Specialty-Based Variation in Applying Maternal-Fetal Surgery Trial Evidence

Abstract

Introduction: The Management of Myelomeningocele Study (MOMS) compared prenatal with postnatal surgery for fetal myelomeningocele (MMC). We sought to understand how subspecialists interpreted the trial results and whether their practice has changed. Materials and Methods: Cross-sectional, mailed survey of 1,200 randomly selected maternal-fetal medicine (MFM) physicians, neonatologists, and pediatric surgeons. Results: Of 1,176 eligible physicians, 670 (57%) responded. Compared to postnatal closure, 33% viewed prenatal closure as “very favorable” and 60% as “somewhat favorable.” Most physicians reported being more likely to recommend prenatal surgery (69%), while 28% were less likely to recommend pregnancy termination. In multivariable analysis, neonatologists were more likely to report prenatal closure as “very favorable” (OR 1.6; 95% CI: 1.03-2.5). Pediatric surgeons and neonatologists were more likely to recommend prenatal closure (OR 2.1; 95% CI: 1.3-3.3, and OR 2.9; 95% CI: 1.8-4.6) and less likely to recommend termination (OR 3.8; 95% CI: 2.2-6.7, and OR 4.7; 95% CI: 2.7-8.1). In addition, physicians with a higher tolerance for prematurity were more likely to report prenatal closure as “very favorable” (OR 1.02; 95% CI: 1.00-1.05). Discussion: In light of the MOMS trial, the vast majority of pediatric subspecialists and MFMs view prenatal MMC closure favorably. These attitudes vary by specialty and risk tolerance.

Pediatric neurosurgeons’ views regarding prenatal surgery for myelomeningocele and the management of hydrocephalus: a national survey

“…A point was given for each instance in which the self-reported acceptable complication rate was less than the rate reported in the MOMS trial for perinatal death (MOMS trial rate: 3%), uterine dehiscence (MOMS trial rate: 10%), and premature delivery (MOMS trial rate: 13%). 1 In this study, as well as in our previous study of MFMs, neonatologists, and pediatric surgeons, [4][5][6] we used the complication rates reported in the first MOMS publication based on 158 of 183 patients (see Appendix A). 2 The incidence of premature delivery in the full MOMS cohort, 183 patients, was later reported at 11%.…”

“…The questionnaire used in this study represented an abridged version of the 32-item questionnaire previously used to sample 400 MFM specialists, 400 neonatologists, and 400 pediatric surgeons randomly selected from member lists of the Society for Maternal-Fetal Medicine, the American Academy of Pediatrics Section on Perinatal Pediatrics, and the American Academy of Pediatrics Section on Surgery, respectively. [4][5][6] This study was reviewed and deemed exempt by the Mayo Clinic Institutional Review Board.…”

“…31 We have previously reported specialty-based variation in the interpretation of the MOMS results and their application to clinical practice among maternal-fetal medicine (MFM) specialists, neonatologists, and pediatric surgeons. [4][5][6] In the present study, we sought to determine how MOMS has influenced the opinions and potential recommendations of pediatric neurosurgeons, how their views compared to those of other specialties involved in the management of MMC, how risk tolerance might impact their views, and how their practice patterns for the management of hydrocephalus compare to those used for the MOMS trial.…”

Attitudes of paediatric and obstetric specialists towards prenatal surgery for lethal and non-lethal conditions

“…We conducted a cross-sectional, mail-based survey in the spring of 2015, as we have described previously 13. The sample included 400 maternal–fetal medicine specialists (MFMs), 400 neonatologists and 400 paediatric surgeons.…”

A study to assess knowledge and acceptability of foetal surgery for spina bifida amongst healthcare professionals in the UK

“…The Management of Myelomeningocele Study (MOMS) (Adzick et al, 2011) published in 2011 provided level 1 evidence that closure of open spina bifida (myelomeningocele, MMC) before birth can reduce the requirement for ventriculoperitoneal shunt placement and improve motor function at 12 and 30 months of age. Following this, a questionnaire study (Antiel et al, 2017) of 670 maternal-fetal medicine (MFM) physicians, neonatologists and paediatric surgeons in the US showed that the majority believed prenatal surgery for fetal spina bifida to be favoured over postnatal surgery. A minority of respondents indicated that they were now less likely to recommend termination of pregnancy, with the majority reporting no change.…”