inhalational anesthetics, increasing risks to mother and fetus. Our objective was to determine if earlier administration of magnesium sulfate would reduce the requirement of inhalational anesthetics in fetal myelomeningocele repair. Materials and Methods: Prospective observational study of fetal myelomeningocele repair was performed from September 2011 to August 2017. Groups compared were: (1) magnesium sulfate at uterine closure; (2) magnesium sulfate at maternal skin incision. Maternal demographics, anesthetic agents, intraoperative complications, and pregnancy outcomes were reviewed. A Student t test was used for analysis. Results: There were 30 cases in group 1 and 21 cases in group 2. There was no difference in gestational age at intervention (24.92 ± 0.62 vs. 25.22 ± 0.47 weeks, p = 0.07) or at delivery (34.83 ± 2.77 vs. 33.98 ± 3.83 weeks, p = 0.38) between groups 1 and 2, respectively. The maximum MAC of sevoflurane was significantly lower in group 2 (1.84 ± 0.25 vs. 1.05 ± 0.28, p < 0.0001). There was no difference in the average dose of phenylephrine used. Discussion: Magnesium sulfate infusion initiated earlier in open fetal surgery reduces the total anesthetic exposure to the fetus.

490: Tocolytic options for open fetal repair of myelomeningocele: Systematic review

To describe current evidence on selection, regimen, efficacy and risks of perioperative tocolytic medications at the time of fetal repair of myelomeningocele. A search of MEDLINE, EMBASE, and SCOPUS databases was conducted from inception to March 2017. Studies that described their tocolytic protocol, gestational age at delivery, prenatal and postnatal outcomes were included. Studies that do not specify fetal myelomeningocele or do not adequately report outcomes were excluded. Neither sample size nor language was a basis for exclusion. Selection was done by 2 independent reviewers. Out of 570 studies retrieved on initial search, 462 were excluded for irrelevance. Of the 61 remaining titles, 17 were animal studies, 17 were reviews, 12 were not limited to fetal myelomeningocele, 3 studied the fetoscopic approach, 4 did not report neonatal outcomes, and 1 article was retracted. Eventually, seven articles were included. Four studies were conducted in the US; 1 study used preoperative indomethacin while the 4 studies used loading and maintenance doses of magnesium sulfate intra- and postoperatively along with postoperative indomethacin. Three of these studies used postoperative terbutaline. Three studies were done outside the US; 2 used preoperative indomethacin and one used diclofenac and Nifedipine. Magnesium sulfate was given intraoperatively. Postoperatively, magnesium sulfate was used in 2 studies and nifedipine was reported in 2 studies in different dosages. Among studies conducted in the US, average latency was 7.3 weeks (range 5.8-10.3 weeks). For studies conducted outside the US, the average latency was 13.7 weeks (range was 12 to 15.4 weeks). However, comparing a single to multiple agents, latency was comparable. Complications related to tocolysis are limited; incidence of pulmonary edema was 3.8% (2.2-5.5%) and is not altered by a single versus multiple medications. Preoperative indomethacin, intra- and postoperative course of magnesium sulfate seem to be the most commonly used and effective tocolytic options in women with open fetal myelomeningocele repair. The risk of pulmonary edema is generally small. There is no evidence that the use of multiple drugs would prolong latency compared to magnesium sulfate alone. However, further studies are needed to optimize the duration of postoperative treatment.

Committee Opinion No. 720: Maternal-Fetal Surgery for Myelomeningocele.

Myelomeningocele, a severe form of spina bifida, occurs in approximately 1 in 3,000 live births in the United States. The extent of disability is generally related to the level of the myelomeningocele defect, with a higher upper level of lesion generally corresponding to greater deficits. Open maternal-fetal surgery for myelomeningocele repair is a major procedure for the woman and her affected fetus. Although there is demonstrated potential for fetal and pediatric benefit, there are significant maternal implications and complications that may occur acutely, postoperatively, for the duration of the pregnancy, and in subsequent pregnancies. Women with pregnancies complicated by fetal myelomeningocele who meet established criteria for in utero repair should be counseled in a nondirective fashion regarding all management options, including the possibility of open maternal-fetal surgery. Maternal-fetal surgery for myelomeningocele repair should be offered only to carefully selected patients at facilities with an appropriate level of personnel and resources.

Committee Opinion No. 720 Summary: Maternal-Fetal Surgery for Myelomeningocele.

Myelomeningocele, a severe form of spina bifida, occurs in approximately 1 in 3,000 live births in the United States. The extent of disability is generally related to the level of the myelomeningocele defect, with a higher upper level of lesion generally corresponding to greater deficits. Open maternal-fetal surgery for myelomeningocele repair is a major procedure for the woman and her affected fetus. Although there is demonstrated potential for fetal and pediatric benefit, there are significant maternal implications and complications that may occur acutely, postoperatively, for the duration of the pregnancy, and in subsequent pregnancies. Women with pregnancies complicated by fetal myelomeningocele who meet established criteria for in utero repair should be counseled in a nondirective fashion regarding all management options, including the possibility of open maternal-fetal surgery. Maternal-fetal surgery for myelomeningocele repair should be offered only to carefully selected patients at facilities with an appropriate level of personnel and resources.

Tocolysis for in utero Surgery: Atosiban Performs Distinctly Better than Magnesium Sulfate

Introduction: To compare tocolysis with magnesium sulfate versus atosiban regarding the occurrence of short-term preterm labor and maternal side effects during and after open fetal myelomeningocele (MMC) repair. Material and Methods: A prospective nonrandomized cohort study was performed including 30 fetal MMC cases. The first 15 cases (group 1) received magnesium sulfate according to the MOMS protocol. In the following 15 cases (group 2), magnesium sulfate was substituted by atosiban. Chorioamniotic membrane separation (CMS), premature prelabor rupture of the fetal membranes (PPROM), preterm delivery <3 weeks after fetal MMC repair, and maternal complications due to the tocolytic medication were the major endpoints. Results: In both groups, one CMS but no PPROM was diagnosed <3 weeks after fetal MMC repair. One patient of group 2 delivered <3 weeks after fetal MMC repair because of an intraoperative placental abruption at 25 weeks. All women of group 1 showed an electrolyte imbalance during magnesium sulfate administration. One woman of group 1 developed several episodes of a third-degree atrioventricular block within the first 3 days after fetal surgery. Lethargy was found in all women during magnesium sulfate therapy. No maternal side effects were found under atosiban. Discussion: The use of atosiban resulted in an almost identical short-term uterine outcome without any serious maternal complications as seen when magnesium sulfate was given. Thus, the authors suggest using atosiban instead of magnesium sulfate in the context of open fetal surgery.