Fetal Surgery for Myelomeningocele: Patient Selection, Perioperative Management and Outcomes

Danzer, Enrico; Adzick, N. Scott

doi:10.1159/000329785

Cited by 22 publications

(17 citation statements)

References 160 publications

(97 reference statements)

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“…Criteria for candidacy for fetal surgery, surgical technique and anesthetic management have been described elsewhere [3,9,10]. Inhalational desflurane provides maternal anesthesia, which importantly also provides for uterine relaxation that is required for successful fetal surgery.…”

Section: Methodsmentioning

confidence: 99%

The Role of Echocardiography in the Intraoperative Management of the Fetus Undergoing Myelomeningocele Repair

Rychik¹,

Cohen

Tran

et al. 2014

Fetal Diagn Ther

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Introduction: Fetal surgery for myelomeningocele (MMC) results in better outcomes compared to postnatal treatment. However, risks are present. We describe our experience with intraoperative fetal echocardiography during repair of MMC and report on the management of serious cardiovascular events. Material and Methods: The subjects included fetuses with intent to repair MMC from January 2011 to February 2014. The protocol involved continuous echocardiography in a looping, sequential manner of systolic function, heart rate and tricuspid and mitral valve regurgitation. Results: A total of 101 cases intended fetal MMC repair; 100 completed surgery. Intraoperative ventricular dysfunction was present in 60% (20 mild, 25 moderate, 15 severe). Heart rate <100 bpm was noted in 11 cases. Tricuspid valve regurgitation was present in 35% (26 mild, 7 moderate, 2 severe); mitral valve regurgitation was present in 19% (15 mild, 4 moderate). Serious cardiovascular events were experienced in 7 cases, which affected the conduct of surgery and/or outcome. In 4 of these, medications were given via the umbilical vein and external cardiac compressions were performed. Fetal echocardiography was used to gauge the efficacy of compressions and to guide resuscitation. Discussion: Cardiovascular compromise is common during fetal surgery for MMC. Intraoperative fetal echocardiography is recommended as a growing number of centers contemplate offering this form of novel, but potentially risky, therapy.

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Section: Methodsmentioning

confidence: 99%

The Role of Echocardiography in the Intraoperative Management of the Fetus Undergoing Myelomeningocele Repair

Rychik¹,

Cohen

Tran

et al. 2014

Fetal Diagn Ther

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“…Fetal surgery has been performed for more than 20 years to minimize the damaging effects of the intrauterine environment [4,15]. The level of the lesion was also found to be related to the outcome of fetal surgery.…”

Section: Discussionmentioning

confidence: 99%

Prenatal Determination of the Upper Lesion Level of Spina Bifida with Three-Dimensional Ultrasound

Büyükkurt

Binokay²,

Seydaoğlu

et al. 2012

Fetal Diagn Ther

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Introduction: To evaluate the role of three-dimensional (3D) sonography in the prenatal detection of the upper pole in fetuses with spina bifida. Material and Methods: Women admitted to a tertiary center with pregnancies with isolated open spina bifida were enrolled in the study. All fetuses had 3D sonography to predict the lesion level. The exact lesion level was ascertained using radiography and/or autopsy following the delivery at term or abortion. Results: Forty-eight cases were eligible for this study. Twenty-eight fetuses were diagnosed in the second trimester and the lesion level was precisely predicted in 24 (86%) of them. In 14 (70%) of the 20 fetuses diagnosed in the last trimester, the level was accurately determined. The remaining 10 fetuses, from both the second and third trimesters, were found to have a lesion level that was within one segment of the predicted lesion level. The correct matching rate was 38/48 (79%), and agreement within one segment was achieved in all cases. Discussion: According to our data, 3D ultrasound is useful for the prenatal determination of lesion level in spina bifida, which is an important prognostic factor.

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“…The karyotype should be normal. Both the anesthesiologist and the maternal-fetal medicine specialists screened for physical maternal risks 55,81 . These were a compromise between the very strict criteria used in Philadelphia and a more wide 72,80 .…”

Section: Preoperative Work Upmentioning

confidence: 99%

“…A wide range of maternal monitoring techniques were used 81 . Prior to the operation, cefazolin (1000 mg I.V.)…”

Section: Surgical Proceduresmentioning

confidence: 99%

The Prenatal Management of Neural Tube Defects: Time for a Re-Appraisal

Endo

Mieghem

Eixarch

et al. 2012

Fet. Matern. Med. Rev.

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The prevalence of neural tube defects (NTD) in Europe is around 9 per 10,000 births making it one of the most frequent congential anomalies affecting the central nervous system. NTD encompass all anomalies that are secondary to failure of closure of the neural tube. In this review, we will first summarize the embryology and some epidemiologic aspects related to NTDs. The review focuses on myelomeningocele (MMC), which is the most common distal closure defect. We will describe the secondary pathologic changes in the central and peripheral nervous system that appear later on in pregnancy and contribute to the condition's morbidity. The postnatal impact of MMC mainly depends on the upper level of the lesion. In Europe, the vast majority of parents with a fetus with prenatally diagnosed NTDs, including MMC, opt for termination of pregnancy, as they are apparently perceived as very debilitating conditions. Animal experiments have shown that prenatal surgery can reverse this sequence. This paved the way for clinical fetal surgery resulting in an apparent improvement in outcome. The results of a recent randomized trial confirmed better outcomes after fetal repair compared to postnatal repair; with follow up for 30 months. This should prompt fetal medicine specialists to reconsider their position towards this condition as well as its prenatal repair. The fetal surgery centre in Leuven did not have a clinical programme for fetal NTD repair until the publication of the MOMS trial. In order to offer this procedure safely and effectively, we allied to a high volume centre willing to share its expertise and assist us in the first procedures. Given the maternal side effects of current open fetal surgical techniques, we have intensified our research programmes to explore minimally invasive alternatives. Below we will describe how we are implementing this.

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Fetal Surgery for Myelomeningocele: Patient Selection, Perioperative Management and Outcomes

Cited by 22 publications

References 160 publications

The Role of Echocardiography in the Intraoperative Management of the Fetus Undergoing Myelomeningocele Repair

The Role of Echocardiography in the Intraoperative Management of the Fetus Undergoing Myelomeningocele Repair

Prenatal Determination of the Upper Lesion Level of Spina Bifida with Three-Dimensional Ultrasound

The Prenatal Management of Neural Tube Defects: Time for a Re-Appraisal

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