A Randomized Trial of Prenatal Versus Postnatal Repair of Myelomeningocele

Abstract

Background-Prenatal repair of myelomeningocele, the most common form of spina bifida, may result in better neurologic function than repair deferred until after delivery. We compared outcomes of in utero repair with standard postnatal repair.

Fetal surgery for spina bifida aperta

“…It showed that mid-gestational multilayered neurosurgical repair through laparotomy and hysterotomy (referred to as OFS) between 19 and 26 weeks of gestation reduces the need for ventriculoperitoneal shunting, improves the degree of hindbrain herniation and better preserves motor function when compared with postnatal surgery (table 1). 26 Subsequently, the long-term outcomes of the full cohort have confirmed and extended on its initial findings 27 28 32–34. The standardised multilayered anatomical repair, which can be used in the majority of patients, is displayed in figure 1.…”

“…Following corporeal hysterotomy, uterine wall thinning may develop in 35% of cases and the risk of peripartal bleeding is increased in the index pregnancy (table 2). 26 Thinning may however increase the risk of potentially life-threatening uterine rupture in the index and future pregnancies. There are no numbers yet on uterine wall thinning or rupture or haemorrhagic complications following SBA repair in subsequent pregnancies, though earlier studies on other OFS procedures quote a rate of thinning/rupture of 14%.…”

“…Summary of results of the randomised MOMS trial 26. When data are available from the complete trial cohort only the latter ones are displayed 27 28 34.…”

“…This was translated clinically with encouraging early results in several small case series 23–25. Eventually, these promising initial results led to the randomised controlled Management of Myelomeningocele Study (MOMS)26 which established the efficacy of fetal SBA repair. Fetal repair has however significant risks, such as premature delivery, maternal complications and the corporeal scar compromises uterine integrity 26–28.…”

Accounting for deaths in neonatal trials: is there a correct approach?

“…A randomised trial (MOMS) of prenatal versus postnatal repair myelomeningocele to postnatal surgery,9 used the BSID-II Psychomotor Development Index (PDI) score as a secondary outcome. There was a significant difference in the mean PDI score between the two groups (p=0.03).…”