Fetal Surgery for the Repair of

Myelomeningocele

Stephane A. Braun, MD, FRCSCDepartment of Plastic Surgery

Monroe Carell Jr. Children’s HospitalVanderbilt University

Nashville, TN

Disclosures

• I have no independent financial relationships with any medical device company.

• MOMS was supported by grants: U10 HD041666, U01HD041665, U10 HD041667, and U10 HD041669 from the Eunice Kennedy Shriver NICHD

• The local database utilized for the Vanderbilt follow up paper was supported by CTSA assistance 1 UL1 RR024975 and 1 UL1 TR000445 from the NIH.

Multidisciplinary team represents obstetrical anesthesia and sonography,maternal-fetal specialists, pediatric cardiology and plastic surgery, pediatric neurosurgery

Management of Myelomeningocele Study

(MOMS)•Feb 2003- Dec 2010•3 Centers•19-25 weeks•Primary Outcome:

– Shunt (and death)

•Secondary Outcomes:– Composite

• Mental development• Motor function

– Hindbrain Herniation– EGA

Uterine incision

Membrane Binding

Exposure of the fetal spinal lesion for repair

Neurosurgical team repair ofThe spinal lesion.

Lesion Repair

Uterine Closing

Abdominal closure

Postoperative Management

– Postop

• Meds, maternal/fetal monitoring, discharge postop D-5, fetal assessment postop D-7

– Return Visit – To local MFM 1 week postop

• Restricted activities, TED stockings

– Prenatal Visits – Weekly

• U/S for AFI, membrane separation

• Telephone conversation with patient and MFM

• Assess for symptoms of PROM and chorioamniotis

• Measurement of lateral ventricle

• BPP after 25 wks; monthly growth U/S

• 32 wks – initiate weekly NST/AFI

Postoperative Management

– Preterm delivery preventives

• Bedrest with membrane separation

• Hospitalization if membrane separation extends to placental cord

with NST every shift

– Cesarean delivery, if:

• Preterm labor unresponsive to tocolytics with cervical change

• Uterine rupture is suspected

• Chorioamnionitis is clinically suspected

• Placenta abruption is suspected

• Nonreassuring fetal testing

• 37 0/7 weeks without amniocentesis

• PPROM management based on routine practice guidelines;

antibiotics x 7 days, delivery at 34 weeks’ gestation.

Bennett, KA, et al. J Neuro Pediatr, May, 2014.

• 43 cases from 3/2011 to 1/2013

• Technique modification– Attention to uterine

membrane manipulation

– Compared to fetal MOMS

• Outcome:– PROM (22% vs. 46%)

– CA separation (0% vs. 26%)

– Term birth (39% vs. 21%)

– All improved compared to MOMS fetal cohort. (p<0.05)

MOMS NEJM MOMS POST MOMS VANDY CECAM

Procedure Period 2003-2010 2003-2010 3/2011-1/2013 2013-?

n 158 (12 months) 78 43 10

Defect Successfully closed 100% 100% 80%

MATERNAL OUTCOMES

Chorionic Membrane Separation 26% 0% 40%

Chorioamnionitis 3% 0% 0%

Oligohydramnios 21% 24% 40%

Premature rupture of membranes 46% 22% 100%

Spontaneous Labor 38% 24% ?

Blood transfusion at delivery 9% 0% 0%

Hysterotomy status at delivery

Intact 64% 88% 100%

Thinning 25% 4% 0%

Area of dehiscence 9% 7% 0%

Complete dehiscence 1% 0% 0%

NEONATAL OUTCOMES

Death 3% 5% 20%

Mean gestational age (weeks) 34.1 34.4 32.4

Gestational Age (weeks)

<30 13% 4% 20%

30-34 33% 29% 70%

35-36 33% 27% 10%

>37 21% 39% 0%

Mean birth weight (gm) 2382 2487 1872

Postnatal repair necessary 13% 5% 25% (2/8)

Surgery for hydrocephalus by one year* 40%* 41%* 38%

• Uterine entry and closure modified to minimize trauma to

the amniotic membrane and chorioamnion separation

• Uterine entry achieved without the use of a trocar or

spear like device

• Allis clamps used to expose the amniotic membrane

• Membrane opened with a spinal needle and the edges of

the membrane sutured to the uterine wall to ensure

hemostasis and prevent separation

• Staple device used to enlarge the hysterotomy

• Uterus closed using figure of eight interrupted suture

followed by a second running locking layer

How Have We Improved?

Cody, 8 mo

Eli, 14 mo

Gabe, 3 mo

Rylie, 12 moLucy, 9 mo

Kinsey

Mason, 6 mo

Rachel, 7 mo

11-month Racer

THANK YOU

Vanderbilt Fetal Center

MOMS Investigators

HCRN Investigators

Vanderbilt SOCKs https://medschool.vanderbilt.edu/socks/