Fetal Myelomeningocele Repair: The Post-MOMS Experience at the Children's Hospital of Philadelphia

Abstract

Background: Fetal myelomeningocele (fMMC) repair has become accepted as a standard of care option in selected circumstances. We reviewed our outcomes for fMMC repair from referral and evaluation through surgery, delivery and neonatal discharge. Material and Methods: All patients referred for potential fMMC repair were reviewed from January 1, 2011 through March 7, 2014. Maternal and neonatal data were collected on the 100 patients who underwent surgery. Results: 29% of those evaluated met the criteria and underwent fMMC repair (100 cases). The average gestational age was 21.9 weeks at evaluation and 23.4 weeks at fMMC repair. Complications included membrane separation (22.9%), preterm premature rupture of membranes (32.3%) and preterm labor (37.5%). Average gestational age at delivery was 34.3 weeks and 54.2% delivered at ≥35 weeks. The perinatal loss rate was 6.1% (2 intrauterine fetal demises and 4 neonatal demises); 90.8% of women delivered at the Children's Hospital of Philadelphia and 3.4% received transfusions. With regard to the neonates, 2 received ventriculoperitoneal shunts prior to discharge; 71.1% of neonates had no evidence of hindbrain herniation on MRI. Of the 80 neonates evaluated, 55% were assigned a functional level of one or more better than the prenatal anatomic level. Conclusion: In an experienced program, maternal and neonatal outcomes for patients undergoing fMMC repair are comparable to results of the MOMS trial.

Fetal Myelomeningocele Repair through a Mini-Hysterotomy

“…We concentrated on the comparison of our data (39 cases with neonatal results) with data from the postMOMs experience, which focused on the perinatal results rather than on a longer-term follow-up of the infants [13] . Our inclusion criteria for fetal MMC repair were comparable, as were most of the maternal and fetal characteristics at the time of fetal surgery, which are summarized as follows (present series × post-MOMs experience): average GA at surgery (24.5 × 23.3 weeks); most frequent upper level of the MMC (L1-L4: 74.2 × 87.0%); average size of the larger lateral cerebral ventricle (11.3 × 10.6 mm), and presence of talipes (38.5 × 15.0%).…”

Establishing Prenatal Surgery for Myelomeningocele in Asia: The Singapore Consensus

“…Europe and Asia had more high-volume centers, whereas South America, the Middle East, and Australia had mainly low-volume centers [59] . A recent post-MOMS publication has shown that only 29% of referrals are actually eligible [60] . It has not been universally agreed if ex utero intrapartum treatment deliveries count toward this minimum annual volume requirement.…”

Prenatal Decision-Making for Myelomeningocele: Can We Minimize Bias and Variability?

“…1 Although it is hoped that an evidence-based approach to medical decisions using the MOMS results would improve the quality of information received by pregnant patients, we believe that unless specific steps are taken, prenatal counseling for myelomeningocele (counseling that occurs in myriad locations across the United States) will be persistently marred by hidden biases and excess variability.…”

“…Adding to the uncertainty, long-term outcomes are unavailable; prognosis remains difficult to predict for any given fetus; and posttrial complication rates reportedly differ from trial results, with higher rates of perinatal death (6% vs 3%) and respiratory distress syndrome (52% vs 21%) but fewer maternal complications (pulmonary edema, 2% vs 6%; maternal transfusion, 3.4% vs 9%). 1 Women undergoing intrauterine surgery require cesarean deliveries for all future pregnancies. The reasoning regarding such multifaceted risk/benefit tradeoffs for obstetric and neonatal interventions is notably difficult for both physicians and patients.…”