MOMS Trial Research Articles

Contemporary Outcomes of a National Fetal Spina Bifida Surgery Service.

To assess contemporary outcomes of fetuses who underwent open fetal spina bifida surgery in Canada. Our clinical program prospectively collected outcomes of all consecutive fetuses who underwent open fetal spina bifida closure at the Ontario Fetal Center in Toronto and who were at least 1year of age at the time of postnatal follow-up. We gathered information on the need for hydrocephalus treatment, motor function, bladder function, as well as neurodevelopment (Ages and Stages Questionnaire and Bayley's scales of infant development). Developmental outcomes were categorized as "Typical Development," "Possible Delay," or "Significantly Delayed." Between 2017 and 2022, 41 fetuses underwent open fetal spina bifida closure. Twenty-four patients (58.5%) responded to the questionnaire at a median age of 46.5months. Eight children (33.3%) required CSF diversion procedures. Bladder management included clean intermittent catheterization (43.5%), spontaneous voiding (34.8%), or both (21.7%), with 43.5% needing medication for overactive bladder. All patients could sit independently, with 50% walking outside and 50% crawling indoors. Among those walking outdoors (50%), 25% did so without orthotics or aid, 58.3% with orthotics, and 16.7% required additional walking aids. Most children demonstrated typical communication and problem-solving skills (79.2%), while gross motor development was significantly delayed in 91.7% of cases. Fine motor skills varied, with 56.5% showing typical development and 34.8% possibly experiencing delays. This study showed a mixed developmental profile among patients who underwent open fetal spina bifida repair, consistent with the MOMs trial findings.

Myelomeningocele operated in utero and the incontinent bladder pattern: Mid-term follow up of a prospective study

In-utero myelomeningocele repair is the gold standard treatment after the publication of the MOMS trial. We have performed a retrospective analysis from our prospective in-utero myelomeningocele closure database (started in 2011), and selected only patients with the incontinent bladder pattern according to the Leal da Cruz categorization (Leal da Cruz, etal. J Urol 2015) to review mid-term clinical outcomes. We identified 30 patients with leaking pressure under 40 cmH20 (incontinent pattern) at first urodynamic evaluation (UE) from the whole cohort of 129 patients who underwent in-utero myelomeningocele closure. We selected patients with a minimum active follow-up of 48 weeks (4 years) to provide mid-term data. Patients were followed according to the same protocol with the proposal of yearly sonogram and UE. All clinical and radiological data were reviewed. We found 11 patients, with a mean age of 10.2 years old, median age at diagnosis of 19 weeks, surgery performed at 25.6 weeks and birth at 33.2 weeks. The mean follow-up was 81.73 months (6.81 years). Mean age at first urological evaluation was 5 months, and UE was 5.6 months. Febrile UTI incidence in the whole observation period was 27.3%. The average initial DLPP was 30 cmH2O. 71.4% of the patients had bladder capacity less than 50% of the expected age. Bladder compliance could not be determined in 63.7% of cases due to leakage. A total of 5.7 urodynamic studies per patient were performed. Surgery was recommended for 8 patients and done in 4 (36.3%). Surgery consisted of Macedo catheterizable reservoir and Macedo-Malone ACE, associated with urethral sling (2 patients) and bladder neck closure (2). It took an average of 5 UE before the final surgical decision was confirmed. Last urodynamic study showed persistent leakage and low DLPP in 3 patients, normal bladder pressure in 2 (under CIC and anticholinergics), and 1 patient changed his bladder pattern into a high risk group. All operated patients are fully continent (urinary >4hs) and fecal. Despite initially presenting a low risk for the most patients, we found surgery in 36.3% (4/11) and if we considered all cases with surgery indication proposed to treat urinary incontinence it would be even higher (72.7%).

