Subsequent Pregnancy Outcomes After Open Maternal-Fetal Surgery for Myelomeningocele

Abstract

(Am J Obstet Gynecol. 2019;220:494.e1–494.e7) Open maternal-fetal surgery (OMFS) for fetal myelomeningocele (fMMC) is associated with a significant reduction in morbidity related to spina bifida. OMFS for fMMC may be associated with adverse outcomes in subsequent pregnancies, but there are limited data available. There is a uterine rupture risk of 4% to 9% associated with a classical hysterotomy, but its unclear whether this risk is similar in hysterotomy for OMFS for fMMC. In 2012, the Fetal Myelomeningocele Consortium, now consisting of 25 institutions, was created to establish a registry of patients undergoing fMMC closure. This study aimed to investigate the maternal and neonatal outcomes in subsequent pregnancies following OMFS for fMMC closure.

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“…In 2019, two papers described the potential maternal complications of fetal surgery. 36,37 The first was a systematic review of 166 studies reporting either open or endoscopic in-utero surgery. This showed that the risk for any maternal complication was higher (20.9%) for open fetal surgery compared to endoscopic surgery (6.2%).…”

“…Here they showed that the risk for rupture (9.6%) and perinatal death was similar to that seen after classical caesarean section. 37 For complex surgeries, like spina bifida repair, fetoscopy requires amnio-insufflation, but the use of dry carbon dioxide has historically been questioned because it causes fetal acidosis. Recent work demonstrated that this can be mitigated by maternal hyperventilation, along with heating and humidifying the gas.…”

Fetal surgical intervention for myelomeningocele: lessons learned, outcomes, and future implications

“…Concern regarding future reproductive outcomes for this unique population is another important element associated with counselling families that are considering fMMC surgery. As part of The Fetal Myelomeningocele Consortium sponsored by the North American Fetal Therapy Network, Goodnight et al 69 evaluated the outcomes in subsequent pregnancies following the index pregnancy. Of nearly 700 patients enrolled in this registry, 77 subsequent pregnancies in 60 women were identified, with 75% reporting one subsequent pregnancy and 25% multiple pregnancies.…”

“…Nevertheless, the risk of uterine dehiscence/ thinning (17.3%) and uterine rupture in subsequent pregnancies was significant (9.6%) and resulted in a fetal death prevalence of nearly 4%. 69 Given the significant emotional, physical, and financial commitments for patients undergoing in utero closure, the MOMS trial also evaluated the impact of fMMC surgery on families and psychological stress. 70 Fetal intervention was associated with a significantly lower negative family and social impact than postnatal repair.…”

“…The live born rate for those progressing beyond 20 weeks was 96.2% and median gestational age at delivery was 37 weeks. Nevertheless, the risk of uterine dehiscence/thinning (17.3%) and uterine rupture in subsequent pregnancies was significant (9.6%) and resulted in a fetal death prevalence of nearly 4% …”