Prenatal Neurosurgical Counseling for Myelomeningocele and Treatment-Determining Factors for Fetal Repair
Belinda Shao1, Christian Schroeder1, Emilija Sagaityte1
1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
Insights
Neurosurgical prenatal counseling (nPNC) for spina bifida (myelomeningocele) was timely for most families. Few modifiable factors deterred patients from fetal repair, indicating effective prenatal care for myelomeningocele (MMC).
Area of Science:
- Fetal Medicine
- Pediatric Neurosurgery
- Maternal-Fetal Medicine
Background:
- Spina bifida guidelines emphasize neurosurgical involvement in prenatal counseling.
- Informed decision-making between prenatal and postnatal myelomeningocele (MMC) repair is crucial.
- This study evaluates the timeliness and factors influencing neurosurgical prenatal counseling (nPNC) for MMC.
Purpose of the Study:
- To assess the timeliness of nPNC for families with MMC at a fetal center.
- To identify modifiable and non-modifiable factors influencing treatment decisions.
- To evaluate patient selection for prenatal versus postnatal MMC repair.
Main Methods:
- Quantified nPNC history and timing for MMC repair cases (2015-2023).
- Assessed fetal repair exclusions, presentation timing, and social determinants.
- Analyzed reasons for declining offered fetal therapy.
Main Results:
- 97% of patients received nPNC, with 82% before 24 weeks gestation.
- Common fetal repair exclusions included lack of hindbrain herniation (43%) and obstetric factors (21%).
- Among eligible patients, 50% chose fetal repair, 45% postnatal repair, and 5% termination; risk (55%) and cost (22%) were key reasons for declining fetal repair.
Conclusions:
- Neurosurgical prenatal counseling (nPNC) was broadly accessible and timely for families with MMC.
- Potentially modifiable barriers minimally impacted decisions regarding fetal repair.
- The study highlights effective prenatal care delivery for myelomeningocele (MMC).
Introduction:
Spina bifida guidelines recommend neurosurgical involvement in prenatal counseling to inform decision-making between prenatal and postnatal myelomeningocele (MMC) repair. This study examines whether families with MMC presenting to one fetal center had timely neurosurgical prenatal counseling (nPNC) encounters and assesses modifiable and non-modifiable treatment-determining factors.
Methods:
History and timing of nPNC were quantified among infants undergoing postnatal and prenatal MMC repair, pregnant patients referred, and MMC studies in a fetal MRI database (2015-2023). Fetal repair exclusions, presentation timing, social determinants, and reported rationale for not selecting offered fetal therapy were assessed.
Results:
Nearly all patients (34/35; 97%) engaged in nPNC, 82% prior to 24 weeks GA. Fourteen patients were excluded from fetal repair for lack of hindbrain herniation (43%), obstetric exclusions (21%), fetal exclusions (21%), suspected closed defect (7%), and delayed presentation (7%). These patients ultimately underwent postnatal repair (71%), and pregnancy termination (14%). The 20 fetal-repair-eligible patients selected fetal repair (50%), postnatal repair (45%), and pregnancy termination (5%). Reasons for declining fetal repair included risk (55%) and cost (22%).
Conclusions:
Among MMC families presenting to a regional fetal therapy center, nPNC was widely extended, in a mostly timely fashion. Very few were deterred from fetal repair by potentially modifiable barriers.
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