Health Disparities and Route of Repair of Fetal Myelomeningocele-Prenatal Versus Postnatal Repair

Background: Spina bifida (SB) is a relatively common birth defect with the highest prevalence among Hispanics. A randomized controlled trial (MOMS) demonstrated that prenatal repair yielded improved outcomes compared to postnatal repair. However, the social determinants of health can significantly impact the overall well-being of affected individuals or their eligibility for some of these evidenced-based interventions. Methods: We conducted a retrospective observational study to describe and compare the mean Child Opportunity Index (COIs) scores among patients treated at a free-standing children’s hospital who underwent either prenatal or postnatal repair of SB from January 1<sup>st</sup>, 2012, to December 31<sup>st</sup>, 2021. We excluded patients with identifiable maternal and fetal contraindications to prenatal repair, as per the MOMS trial eligibility, apart from those pertaining to socio-economic status. RESULTS: Among a total cohort of 51 fetuses, 86% (n = 44) underwent postnatal repair for SB, while 14% (n = 7) received prenatal repair. Patients who underwent prenatal repair exhibited lower COI scores across all domains (education, health, and environment, social and economic) on national, state, and metro levels compared to the postnatal group. Our cohort showed a higher percentage of primary commercial insurance in the prenatal (fetal) surgery group (57.14%) versus the postnatal surgery group (47.73%), without attaining statistical significance (p=0.25). Conclusion: While COI scores across all domains were lower in the prenatal cohort, our data does not suggest a statistically significant difference between prenatal and postnatal surgery groups. This highlights the need for future studies with larger sample sizes to further explore and define this relationship.

EP09.15: Laparotomy‐assisted fetoscopic repair of fetal spina bifida in Latin America: can we obtain similar results from the MoMs trial?

EP09.15: Laparotomy‐assisted fetoscopic repair of fetal spina bifida in Latin America: can we obtain similar results from the MoMs trial?

Prenatal Spina Bifida Repair: Defendable Trespassing of MOMS Criteria Results in Commendable Personalized Medicine

Introduction: We hypothesize that after publication of the quintessence of the MOMS trial, eligibility criteria for prenatal spina bifida (SB) repair may be modified if a tenable argumentation underlies this decision. Methods: Our first 154 fetal surgery patients were analyzed with particular focus on how many, which, and why the original eligibility criteria, set forth by the MOMS Trial Protocol, were disobeyed, and what the eventually detectable, negative and positive impacts of these deviations on outcomes were. Results: A total of 152 patients (2 missing consent) were included (100%). In 69 patients (45.4%), a total of 89 eligibility criteria were disobeyed. In 54 (35.6%) cases, the following maternal criteria were concerned: gestational age at operation of >25+6 weeks in 17 (11.2%), uterine pathologies in 13 (8.6%) women, preoperative BMI ≥35 kg/m² in 12 (7.9%), previous hysterotomy in 7 (4.6%), previous prematurity in 3 (2%), HIV/hepatitis B in 2 (1.3%), psychosocial issues in 2 (1.3%), and placenta praevia in 1 (0.7%). In 32 (21.1%) cases, fetal criteria were disobeyed 34 times: Fetal anomaly unrelated to SB in 19 (12.5%), no/minimal evidence of hindbrain herniation in 13 (8.6%), and severe kyphosis in 2 (1.3%). We could not identify cases where non-observation of criteria led to clear-cut maternal and/or fetal disadvantages. Conclusion: This study shows that MOMS trial eligibility criteria for prenatal SB repair should be modified or even abandoned with adequate medical and ethical argumentation, and with written parental informed consent after non-directive, full disclosure counseling. This clear-cut change of paradigm is a necessity as it leads toward personalized medicine, allowing more fetuses to benefit from fetal surgery than would have benefitted with the former, published, MOMS criteria in place.

Fetal Surgery for Myelomeningocele: Neurosurgical Perspectives.

More than 30years have elapsed since it was recognised that folic acid supplementation could substantially reduce the risk of open neural tube defects (ONTDs). During that time, many countries have adopted policies of food fortification with demonstrable reduction in the incidence of both cranial and spinal ONTDs. Improved prenatal detection and termination has also resulted in a reduction in the number of affected live births. Nonetheless, in the USA about 1500 children, and in the UK around 500 children are born each year with myelomeningocele (MMC) and so the management of MMC and its complications continues to constitute a significant clinical workload for many paediatric neurosurgical units around the world.Until recently, the options available following antenatal diagnosis of MMC were termination of pregnancy or postnatal repair. As a result of the MOMS trial, prenatal repair has become an additional option in selected cases (Adzick et al., N Engl J Med 364(11):993-1004, 2011). Fetal surgery for myelomeningocele is now offered in more than 30 centres worldwide. The aim of this chapter is to review the experimental basis of prenatal repair of MMC, to critically evaluate the neurosurgical implications of this intervention and to describe the technique of 'open' repair, comparing this with emerging minimally invasive alternatives.

