[Preliminary results from the French study on prenatal repair for fetal myelomeningoceles (the PRIUM study)]

Historical Clinical Outcomes of Children with Myelomeningocele Meeting the Criteria for Fetal Surgery: A Retrospective Cohort Survey of Brazilian Patients

OBJECTIVE

 To analyze the historical clinical outcomes of children with myelomeningocele (MMC) meeting the criteria for fetal surgery, but who underwent postnatal primary repair.

METHODS

 Data from children undergoing postnatal MMC repair between January 1995 and January 2015 were collected from the Neurosurgery Outpatient Clinic's medical records. Children were included if they had ≥ 1 year of postoperative follow-up and met the criteria for fetal surgery. The children's data were then stratified according to whether they received a shunt or not. The primary outcome was mortality, and secondary outcomes were educational delays, hospitalization, recurrent urinary tract infections (UTIs), and renal failure.

RESULTS

 Over the 20-year period, 231 children with MMC were followed up. Based on clinical data recorded at the time of birth, 165 (71.4%) qualify of fetal surgery. Of the 165 patients, 136 (82.4%) underwent shunt placement. The mortality rate was 5.1% in the group with shunt and 0% in the group without, relative risk (RR) 3.28 (95% confidence interval, 95% CI, 0.19-55.9). The statistically significant RRs for adverse outcomes in the shunted group were 1.86 (95% CI, 1.01-3.44) for UTI, 30 (95% CI, 1.01-537) for renal failure, and 1.77 (95% CI, 1.09-2.87) for hospitalizations.

CONCLUSION

 Children with MMC qualifying for fetal surgery who underwent shunt placement were more likely to have recurrent UTIs, develop renal failure, and be hospitalized. Since approximately half of the shunt procedures could be avoided by fetal surgery, there is a clinical benefit and a possible financial benefit to the implementation of this technology in our setting.

Prenatal neurosurgical counseling for conditions affecting the fetal nervous system

OBJECTIVE

The aim of this study was to share a single center's experience of prenatal neurosurgical counseling and explore pregnant women's experiences with counseling.

MATERIAL AND METHODS

This retrospective study analyzed data for 81 women who received prenatal counseling in a single institution (same senior pediatric neurosurgeon) over a 6-year period. Additionally, a retrospective questionnaire study was conducted with 33 women who chose to continue their pregnancy, to assess the strengths and weaknesses of counseling and analyze the reasons for their decision.

RESULTS

Spinal dysraphism was the most frequent condition leading to prenatal counseling, followed by conditions affecting the cerebrospinal fluid. 57.6% of the women did not follow the French national recommendations on folic acid supplementation in the periconceptional period, and 38.3% underwent termination of pregnancy (TOP). One-third of the 33 women who answered our questionnaire changed their mind about TOP after counseling, and 50% reported that the information provided influenced their decision.

CONCLUSION

Prenatal neurosurgical counseling is nowadays an important part of a pediatric neurosurgeon's practice. It provides specific information to the woman to decide whether to continue the pregnancy. Urological concerns are frequent among the malformations encountered. Hence, we conclude that these women should be offered the possibility of seeing a urologist. Areas for improvement include greater awareness regarding folic acid supplementation and improved psychological care. The advantage for a woman of consulting a neurosurgeon consists in receiving information that is as accurate as possible about the level of disability of the future child and about surgery and follow-up.

[The ethics of fetal myelomeningocele surgery]

Fetal myelomeningocele surgery was introduced in France in 2014. Developments in prenatal diagnosis of neural tube defects have accompanied the development of prenatal diagnosis. This fetal surgery represents one of the three possible care paths for pregnant women faced with this prenatal diagnosis. The ethical issues of this fetal surgery are discussed and in particular regarding prenatal counselling and patient autonomy of choice.

