American College of Obstetricians and Gynecologists recommends counseling for prenatal spina bifida surgery
Published On: 1/21/2013 2:48:37 PM
BY MARY ELLEN SCHNEIDER
IMNG Medical News
Certain pregnant women who are carrying a fetus with severe
spina bifida should be counseled about the potential benefits and
risks of maternal-fetal surgery, according to the American College
of Obstetricians and Gynecologists.
The ACOG Committee on Obstetric Practice recently recommended counseling about maternal-fetal
surgery for myelomeningocele, the most severe form of spina bifida,
following promising results from the procedure in an 8-year
randomized controlled trial (Obstet. Gynecol. 2013;121:218-9).
In the Management of Myelomeningocele Study (MOMS), prenatal repair before 26 weeks of
gestation reduced the need for a shunt at 12 months and also
decreased the rate of hindbrain herniation by one-third at 12
months of age. The procedure also doubled the rate of independent
walking and produced higher levels of functioning than were
expected based on anatomic levels (N. Engl. J. Med. 2011;364:993-1004).
But the study, which was sponsored by the National Institutes of
Health, also found significant maternal and fetal risks. For
example, the surgery was associated with high rates of preterm
birth, fetal bradycardia, oligohydramnios, placental abruption,
pulmonary edema, maternal transfusion at delivery, and an increased
incidence of uterine thinning.
ACOG cautions that the MOMS trial used stringent inclusion
criteria and rigorous requirements for the experience of the
surgeons involved. As a result, outcomes from the trial should be
considered a "best-case scenario," the committee members wrote.
They urged physicians to use the same inclusion criteria as the
researchers when considering which women to counsel about the
maternal-fetal surgery. The criteria were a singleton pregnancy,
myelomeningocele with the upper boundary between T-1 and S-1,
evidence of hindbrain herniation, gestational age between 19.0 and
25.9 weeks, and a normal karyotype. The major exclusion criteria
included a fetal anomaly unrelated to the myelomeningocele; severe
kyphosis; risk of preterm birth; a maternal body mass index of 35
kg/m2 or more; and contraindications to surgery,
including previous hysterotomy in the active uterine segment.
Women should also be counseled about the implications of the
surgery for future pregnancies, the ACOG committee recommended.
"It is a highly technical procedure with potential for
significant morbidity and possibly mortality, even in the best and
most experienced hands," they wrote. "Maternal-fetal surgery for
myelomeningocele should only be offered at facilities with the
expertise, multidisciplinary teams, services, and facilities to
provide the intensive care required for these patients."
The study authors declared that they received funding from the
National Institutes of Health. One of the authors reported
receiving funding from Vanderbilt University in Nashville,