Prenatal myelomeningocele repair: report of an inaugural case and considerations about the implementation of a new fetal neurosurgery program

Myelomeningocele (MMC) or open spina bifida is a neural tube defect which consists of a cleft in the vertebral column and a correspondent defect in the skin, causing the meninges and the spinal cord to be exposed. Despite some recommendations for nutrient supplementation during pregnancy, MMC remains very prevalent, especially in poor regions. MMC causes paralysis, urinary and gastrointestinal dysfunction, motor and neurological deficits, hydrocephalus and hindbrain herniation. Until 1997, the only way to repair this defect was performing surgery right after birth. In 2011, MOMS trial revealed a positive impact of prenatal surgery compared to postnatal. This paper reports the first case of one of the first myelomeningocele prenatal surgery programs in the North and Northeast regions of Brazil and discusses some issues about the implementation of new programs. The patient was a 34 years old woman in her second pregnancy, who was diagnosed at 22 weeks. She was submitted to an open fetal surgery applying MOMS protocol at 26 weeks of pregnancy and underwent cesarean at 36 weeks and five days of pregnancy. After two-years follow up, the baby girl did not need shunt for hydrocephalus, but has motor deficit in the lower limbs. Although fetal surgery is a high-tech procedure that demands a well-trained team, many families come from low-income regions. This way, the implementation of new services has an important social impact.

Profiling in utero fetal cerebrospinal fluid (CSF) cell populations by single-cell RNA-sequencing (scRNA-seq)

Previously, the MOMS trial and later fetoscopic approaches demonstrated mid-gestation in utero repair of myelomeningocele (or MMC, the most common form of spina bifida) decreased the need for postnatal shunts and improved early motor function. During repair, the protruding MMC sac filled with cerebrospinal fluid (CSF) must be surgically reduced to enable closure. We hypothesized in-depth molecular characterization of fetal CSF by single-cell RNA-sequencing (scRNA-seq) would yield unparalleled and comprehensive insights into the composition and functions of CSF cell populations.

Pseudomeningocele after in utero repair of myelomeningocele as an early sign of hypertensive hydrocephalus – a case report and review of the literature

Background Myelomenigocele (MMC) is the most common congenital defect of the spine. The Management of Myelomeningocele study (MOMS trial) demonstrated that the prenatal repair decreased shunt implant, reversal of hindbrain herniation and better neurologic function compared to postnatal repair. Several ultrasound findings can predict the risk of postnatal hydrocephalus after intrauterine MMC repair. This report shows a prenatal pseudomenigocele after intrauterine correction of MMC as an early sign of hydrocephalus.
 Method A 34-year-old female G2P1 with a prenatal diagnosis of MMC with anatomical level L4 and ventricular enlargement was submitted to open surgery intrauterine repair. Follow up ultrasound showed regression of the lemon sign, partial regression of hindbrain herniation and a progressive increase in the wound with local bulging characterizing a pseudomingocele. In the postnatal period, after correction of the pseudomenigocele, the neonate showed signs of hipertensive hydrocephalus. After ventriculoperitoneal shunt, the patient was discharged.
 Conclusion Presence of pseudomeningocele prenatally after in utero repair of MMC may represent an early sign of hypertensive hydrocephalus.

Prevalence of high-risk bladder categorization with prenatal and postnatal myelomeningocele repair types.

