Position statement on fetal myelomeningocele repair

Cohen, Alan R.; Couto, James; Cummings, James J.; Johnson, Anthony; Joseph, Gerald F.; Kaufman, Bruce A.; Litman, Ronald S.; Menard, M. Kathryn; Moldenhauer, Julie S.; Pringle, Kevin C.; Schwartz, Marshall Z.; Walker, William O.; Warf, Benjamin C.; Wax, Joseph R.

doi:10.1016/j.ajog.2013.09.016

Cited by 76 publications

(81 citation statements)

References 5 publications

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“…an increased risk for preterm delivery and resulting low birth weight, increased risk for neonatal respiratory distress syndrome, and higher risk for operative and obstetrical complications such as pulmonary edema, membrane rupture and related problems, thinning or dehiscence at the hysterotomy site, the future need for cesarean delivery, and a recovery period of 2 years until the next attempted pregnancy. Lastly, when patients opt for fetal surgery, we clarify that the experience with fetal repair in Europe is far from what it is in the hands of the MOMS trial participants [40]. We mention how our team got acquainted with the procedure, what our experience is and that, in the first 5 cases, on-site training was still taking place.…”

Section: Discussionmentioning

confidence: 99%

“…Complex multidisciplinary pathology and subsequent procedures require a certain regularity - hence volume - in assessed and operated cases. Although some team members observed many cases elsewhere, and the entire team has already performed more than the minimum of 5 cases according to the recent position statement [40], we are somewhat concerned about the viability of this (or similar) limited volume fetal spina bifida repair program in Europe. In view of the low rates of live-born spina bifida cases, as well as the low uptake rate for fetal surgery, we may not achieve a sufficient patient accrual rate to allow, for example, the training of a large number of surgeons.…”

Section: Future Perspectivesmentioning

confidence: 99%

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Prenatal Diagnosis and Patient Preferences in Patients with Neural Tube Defects around the Advent of Fetal Surgery in Belgium and Holland

Ovaere

Eggink²,

Richter³

et al. 2014

Fetal Diagn Ther

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Introduction: We review the characteristics and prenatal choices of patients recently evaluated for neural tube defects (NTD) at two tertiary units. The prenatal diagnosis of NTD allows parents to consider all prenatal options. In selected cases of spina bifida aperta this also includes fetal surgery, which we started offering after combined ‘in-house' and ‘exported' training. Material and Methods: This is a retrospective review of prospectively collected data on NTD diagnosed over the last 8 years and recent fetal surgery referrals. Results: A total of 167 patients were referred for assessment at a median of 19 weeks. Cranial lesions were diagnosed significantly earlier than spinal lesions. Of the open spinal lesions, 77% were isolated. Of these, 22% were managed expectantly and 1 (1%) had fetal surgery. There was no correlation between parental decisions on prenatal management with disease-specific severity markers. We had 14 fetal surgery referrals, all but 1 from beyond our typical referral area; 6 of the assessed patients were operated on, 4 were expectantly managed and 4 requested termination of pregnancy (TOP). These pregnancy outcomes were in the expected range. Discussion: Open spina bifida is mainly diagnosed in the second trimester and 76% of subjects request TOP, irrespective of the severity indicators. The number of local patients considering fetal surgery is low.

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Section: Discussionmentioning

confidence: 99%

Section: Future Perspectivesmentioning

confidence: 99%

Prenatal Diagnosis and Patient Preferences in Patients with Neural Tube Defects around the Advent of Fetal Surgery in Belgium and Holland

Ovaere

Eggink²,

Richter³

et al. 2014

Fetal Diagn Ther

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“…Our series highlights the importance of careful fetal echocardiographic monitoring during fetal surgery - an important recommendation at this time as a growing number of centers contemplate offering this form of novel and potentially risky therapy for their patients [19]. …”

Section: Discussionmentioning

confidence: 99%

The Role of Echocardiography in the Intraoperative Management of the Fetus Undergoing Myelomeningocele Repair