Open fetal surgery for myelomeningocele repair in France

INTRODUCTION

Open fetal myelomeningocele (MMC) surgery is currently the standard of care option for prenatal MMC repair. We described the population referred to our center and reviewed outcome after open fetal MMC repair.

MATERIAL AND METHODS

All patients referred to our center for MMC were reviewed from July 2014 to June 2020. For all the patients who underwent fetal MMC repair, surgical details, maternal characteristics and data from the neonatal to the three-years-old evaluations were collected.

RESULTS

Among the 126 patients referred to our center, 49.2% were eligible and 27.4% (n = 17) of them underwent fetal MMC repair. Average gestational age at fetal surgery was 24⁺⁶ weeks. There was no case of fetal complication and the only maternal complication was one case of transfusion. We recorded 70% of premature rupture of membranes and 47% of premature labor. Average gestational age at delivery was 34⁺² weeks and no patient delivered before 30 weeks. There was no case of uterine scar dehiscence or maternal complication during cesarean section. After birth, 59% of the children had a hindbrain herniation reversal. At 1-year-old, 42% were assigned a functional level of one or more better than expected according to the prenatal anatomic level and 25% required a ventriculoperitoneal shunt. At 3-year-old, all the children attended school and 75% were able to walk with orthotics or independently.

CONCLUSION

Open fetal surgery enables anatomical repair of the MMC lesion, a potential benefit on cerebral anomalies and motor function, with a low rate of perinatal and maternal complications.

New insights in cerebral findings associated with fetal myelomeningocele: a retrospective cohort study in a single tertiary centre

OBJECTIVE

To investigate cerebral anomalies other than Chiari type 2 malformation in fetuses with myelomeningocele (MMC).

DESIGN

A retrospective cohort study in a single tertiary centre.

SETTING

A review of associated cerebral anomalies in cases with prenatal diagnosis of myelomeningocele.

POPULATION

Seventy cases of fetal myelomeningocele.

METHODS

Ultrasound and MRI images were blindly reviewed. Postnatal imaging and results of the postmortem results were also reviewed. The association between cerebral anomalies and the following ultrasound findings was measured: level of the defect, ventriculomegaly, microcephaly and fetal talipes.

MAIN OUTCOME MEASURES

A microcephaly was observed in 32/70 cases (46%) and a ventriculomegaly was observed in 39/70 cases (56%). Other cerebral anomalies were diagnosed in 47/70 (67%).

RESULTS

Other cerebral anomalies were represented by 42/70 cases with abnormal CC (60%), 8/70 cases with perinodular heterotopia (PNH; 11%), 2/70 cases with abnormal gyration (3%). MRI performed only in fetal surgery cases confirmed the ulltrasound findings in all cases and provided additional findings in two cases (PNH). Risk ratios of fetal cerebral anomalies associated with MMC did not reach significance for microcephaly, ventriculomegaly, talipes or the level of the defect There was an overall good correlation between pre- and postnatal findings with a Kappa value of 0.79 [95% CI 0.57-1] and 82% agreement.

CONCLUSION

Fetal brain anomalies other than Chiari type 2 malformation are frequently observed in fetuses with myelomeningocele, predominantly represented by CC anomalies. Whether these associated cerebral anomalies have an impact on selecting cases eligible for fetal surgery needs further evaluation.

TWEETABLE ABSTRACT

Fetal cerebral anomalies other than Chiari type 2 malformation, microcephaly, and ventriculomegaly may be associated with MMC in up to 67% of the cases.

Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta-analysis

OBJECTIVE

To establish maternal complication rates for fetoscopic or open fetal surgery.

METHODS

We conducted a systematic literature review for studies of fetoscopic or open fetal surgery performed since 1990, recording maternal complications during fetal surgery, the remainder of pregnancy, delivery, and after the index pregnancy.