Urologic substudies of prenatal myelomeningocele (MMC) closure have focused primarily on continence without significant clinical benefit. Fetoscopic MMC repair (FMR) is a newer form of prenatal intervention and touts added benefits to the mother, but urological outcomes have yet to be analyzed. We set out to focus on bladder safety rather than continence and examined bladder outcomes with different prenatal MMC repairs (FMR and prenatal open [POMR]) and compared bladder-risk-categorization to traditional postnatal repair (PSTNR). An IRB-approved retrospective analysis of all patients undergoing all forms of MMC repairs with inclusion and exclusion criteria based on the MOMS trial was performed. Bladder safety assessment required initial urodynamic studies (UDS), renal bladder ultrasound (RBUS), and/or voiding cystourethrogram (VCUG) within the 1st year of life. Follow-up analyses within the cohorts required follow-up studies within 18 months after initial evaluations. Outcomes assessed included bladder-risk-categorization based on the CDC UMPIRE study (high, intermediate, and safe), hydronephrosis (HN), and vesicoureteral reflux (VUR). A single reader evaluated each UDS. Initial UDS in 93 patients showed that the prevalence of high-risk bladders were 35% FMR versus 36% PSTNR and 60% POMR. Follow-up UDS showed only 8% of FMR were high-risk compared to 35% POMR and 36% PSTNR. Change from initial to follow-up bladder-risk-category did not reach significance (p = .0659); however, 10% PSTNR worsened to high-risk on follow-up, compared to none in either prenatal group. Subanalysis of follow-up UDS between the prenatal cohorts also was not significant (p = .055). Only 8% of FMR worsened or stayed high-risk compared to 35% with POMR (p = .1). HN was significantly different at initial and subsequent follow up between the groups with the least in the FMR group. Early outcome UDS analyses demonstrated lower incidence of high-risk bladders in FMR patients with a trend toward clinically significant improvement compared to POMR in regard to all evaluated metrics. Larger, prospective, confirmatory studies are needed to further evaluate the potential benefits on FMR on bladder safety and health.

83 Ambulatory status after prenatal (fetoscopic/open) and postnatal spina bifida repair. Predictors for independent ambulation

Identifying which clinical parameters can predict reliably the chances of a fetus/baby to ambulate independently is of critical relevance. The aims of this study were to compare the ambulatory status of a cohort of children who had prenatal spina bifida repair against those who had postnatal repair and identify predictors for independent ambulation. Retrospective cohort of children who had in utero repair (fetoscopic (N=29), open-hysterotomy (N=27) approaches) or postnatal repair (N=26) in the same institution. Prenatal repair cases followed MOMS trial inclusion criteria for surgery. Postnatal repair cases met MOMS trial criteria based on fetal imaging. Motor function (MF) assessment by ultrasound was recorded at initial evaluation(MF1), 6 weeks post repair(MF2) and prior to birth(MF3). In utero MF was established by the highest myotome used in lower extremities. S1 MF was classified as “intact motor function”. MF was also recorded at birth and 12 months using standard neurological exam. Ambulatory status was recorded longitudinally and classified as independent ambulator (with/without orthosis), walking with assistive devices (ie walker) or as not ambulatory Prenatal and postnatal repair groups showed similar neural tube defects and in utero MF. Gestational age at delivery and birthweights were higher in the postnatal repair group(Table1). No differences in ambulation were observed between groups before 30 months. At that time, a higher proportion of prenatally repaired cases were able to walk. No differences were seen between both methods for prenatal repair(Fig1). Logistic regression analyses showed how “intact MF” at 12 months [OR: 13.6 (95%CI: 2.6-70.9),p<0.01], at MF1 [12.5(1.47-106),0.02], at birth [7.6 (1.89-31.09),p<0.01] and absence of club feet [5.1 (1.25-20.9),0.02] predicted significantly having independent ambulation at 30 months in the prenatal repair group Independent ambulation after prenatal spina bifida repair can be predicted by observing S1 MF pre- and postnatally, this finding can have important clinical implications and on parental counseling.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Intrauterine surgery: how far we have come in 30 years.

Intrauterine surgery: how far we have come in 30 years.

Improved Postoperative Metrics with Modified Myofascial Closure in Fetal Myelomeningocele Repair.

The effect of modifications in fetal myelomeningocele (fMMC) closure techniques has not been extensively studied. To study the effect of a modified closure technique on fMMC postnatal patient outcomes: hydrocephalus, hindbrain herniation, and cyst development. We performed single-center retrospective study of a subset of post-MOMS (Management of Myelomeningocele Study) trial patients who underwent fMMC closure. After January 2015, the fetal myofascial closure technique was modified. Needlepoint monopolar cautery was used to raise dural lined myofascial flaps to create a more robust closure. Outcomes between the pre- and postmodification groups were compared with regard to hindbrain herniation, hydrocephalus, and cyst development. Families who transitioned care to local institutions were contacted via telephone for outcome information. From January 2011 to May 2016, data were reviewed from 119 fMMC closure patients. Patients without full follow-up data were excluded from the final analysis. Cerebrospinal fluid diversion was seen in 32 of 74 patients with the standard technique compared to 14 of 45 with the modified closure and was significantly decreased in postmodification when compared to that of the MOMS trial (P=.01). Hindbrain herniation resolution was significantly decreased in both the pre- and postmodification groups compared to that of the MOMS trial (P<.01). Prior to January 2015 with standard closure, 23 cysts required resection whereas no cysts required resection in the modified repair group (P<.01). Modified myofascial closure for fMMC closure is safe and feasible. The new approach reflects a decreased rate of cyst development requiring surgical resection, and a trend for improved rates of hindbrain herniation and hydrocephalus.

