Fetal surgery for open spina bifida

M R C O G PA R T 2 · S O S P O C K E T C A R D · K N O W L E D G E A R E A 5 – A N T E N ATA L C A R E

Fetal Surgery for Open Spina Bifida Sacco A et al. Fetal surgery for open spina bifida. TOG 2019;21:271–282. doi:10.1111/tog.12603

4.63/10,000 44% vs 84% 45% vs 24% WORLDWIDE SPINA BIFIDA INCIDENCE VP SHUNT: PRENATAL VS POSTNATAL (MOMS) INDEPENDENT WALKING AT 30MO (MOMS)

DO N' T-M IS S FA C TS

  1. MOMS trial (n=183): prenatal vs postnatal repair – VP shunt 44% vs 84%; hindbrain herniation at 12mo 64% vs 96%; independent walking at 30mo 44.8% vs 23.9%

  2. Trade-off = prematurity: mean GA at birth 34.1 vs 37.3 weeks; 13% delivered <30 weeks; RDS 21% vs 6%

  3. Maternal risks: placental abruption 6.6%, pulmonary oedema 5.5%, transfusion 8.8%, uterine dehiscence 9.1%/rupture 2.3%

  4. Fetal death risk with surgery 3% vs neonatal death 2% after postnatal repair (not statistically different) – but is an active parental choice

  5. Surgery window: 23+0–25+6 weeks (not before 23 weeks – earlier surgery ↑ PPROM/chorioamniotic separation/preterm birth)

  6. Folic acid: MRC Vitamin Study – peri-conceptual supplementation cuts recurrence risk by ~70%; WHO dose 400 µg/day from 2 months pre-conception

  7. Preterm labour after fetal surgery → emergency caesarean (uterine rupture risk); otherwise elective caesarean at 37 weeks

  8. Fetoscopic repair: higher PPROM (79% vs 36%) and neonatal repair-site treatment (30% vs 7%); ACOG (2017) restricts to research settings only

AMBULATION BY LESION LEVEL (ADULTHOOD)

Sacral: 93% L5: 91% L4: 57% L1–3/thoracic: 0%

KEY NUMBERS

UK incidence: 700–900/year; hydrocephalus in up to 80% Availability: 23 centres worldwide, 6 in Europe; NHS England commissioning 2 UK centres (2019) 10-year follow-up (n=42): 79% community ambulators; VP shunt rate 43% (61% needed revision)

ABBREVIATION KEY

MMC — myelomeningocele MRI — magnetic resonance imaging

CSF — cerebrospinal fluid BMI — body mass index

MOMS — Management of Myelomeningocele Study ACOG — American College of Obstetricians and Gynecologists

VP shunt — ventriculoperitoneal shunt GIFT-Surg — Guided Instrumentation for Fetal Therapy and Surgery project MRC — Medical Research Council FASP — Fetal Anomaly Screening Programme WHO — World Health Organization NHS — National Health Service IQ — intelligence quotient EPSRC — Engineering and Physical Sciences Research Council PPROM — preterm premature rupture of membranes

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — Sacco A et al. Fetal surgery for open spina bifida. TOG 2019;21:271–282. doi:10.1111/tog.12603

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