Prenatal Repair of Spina Bifida: A 2-Center Experience with Open Intrauterine Neurosurgery in Chile

Abstract

Objective: To report the experience with prenatal repair of open spina bifida (OSB) from 2 centers in Chile. Methods: Women with a second-trimester fetus with OSB were offered intrauterine neurosurgical repair following the protocol from the Management of Myelomeningocele Study (MOMS) trial. Pediatric follow-up with infants reaching 12 and 30 months of life was also reviewed. Results: Fifty-eight fetuses with OSB underwent intrauterine repair at an average (±SD) gestational age of 24.8 ± 0.9 weeks. There were 3 (5.1%) intrauterine deaths. The average gestational age at delivery of the remaining 55 cases was 33.3 ± 3.6 weeks, and the average birth weight was 2,172 ± 751 g. Delivery before 30 weeks occurred in 11 cases (20.0%). Two (3.6%) neonatal deaths (<28 days) occurred. At 12 months, a ventriculoperitoneal shunt or an endoscopic third ventriculostomy was required in 25% of the cases. At 30 months, 72.4% of the infants were able to walk. Discussion: Prenatal neurosurgical repair of OSB is a complex and challenging intervention. Major complications include perinatal death and severe prematurity. No major maternal complications occurred in our series. A reduction in the need for cerebrospinal fluid diversion and an improved ability to walk seem to be the greatest longterm advantages of this procedure.

Open Fetal Microneurosurgery for Intrauterine Spina Bifida Repair

“…Our first 2 surgeries were performed in collaboration with specialists from Santiago, Chile, led by Professor Waldo Sepulveda, who at that time had performed 35 procedures and whose experience was recently published, including 58 consecutive interventions [6]. The following interventions were performed by our local Mexican group, which included a multidisciplinary team involving maternal-fetal medicine specialists (M.M.R., J.L.G., and H.L.B.…”

“…Our first 2 surgeries were performed in collaboration with specialists from Santiago, Chile, led by Professor Waldo Sepulveda, who at that time had performed 35 procedures and whose experience was recently published, including 58 consecutive interventions [6] In brief, under maternal regional and general anesthesia with sevoflurane, a maternal Pfannenstiel laparotomy through a low transverse abdominal incision was performed to allow uterine exteriorization from the abdominal cavity. The fetal position was evaluated by ultrasound and, if necessary, the fetus was moved by a gentle external manipulation to reach the optimal position, that is, a longitudinal position, with cephalic presentation and with the SB defect located against the uterine wall and in the contralateral side of the placenta.…”

“…However, the aforementioned fetal intervention is also associated with potential maternal and fetal risks such as preterm delivery, placental abruption, preterm rupture of the membranes, perinatal mortality, uterine bleeding requiring blood transfusion, uterine dehiscence at delivery, and higher risk of preterm delivery even in subsequent pregnancies [4][5][6], and therefore, the design of novel minimally invasive techniques is in the research agenda of different fetal surgery centers [7].…”

Open intrauterine repair of spina bifida aperta: Historical aspects, current availability, and clinical outcomes from the Latin American Spina Bifida Consortium

“…In one case there was a nonreducible umbilical cord prolapse immediately after hysterotomy resulting in an intraoperative fetal death. 23 There was another case of intraoperative fetal death due to abruptio placenta (CUB). Regarding maternal intraoperative complications, there was a bladder injury of about 1 cm noted before closure of the laparotomy, which was repaired and managed with a urinary catheter for 7 days without any additional consequences (HCVB).…”

“…± 3.2 weeks' gestation (range,[23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39]. Overall, severe premature delivery occurring at <30 weeks was recorded in 36 of these cases (11.5%), delivery between 30 and 34 weeks in 118 cases (37.6%), and delivery at ≥35 weeks in 160 cases (51.0%).…”