585: Fetal MMC Closure Stratified by Maternal BMI: a sub-analysis of the MOMS trial cohort

Obesity is a known risk factor for many obstetric complications. However, little is known about the impact of increased maternal BMI on outcomes of maternal-fetal surgery for myelomeningocele closure. The objective of this study was to evaluate operative, obstetric and neonatal outcomes stratified by maternal BMI for the cohort of patients who underwent open fetal surgery in the MOMS trial. This study is a sub analysis of data collected from the multicenter, randomized prospective MOMS trial comparing open maternal fetal surgery for MMC closure compared to routine neonatal closure. Only the women who underwent maternal-fetal surgery were included. Outcomes were compared based on maternal BMI: normal BMI/overweight BMI < 30 and obese with BMI 30-34.99. Data analyzed included maternal demographics, preoperative factors, length of surgery, obstetric and neonatal outcomes. Statistical analysis included Fisher’s exact test for categorical variables and t-tests for continuous variables. 91 women underwent fetal surgery in the original trial. Of those, 74 had BMI < 30 and 17 had BMI 30-34.99. Results are presented in the Table. There were no significant differences in maternal demographics, preoperative factors, obstetric complications, or gestational age at delivery. Preoperative factors were similar between the two groups except for the measurement of ventricle on the downside being larger in the BMI 30-34.99 BMI group (14.2 mm versus 11.3 mm, p=0.007). Neonatal outcomes were similar between the two groups, except for the greater need for shunt at 12 months in the 30-34.99 BMI group (70.6% versus 37.8%, p=0.028) consistent with the larger ventricle size. Maternal BMI in the obese range is not associated with increased maternal or obstetric risk for women undergoing open fetal surgery for MMC closure. There does not appear to be an effect of increased maternal BMI on neonatal outcomes, except for preoperative ventricle size and the need for shunt, which may be related to the small number and requires additional study.

Benchmarking against the MOMS Trial: Zurich Results of Open Fetal Surgery for Spina Bifida

Introduction: The Management of Myelomeningocele Study, a.k.a. the MOMS trial, was published in 2011 in the New England Journal of Medicine. This prospective randomized controlled trial proved to be a milestone publication that provided definitive evidence that fetal surgery is a novel standard of care for select fetuses with spina bifida aperta (SB). The goal of our study is to assess whether our center can match these benchmark results. Materials and Methods: Our study was conducted according to the MOMS protocol using the same inclusion and exclusion criteria and looked at the same outcome parameters that were used in the MOMS trial. Zurich and MOMS results were compared. Results: We enrolled 20 patients between December 2010 and May 2015 all of whom underwent fetal surgery for SB. Among 51 different outcome variables, there were only 3 favorable (multiplicity-adjusted) significant differences (gestational age at birth, hindbrain herniation, and psychomotor development). There were no statistically significant differences regarding any other parameters. Conclusion: Our findings confirm that rigorous apprenticeship, training, and comprehensive prospective data collection enable centers like the Zurich Center for Fetal Diagnosis and Therapy to achieve benchmark results for open fetal surgery for myelomeningocele and myeloschisis. These results justify the existence and continuation of our program. Outcome documentation is an essential element of quality management. It is medically and ethically fundamental for fetal medicine and surgery centers offering high-end innovative medical care.

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.

Prenatal brain imaging for predicting need for postnatal hydrocephalus treatment in fetuses that had neural tube defect repair in utero.

