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Current Selection Criteria and Perioperative Therapy Used for Fetal Myelomeningocele Surgery
Kenneth J Moise1, Julie S Moldenhauer, Kelly A Bennett
1Departments of Obstetrics, Gynecology and Reproductive Sciences and Pediatric Surgery, University of Texas Health School of Medicine at Houston, and the Fetal Center, Children's Memorial Hermann Hospital, Houston, Texas; the Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, and the Fetal Center, Vanderbilt University Medical Center, Nashville, Tennessee; the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina; the Department of Surgery, Division of Pediatric Surgery, Alpert Medical School of Brown University, Providence, Rhode Island; the Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; the Department of Pediatrics, Division of Cardiology, and the Fetal Treatment Center, University of California San Francisco, San Francisco, California; the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Ochsner Baptist Medical Center, New Orleans, Louisiana; the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Michigan Health Systems, Ann Arbor, Michigan; the Department of Obstetrics, Gynecology and Women's Health, Division of Maternal-Fetal Medicine, St. Louis University School of Medicine, St. Louis, Missouri; and the Department of Surgery, Division of Pediatric Neurosurgery, Mayo Clinic, Rochester, Minnesota.
Objective:
To determine the current maternal and fetal selection criteria and operative approaches used at centers performing fetal myelomeningocele surgery.
Methods:
The 17 principal investigators participating in the Fetal Myelomeningocele Consortium were asked to participate in an anonymous online survey regarding the current practice of maternal-fetal surgery for neural tube defect repair and results were tabulated. The 35-question survey related to diagnostic testing, inclusion and exclusion criteria, and clinical management.
Results:
Sixty-five percent (11/17) of principal investigators responded to the survey and not all centers responded to all 35 questions. All centers continue to use magnetic resonance imaging in their preoperative evaluation. Diagnostic testing from amniocentesis is varied: 5 of 11 (45%) require amniotic fluid α-fetoprotein, 4 of 10 (40%) amniotic fluid acetylcholinesterase, and 8 of 11 (73%) DNA microarray. There is also variation from the Management of Myelomeningocele Study with regard to body mass index (BMI) (1/11; 9% would offer surgery with BMIs higher than 35), maternal medical risk factors (surgery would be offered for controlled pregestational diabetes [3/10 (30%)]), hepatitis C with negative viral load (4/11 [36%]), and human immunodeficiency virus with an undetectable viral load (1/10 [10%] or an obstetric history [3/11 (27%)] would offer surgery with a history of preterm delivery on progesterone). Ten of 11 (91%) centers did not consider ventriculomegaly of 18 mm and 9 of 11 (82%) centers did not consider lack of leg movement as an exclusion criteria. Nuances in the perioperative and intraoperative management were also reported, including 5 of 11 (45%) use intraoperative echocardiography and alterations in postoperative tocolytics.
Conclusion:
Variation in practice patterns for offering and performing maternal-fetal surgery for myelomeningocele repair exists among centers. Ongoing evaluation of inclusion and exclusion criteria as well as operative techniques is warranted to ensure continued safety, effectiveness, and beneficence.
