19-Year Follow-Up of Fetal Myelomeningocele Brought to Term

Abstract

We conducted a 19-year follow-up study of 223 infants with myelomeningocele born by cephalic presentation, 68 born by pre-rupture of amniotic membranes cesarean section (PRAM C/S) and 155 born vaginally to determine outcome. We recorded radiographic level as the last intact vertebral arch at the cephalad end of the spinal defect from standard AP films of the spine. Protrusions of the lesions dorsal to the back were obtained from medical records or parental recall. Subsequent spinal cord abnormalities (hydromyelia, tethered cord and hypoplasia) were determined by patient's symptoms and verified by MRI. Data were from our Patient Data Management System and analyzed using Microsoft Excel and Epi Info 6. Flat lesions protruding less than 1.0 cm beyond the plane of the back and those associated with breech position or kyphus were not benefited by PRAM CIS (Fisher's Exact, p = 0.58 between the two types of delivery for motor level). Flat lesions were more common in the vaginally delivered group (p = 0.01). Lesions protruding equal to 1.0 cm or beyond were associated with less paralysis after PRAM C/S (p = 0.01). Although tethered cord syndrome was more common in the PRAM C/S group (p = 0.02), there was no difference in the muscle strength loss between the PRAM C/S and the vaginally delivered groups. Symptomatic hydromyelia was equally distributed but spinal cord hypoplasia was more common in the PRAM C/S group (p = 0.03). Due to the limited numbers of patients in each group available for analysis, we recommend further study to ascertain the appropriate management of fetal myelomeningocele diagnosed in utero and brought to term.

Pediatric perspective on prenatal counseling for myelomeningocele

“…Our large study of fetuses with myelomeningocele suggests that cesarean section delivery improves motor outcomes and may decrease the likelihood of infection and prevent brain damage from bleeding (Luthy et al, 1991). We now recommend cesarean section delivery before rupture of amniotic membranes for fetuses with myelomeningocele meeting the following criteria: 1) lesion protruding more than 1 cm beyond the surface of the back; 2) intact knee movement; and 3) absence of other severe, untreatable malformations or chromosomal anomalies (Liu et al, 1999). Several smaller studies have not confirmed a positive effect for pre-labor cesarean section; however, these studies did not take into account the selection criteria above (Merrill et al, 1998;Owen, 1998;Lewis et al, 2004).…”

Determination of Tripler Army Medical Center Outpatient Service and Ambulatory Procedure Charges to the Veterans Administration for Fiscal Year 2000

“…Spreadsheet software is widely used in the business community for data manipulation, calculation and presentation. Previous studies suggest Excel is a valid and reliable business tool (Brown, 1999;Liu, Shurtleff, Ellenbogen, Loeser, & Kropp, 1999;Walter, 1999). Excel® greatly simplified the repetitive calculations associated with rate analysis.…”

Fetal endoscopic myelomeningocele repair

“…It has the potential of being useful in distinguishing between toxicity from late gestational amniotic fluid to exposed nerves 2 and the trauma of delivery. [3][4][5] To do so would require comparing patients with prenatally repaired myelomeningocele lesions to children with myelomeningocele and functional leg muscles, and a sac protruding 2cm or more beyond the dorsal plane of the back prior to rupture of the amniotic membranes. 4,5 Muscle ultrasound density would be more useful in predicting future lower extremity function in the newborn with myelomeningocele if used to more accurately display individual muscle density over time.…”

“…[3][4][5] To do so would require comparing patients with prenatally repaired myelomeningocele lesions to children with myelomeningocele and functional leg muscles, and a sac protruding 2cm or more beyond the dorsal plane of the back prior to rupture of the amniotic membranes. 4,5 Muscle ultrasound density would be more useful in predicting future lower extremity function in the newborn with myelomeningocele if used to more accurately display individual muscle density over time. 6,7 Fetal endoscopic myelomeningocele closure, the second technological advance, is listed in both the title and conclusion of the article.…”

“…Bilateral vasculopathy and duration of the disease are other important factors, suggested by the study by Williams et al 2 Even with these elements, choosing the right moment for surgery candidacy may be quite difficult and subjective. Because surgery increases cognitive abilities (or prevents further decline) and decreases stroke occurrence, 4,5 other quantitative tools are needed to evaluate the chronic effects of hypoxia. In this way, cognitive and behavioral aspects should be further studied using thorough longitudinal pre-and post-operative neuropsychological follow-up.…”