To determine if brain imaging in fetuses that underwent prenatal repair of neural tube defect (NTD) can predict the need for postnatal hydrocephalus treatment (HT) in the first year postpartum. This was a retrospective study of fetuses diagnosed with open NTD that had in-utero myelomeningocele repair between April 2014 and April 2016. Independent variables were collected from four chronological sets of fetal images: presurgery ultrasound, presurgery magnetic resonance imaging (MRI), 6-week postsurgery MRI and predelivery ultrasound. The following independent variables were collected from all image sets unless otherwise noted: gestational age, head circumference, mean ventricular width, ventricular volume (MRI only), hindbrain herniation (HBH) score (MRI only), and level of lesion (LOL), defined as the upper bony spinal defect (presurgery ultrasound only). Based on these measurements, additional variables were defined and calculated including change in degree of HBH, ventricular width growth (mm/week) and ventricular volume growth (mL/week). The need for HT (by either ventriculoperitoneal shunt or endoscopic third ventriculostomy with choroid plexus cauterization) was determined by a pediatric neurosurgeon using clinical and radiographic criteria; a secondary analysis was performed using the MOMS trial criteria for hydrocephalus. The predictive value of each parameter was assessed by receiver-operating characteristics curve and logistic regression analyses. Fifty affected fetuses were included in the study, of which 32 underwent open hysterotomy and 18 fetoscopic repair. Two neonates from the open hysterotomy group died and were excluded from the analysis. The mean gestational ages for the presurgery ultrasound, presurgery MRI, postsurgery MRI and predelivery ultrasound were 21.8 ± 2.1, 22.0 ± 1.8, 30.4 ± 1.6 and 31.0 ± 4.9 weeks, respectively. A total of 16 subjects required HT. The area under the curve (AUC) of predictive accuracy for HT showed that HBH grading on postsurgery MRI had the strongest predictive value (0.86; P < 0.01), outperforming other predictors such as postsurgery MRI ventricular volume (0.73; P = 0.03), MRI ventricular volume growth (0.79; P = 0.01), change in HBH (0.82; P = 0.01), and mean ventricular width on predelivery ultrasound (0.73; P = 0.01). Other variables, such as LOL, mean ventricular width on presurgery ultrasound, mean ventricular width on presurgery and postsurgery MRI, and ventricular growth assessment by MRI or ultrasound, had AUCs < 0.7. Optimal cut-offs of the variables with the highest AUC were evaluated to improve prediction. A combination of ventricular volume growth ≥ 2.02 mL/week and/or HBH of 3 on postsurgery MRI were the optimal cut-offs for the best prediction (odds ratio (OR), 42 (95% CI, 4-431); accuracy, 84%). Logistic regression analyses showed that persistence of severe HBH 6 weeks after surgery by MRI is one of the best predictors for HT (OR, 39 (95% CI, 4-369); accuracy, 84%). There was no significant change in the results when the MOMS trial criteria for hydrocephalus were used as the dependent variable. Persistence of HBH on MRI 6 weeks after prenatal NTD repair independently predicted the need for postnatal HT better than any ultrasound- or other MRI-derived measurements of ventricular characteristics. These results should aid in prenatal counseling and add support to the hypothesis that HBH is a significant driver of hydrocephalus in myelomeningocele patients. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

211: Chorioamniotic separation after prenatal myelomeningocele repair

To assess the risks associated with development of CAS after prenatal MMC repair We conducted a retrospective cohort study of patients who underwent open or fetoscopic prenatal MMC repair from December 2011-May 2018. Open repair technique was performed as reported in the MOMS Trial. Fetoscopic repair was performed using uterine CO2 insufflation, two or three ports, and an exteriorized uterus. Perinatal outcomes of patients who developed CAS after prenatal MMC repair were compared with those of patients who did not develop CAS. Degree of CAS was classified as mild if CAS occupied <25% of uterine surface area, moderate if 25-50%, or severe if >50%. Comparisons between cases with and without CAS were performed using Student's t-test, Chi-square, or Fisher’s exact test. Logistic regression analysis was used to determine risk of developing CAS, PPROM, or preterm delivery. Of 73 patients who underwent prenatal MMC repair, 24 (32.9%) developed CAS. CAS was detected at median of 28.9 (25.4 – 37.6) weeks gestation and 4 (0.4 – 12.6) weeks post-surgery. 70.8% of CAS cases were identified after fetoscopic repairs and 29.2% after open repairs (p=0.05). Development of CAS after fetoscopic repairs was independent of number of ports (3 ports: 35.3% vs. 2 ports: 64.7%; p=0.7) or maximal uterine pressure used (CAS: 11.9±1.7 mmHg vs. no CAS: 11.8±1.9 mmHg; p=0.7). Four variables were assessed for increased risk of developing CAS. Anterior placenta was the only variable with significant predictive value (p=0.03; OR: 3.23, 95% CI: 1.1-18.2). Fetoscopic repair, duration of surgery >3 hours, and use of three ports did not significantly increase risk of developing CAS. Cases with CAS developed PPROM 5.2 times more frequently than cases without CAS (95% CI:1.5-18.3; p<0.01). Cases of PPROM preceded by CAS occurred at later gestational age than those not preceded by CAS. A trend was noted for an association between CAS and placental abruption. When cases of moderate or severe CAS (n=11) were compared with mild CAS cases (n=12; severity of 1 case could not be assessed) at time of diagnosis, a trend for longer interval between CAS and delivery was observed in mild cases [7.8 (1.3-12.28) weeks vs. 2 (0.1-13.2 weeks); p=0.02]. Development of CAS increases the risk of adverse perinatal events. Efforts should be taken to reduce its incidence after prenatal MMC repair.