Rychik¹,

Cohen

Tran

et al. 2014

Fetal Diagn Ther

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Introduction: Fetal surgery for myelomeningocele (MMC) results in better outcomes compared to postnatal treatment. However, risks are present. We describe our experience with intraoperative fetal echocardiography during repair of MMC and report on the management of serious cardiovascular events. Material and Methods: The subjects included fetuses with intent to repair MMC from January 2011 to February 2014. The protocol involved continuous echocardiography in a looping, sequential manner of systolic function, heart rate and tricuspid and mitral valve regurgitation. Results: A total of 101 cases intended fetal MMC repair; 100 completed surgery. Intraoperative ventricular dysfunction was present in 60% (20 mild, 25 moderate, 15 severe). Heart rate <100 bpm was noted in 11 cases. Tricuspid valve regurgitation was present in 35% (26 mild, 7 moderate, 2 severe); mitral valve regurgitation was present in 19% (15 mild, 4 moderate). Serious cardiovascular events were experienced in 7 cases, which affected the conduct of surgery and/or outcome. In 4 of these, medications were given via the umbilical vein and external cardiac compressions were performed. Fetal echocardiography was used to gauge the efficacy of compressions and to guide resuscitation. Discussion: Cardiovascular compromise is common during fetal surgery for MMC. Intraoperative fetal echocardiography is recommended as a growing number of centers contemplate offering this form of novel, but potentially risky, therapy.

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“…Commentators have expressed concern regarding training and competence even in basic prenatal diagnostic procedures, given the rapid uptake of non-invasive prenatal testing (Hui et al, 2016). At the other extreme, minimum criteria have been proposed for centers wishing to offer advanced fetal surgeries, such as fetal myelomeningocoele repair, in order to fully realize the benefits observed in trial settings (Cohen et al, 2014). Such criteria are useful, but are arguably easier to impose in rare elective surgeries than in a more common condition such as TTTS where the need for surgery may become urgent, in a patient often difficult to transfer.…”

Section: The Challenge Of Achieving and Maintaining Procedural Competmentioning

confidence: 99%

Balancing Patient Access to Fetoscopic Laser Photocoagulation for Twin-to-Twin Transfusion Syndrome With Maintaining Procedural Competence: Are Collaborative Services Part of the Solution?

et al. 2016

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The benefits of fetoscopic laser photocoagulation (FLP) for treatment of twin-to-twin transfusion syndrome (TTTS) have been recognized for over a decade, yet access to FLP remains limited in many settings. This means at a population level, the potential benefits of FLP for TTTS are far from being fully realized. In part, this is because there are many centers where the case volume is relatively low. This creates an inevitable tension; on one hand, wanting FLP to be readily accessible to all women who may need it, yet on the other, needing to ensure that a high degree of procedural competence is maintained. Some of the solutions to these apparently competing priorities may be found in novel training solutions to achieve, and maintain, procedural proficiency, and with the increased utilization of 'competence based' assessment and credentialing frameworks. We suggest an under-utilized approach is the development of collaborative surgical services, where pooling of personnel and resources can improve timely access to surgery, improve standardized assessment and management of TTTS, minimize the impact of the surgical learning curve, and facilitate audit, education, and research. When deciding which centers should offer laser for TTTS and how we decide, we propose some solutions from a collaborative model.

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Position statement on fetal myelomeningocele repair

Cited by 76 publications

References 5 publications

Prenatal Diagnosis and Patient Preferences in Patients with Neural Tube Defects around the Advent of Fetal Surgery in Belgium and Holland

Prenatal Diagnosis and Patient Preferences in Patients with Neural Tube Defects around the Advent of Fetal Surgery in Belgium and Holland

The Role of Echocardiography in the Intraoperative Management of the Fetus Undergoing Myelomeningocele Repair

Balancing Patient Access to Fetoscopic Laser Photocoagulation for Twin-to-Twin Transfusion Syndrome With Maintaining Procedural Competence: Are Collaborative Services Part of the Solution?

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