Reducing perinatal complications and preterm delivery for patients undergoing in utero closure of fetal myelomeningocele: further modifications to the multidisciplinary surgical technique Clinical article
Reducing perinatal complications and preterm delivery for patients undergoing in utero closure of fetal myelomeningocele: further modifications to the multidisciplinary surgical technique Clinical article
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DOI：
10.3171/2014.3.peds13266
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发表时间：
2014-07-01
影响因子：
1.9
通讯作者：
Tulipan, Noel B.
中科院分区：
文献类型：
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作者：
Bennett, Kelly A.;Carroll, Mary Anne;Tulipan, Noel B.
object.随着越来越多的儿科神经外科医生参与胎儿脊髓脊膜膨出闭合工作，在整个手术方法中检查可以最大限度地提高有益结果的精细技术变得至关重要。作者比较了接受改良技术的患者与接受胎儿修补术的患者的结局，这是早期脊髓脊膜膨出治疗研究（MOMS）的一部分。收集了2011年3月至2013年1月在范德比尔特胎儿中心接受子宫内脊髓脊膜膨出闭合术的43例分娩患者的人口统计学和结局数据（研究队列），并与作为MOMS一部分接受胎儿修复术的78例患者的数据（MOMS队列）进行了比较。对于研究队列，未使用子宫套管针，并修改了子宫进入、操作和闭合，以尽量减少羊膜分离。每周超声报告从初级母胎医学提供者获得并审查。正态性检验显示研究队列的分布呈正态;因此，使用参数统计进行比较。与MOMS队列相比，研究队列中胎膜早破（22% vs 46%，p = 0.011）和绒毛膜羊膜分离（0% vs 26%，p <0.001）的发生率较低。两组间羊水过少的发生率无差异。研究队列的平均（+/-SD）胎龄为34.4（+/-6.6）周，与MOMS队列（34.1 +/-3.1周）相似。然而，研究队列中足月（37周或以上）出生婴儿的比例（16/41; 39%）显著高于MOMS队列（16/78; 21%）（p = 0.030）。与MOMS队列中78例患者中的10例（13%）相比，研究队列中41例婴儿中仅2例（4%）在妊娠30周前分娩（p = 0.084，接近显著性）。对于研究队列，2例胎儿死亡归因于干预，认为均与胎盘破坏相关;其中1例母亲既往患有未识别的血栓形成倾向。死亡率没有统计学差异之间的队列。这些早期结果表明，手术团队对子宫进入、操作和闭合的仔细注意可以降低胎膜早破和绒毛膜羊膜分离的发生率，并可以减少早期早产。虽然这些结果是有希望的，但它们的确认将需要对更大系列的患者进行进一步研究。
Object. As more pediatric neurosurgeons become involved with fetal myelomeningocele closure efforts, examining refined techniques in the overall surgical approach that could maximize beneficial outcomes becomes critical. The authors compared outcomes for patients who had undergone a modified technique with those for patients who had undergone fetal repair as part of the earlier Management of Myelomeningocele Study (MOMS).Methods. Demographic and outcomes data were collected for a series of 43 delivered patients who had undergone in utero myelomeningocele closure at the Fetal Center at Vanderbilt from March 2011 through January 2013 (the study cohort) and were compared with data for 78 patients who had undergone fetal repair as part of MOMS (the MOMS cohort). For the study cohort, no uterine trocar was used, and uterine entry, manipulation, and closure were modified to minimize separation of the amniotic membrane. Weekly ultrasound reports were obtained from primary maternal-fetal medicine providers and reviewed. A test for normality revealed that distribution for the study cohort was normal; therefore, parametric statistics were used for comparisons.Results. The incidence of premature rupture of membranes (22% vs 46%, p = 0.011) and chorioamnion separation (0% vs 26%, p < 0.001) were lower for the study cohort than for the MOMS cohort. Incidence of oligohydramnios did not differ between the cohorts. The mean (+/- SD) gestational age of 34.4 (+/- 6.6) weeks for the study cohort was similar to that for the MOMS cohort (34.1 +/- 3.1 weeks). However, the proportion of infants born at term (37 weeks or greater) was significantly higher for the study cohort (16 of 41; 39%) than for the MOMS cohort (16 of 78; 21%) (p = 0.030). Compared with 10 (13%) of 78 patients in the MOMS cohort, only 2 (4%) of 41 infants in the study cohort were delivered earlier than 30 weeks of gestation (p = 0.084, approaching significance). For the study cohort, 2 fetal deaths were attributed to the intervention, and both were believed to be associated with placental disruption; one of these mothers had previously unidentified thrombophilia. Mortality rates did not statistically differ between the cohorts.Conclusions. These early results suggest that careful attention to uterine entry, manipulation, and closure by the surgical team can result in a decreased rate of premature rupture of membranes and chorioamnion separation and can reduce early preterm delivery. Although these results are promising, their confirmation will require further study of a larger series of patients.