A study to assess global availability of fetal surgery for myelomeningocele.

To establish the provision of fetal surgery for myelomeningocele (MMC) worldwide. Through the International Society for Prenatal Diagnosis (ISPD) Fetal Therapy Special Interest Group and the North American Fetal Therapy Network (NAFTNet), fetal therapy centres were surveyed (September 2017-June 2018) regarding availability of fetal MMC surgical repair, patient inclusion criteria, repair techniques, number of cases, and outcome reporting. Responses were summarised on an interactive map on the ISPD website. Forty-four of 59 centres responded (74.6%) of which 34 centres (77.1%) currently offered fetal surgery for MMC and seven centres (15.9%) were awaiting a first case after service set up. Patient inclusion criteria were similar and based on the Management of Myelomeningocele (MOMS) trial. Five centres (14.7%) operated beyond 26weeks' gestational age, outside the MOMS criteria. Open fetal surgery was provided in 23 centres (67.6%), fetoscopic surgery only in five (14.7%), and six centres offered both types (17.6%). Neurosurgical closure was similar for open surgery but highly variable in fetoscopy surgery. The median number of cases per centre was 21 (range 1-253). Fetal surgery for MMC is now offered globally. Two thirds of centres offer open repair via hysterotomy using criteria based on the MOMS trial.

Lifestyle behaviors and ethnic identity among diverse women at high risk for type 2 diabetes

BackgroundDiet and physical activity lifestyle behaviors are modifiable risk factors for type 2 diabetes and are shaped by culture, potentially influencing diabetes health disparities. ObjectivesWe examined whether ethnic identity—the strength of attachment to one’s ethnic group, and a long-standing focus of psychological research—could help account for variations in lifestyle behaviors within a diverse population at high risk for chronic disease. MethodsUsing data from the Gestational Diabetes’ Effects on Moms trial, this US-based cross-sectional study included 1463 pregnant women (74% from minority ethnic/racial groups; 46% born outside the US) with gestational diabetes (GDM), a common pregnancy complication conferring high risk for type 2 diabetes after delivery. Mixed linear regression models examined whether ethnic identity is associated with lifestyle behaviors after adjusting for demographic, clinical, and acculturative characteristics (e.g., nativity and length of residence in the US). ResultsIn the overall sample, a one-unit increase in ethnic identity score was significantly associated with 3% greater fiber intake, 4% greater fruit/vegetable intake, 11% greater total activity, and 11% greater walking (p values < 0.01). Within ethnic/racial groups, a one-unit increase in ethnic identity score was significantly associated with 17% greater fiber intake among Filipina women; 5% lower total caloric intake among non-Hispanic White women; and 40% greater total activity, 35% greater walking, and 8% greater total caloric intake among Latina women (p values ≤ 0.03). ConclusionResults from this large study suggest that ethnic group attachment is associated with some lifestyle behaviors, independent of acculturation indicators, among young women with GDM who are at high risk for type 2 diabetes. Stronger ethnic identity may promote certain choices known to be associated with reduced risk of type 2 diabetes. Prospective research is needed to clarify the temporal nature of associations between ethnic identity and modifiable diabetes risk factors.