RESULTS

One hundred sixty-six studies were included, reporting outcomes for open fetal (n = 1193 patients) and fetoscopic surgery (n = 9403 patients). No maternal deaths were reported. The risk of any maternal complication in the index pregnancy was 20.9% (95%CI, 15.22-27.13) for open fetal and 6.2% (95%CI, 4.93-7.49) for fetoscopic surgery. For severe maternal complications (grades III to V Clavien-Dindo classification of surgical complications), the risk was 4.5% (95% CI 3.24-5.98) for open fetal and 1.7% (95% CI, 1.19-2.20) for fetoscopic surgery. In subsequent pregnancies, open fetal surgery increased the risk of preterm birth but not uterine dehiscence or rupture. Nearly one quarter of reviewed studies (n = 175, 23.3%) was excluded for failing to report the presence or absence of maternal complications.

CONCLUSIONS

Maternal complications occur in 6.2% fetoscopic and 20.9% open fetal surgeries, with serious maternal complications in 1.7% fetoscopic and 4.5% open procedures. Reporting of maternal complications is variable. To properly quantify maternal risks, outcomes should be reported consistently across all fetal surgery studies.

Tocolysis for open prenatal repair of myelomeningocele: systematic review

Objectives: To summarize current evidence on the use of tocolytic medications perioperatively for open prenatal repair of fetal myelomeningocele including tocolytic agent options, regimens, efficiency, and potential risks.Methods: 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, perinatal outcomes were included. Studies that did not exclusively assessed fetal myelomeningocele or did not adequately endorse obstetric and neonatal outcomes were excluded. Neither sample size nor language was a basis for exclusion.Results: 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 studied a spectrum of anomalies, three specified fetoscopy, four did not report neonatal outcomes, and one article was retracted. Two studies were added to the pool when the literature search was updated. Nine articles were eventually included; three case reports, six cohort studies with a total of 205 cases. Fetuses were managed at gestational ages between 19 and 30 weeks. Although tocolytic regimens were variable, indomethacin was commonly utilized as a preoperative tocolytic. Magnesium sulfate was usually initiated intraoperatively and was resumed postoperatively for a variable duration (18-48 hours) with or without subcutaneous terbutaline. Gestational age at delivery ranged from 30-37 weeks with an average of 33-35 weeks. Pulmonary edema was reported in two studies to be 2.2-5.5%. Perinatal outcomes were overall favorable.Conclusion: Preoperative indomethacin and postoperative course of magnesium sulfate seem to be a favorable tocolytic option in women with open prenatal myelomeningocele repair. Risks are generally minimal. However, adequate information on the duration of postoperative tocolysis seems to be inadequate.

A case of prenatally diagnosed limited dorsal myeloschisis with good prognosis

Diagnosis of fetal spinal dysraphism is a challenge. It is difficult to distinguish between a meningocele, myelomeningocele, and a recently described entity called limited dorsal myeloschisis (LDM). Although myelomeningocele is associated with a poor prognosis, LDM can have a good outcome. We present a case of prenatally diagnosed LDM. Because sonographic examination revealed a round, cystic, septated cervical mass without associated cerebral anomalies, the lesion was initially considered an isolated meningocele. Fetal MRI contributed to correct the diagnosis. A diagnostic error can lead to the wrong surgical support or even the termination of pregnancy. Therefore, we highlight the importance of fetal MRI in such cases, particularly when no cerebral abnormalities are observed on sonographic examination.

Comparison of Prenatal and Postnatal Management of Patients with Myelomeningocele

Myelomeningocele (MMC) is a costly lifetime disease with many comorbidities, including sensory and motor lower limb disability, bladder/bowel dysfunction, scoliosis, club foot, and hydrocephalus. MMC treatment options have changed over time because routine use of fetal ultrasonography and MRI has provided prenatal diagnosis and the potential for fetal surgery. There is still no consensus on how to treat the MMC diagnoses prenatally, mainly related to the infrastructure required to operate on pregnant patients. This article provides an overview of prenatal and postnatal MMC repair and the features in the prenatal diagnosis.