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Subsequent pregnancy outcomes after open maternal-fetal surgery for myelomeningocele

Published:March 15, 2019DOI:https://doi.org/10.1016/j.ajog.2019.03.008

      Background

      Open maternal-fetal surgery for fetal myelomeningocele results in reduction in neonatal morbidity related to spina bifida but may be associated with fetal, neonatal, and maternal complications in subsequent pregnancies.

      Objective

      The objective of this study was to ascertain obstetric risk in subsequent pregnancies after open maternal-fetal surgery for fetal myelomeningocele closure.

      Study Design

      An international multicenter prospective observational registry created to track and report maternal, obstetric, fetal/neonatal, and subsequent pregnancy outcomes following open maternal-fetal surgery for fetal myelomeningocele was evaluated for subsequent pregnancy outcome variables. Institutional Review Board approval was obtained for the registry.

      Results

      From 693 cases of open maternal-fetal surgery for fetal myelomeningocele closure entered into the registry, 77 subsequent pregnancies in 60 women were identified. The overall live birth rate was 96.2%, with 52 pregnancies delivering beyond 20 weeks gestational age and median gestational age at delivery of 37 (36.3–37.1) weeks. The uterine rupture rate was 9.6% (n = 5), resulting in 2 fetal deaths. Maternal transfusion was required in 4 patients (7.7%).

      Conclusion

      The risk of uterine rupture or dehiscence in subsequent pregnancies with associated fetal morbidity after open maternal-fetal surgery is significant, but is similar to that reported for subsequent pregnancies after classical cesarean deliveries. Future pregnancy considerations should be included in initial counseling for women contemplating open maternal-fetal surgery.

      Key words

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      References

        • Adzick N.S.
        • Thom E.A.
        • Spong C.Y.
        • et al.
        MOMS Investigators. A randomized trial of prenatal versus postnatal repair of myelomeningocele.
        N Engl J Med. 2011; 364: 993-1004
        • Landon M.A.
        • Lynch C.D.
        Optimal timing and mode of delivery after cesarean with previous classical incision or myomectomy; a review of the data.
        Semin Perinatol. 2011; 35: 257-261
        • Chauhan S.P.
        • Magann E.F.
        • Wiggs C.D.
        • Barrilleaux P.S.
        • Martin Jr., J.N.
        Pregnancy after classic cesarean delivery.
        Obstet Gynecol. 2002; 100: 946-950
        • Wilson R.D.
        • Lemerand K.
        • Johnson M.P.
        • et al.
        Reproductive outcomes in subsequent pregnancies after a pregnancy complicated by open maternal-fetal surgery (1996-2007).
        Am J Obstet Gynecol. 2010; 203: 209.e1-209.e6
        • Zamora I.J.
        • Ethun C.G.
        • Evans L.M.
        • et al.
        Maternal morbidity and reproductive outcomes related to fetal surgery.
        J Pediatr Surg. 2013; 48: 951-955
        • Thom E.A.
        Maternal reproductive outcomes after in-utero repair of myelomeningocele.
        Am J Obstet Gynecol. 2016; 214: 36
        • Harris P.A.
        • Taylor R.
        • Thielke R.
        • Payne J.
        • Gonzalez N.
        • Conde J.G.
        Research electronic data capture (REDCap) – A metadata-driven methodology and workflow process for providing translational research informatics support.
        J. Biomed Inform. 2009; 42: 377-381
        • Moise K.J.
        • Moldenhauer J.S.
        • Bennett K.A.
        • et al.
        Current selection criteria and perioperative therapy used for fetal myelomeningocele surgery.
        Obstet Gynecol. 2016; 127: 593-597
        • Landon M.B.
        • Hauth J.C.
        • Leveno K.J.
        • et al.
        National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery.
        N Engl J Med. 2004; 351: 2581-2589
        • Shipp T.D.
        • Zelop C.D.
        • Repke J.T.
        • Cohen A.
        • Lieberman E.
        Interdelivery interval and risk of symptomatic uterine rupture.
        Obstet Gynecol. 2001; 92: 175
        • Bujold E.
        • Gauthier R.J.
        Risk of uterine rupture associated with an interpregnancy interval between 18 and 24 months.
        Obstet Gynecol. 2010; 115: 1003
        • Spong C.Y.
        • Mercer B.M.
        • D'alton M.
        • Kilpatrick S.
        • Blackwell S.
        • Saade G.
        Timing of indicated late-preterm and early-term birth.
        Obstet Gynecol. 2011; 118: 323
      1. Medically indicated late-preterm and early-term deliveries. ACOG Committee Opinion No. 560. American College of Obstetricians and Gynecologists.
        Obstet Gynecol. 2013; 121: 908-910
        • Tita A.T.
        • Landon M.B.
        • Spong C.Y.
        • et al.
        • Timing of elective repeat cesarean delivery at term and neonatal outcomes
        Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network.
        N Engl J Med. 2009; 360: 111-120
        • Zaretsky M.V.
        • Liechty K.W.
        • Galan H.L.
        • et al.
        Modified hysterotomy closure technique for open fetal surgery.
        Fetal Diagn Ther. 2018; 44: 105-111
        • Kohn J.R.
        • Rao V.
        • Sellner A.A.
        • et al.
        Management of labor and delivery after fetoscopic repair of an open neural tube defect.
        Obstet Gynecol. 2018; 131: 1062-1068
        • Belfort M.A.
        • Whitehead W.E.
        • Shamshirsaz A.A.
        • et al.
        Fetoscopic open neural tube defect repair: development and refinement of a two-port, carbon dioxide insufflation technique.
        Obstet Gynecol. 2017; 129: 734-743
        • Araujo Junior E.
        • Eggink A.J.
        • van den Dobbelsteen J.
        • Martins W.P.
        • Oepkes D.
        Procedure-related complications of open vs endoscopic fetal surgery for treatment of spina bifida in an era of intrauterine myelomeningocele repair: systematic review and meta-analysis.
        Ultrasound Obstet Gynecol. 2016; 48: 151-160
        • Williams J.
        • Mai C.T.
        • Mulinare J.
        • et al.
        Updated estimates of neural tube defects prevented by mandatory folic acid fortification — United States, 1995–2011.
        MMWR Morb Mortal Wkly Rep. 2015; 64: 1-5
      2. Maternal–fetal surgery for myelomeningocele. ACOG Committee Opinion No. 720. American College of Obstetricians and Gynecologists.
        Obstet Gynecol. 2017; 130: 164-167
        • Silver R.M.
        • Landon M.B.
        • Rouse D.J.
        • et al.
        Maternal morbidity associated with multiple repeat cesarean deliveries.
        Obstet Gynecol. 2006; 107: 1226
      3. Early pregnancy loss. ACOG Practice Bulletin No. 200. American College of Obstetricians and Gynecologists.
        Obstet Gynecol. 2018; 132: e197-e207

      Linked Article

      • Uterine legacy of open maternal–fetal surgery: preterm uterine rupture
        American Journal of Obstetrics & GynecologyVol. 221Issue 5
        • Preview
          We congratulate Goodnight et al1 on the publication of a study in the Journal in March of 2019 titled, “Subsequent pregnancy outcomes after open maternal-fetal surgery for myelomeningocele.” Using an international multicenter prospective observational registry, the authors’ analysis of 52 subsequent pregnancies after open maternal–fetal surgery (OMFS) for fetal myelomeningocele revealed that the risk of uterine rupture was 9.6% (5/52) and the additional risk of uterine dehiscence/thinness was 17.3% (9/52).
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