Maternal fetal surgery for myelomeningocele
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Maternal-Fetal Surgery for Myelomeningocele. Catherine Y Spong, MD Pregnancy and Perinatology Branch, NICHD National Institutes of Health. MOMS Centers The Children’s Hospital of Philadelphia University of California-San Francisco Vanderbilt University Medical Center Coordinating Center

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Maternal-Fetal Surgery for Myelomeningocele

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Maternal fetal surgery for myelomeningocele

Maternal-Fetal Surgery for Myelomeningocele

Catherine Y Spong, MD

Pregnancy and Perinatology Branch, NICHD

National Institutes of Health


Maternal fetal surgery for myelomeningocele

  • MOMS Centers

    • The Children’s Hospital of Philadelphia

    • University of California-San Francisco

    • Vanderbilt University Medical Center

  • Coordinating Center

    • The George Washington University Biostatistics Center

  • NICHD

    • Pregnancy & Perinatology Branch


Management of myelomeningocele study moms

Management of Myelomeningocele Study (MOMS)

Aim: To compare the safety and efficacy of in utero repair of open neural tube defects with standard postnatal repair

Intervention: Unmasked randomized clinical trial

Outcome evaluation by blinded independent investigators


Myelomeningocele

Myelomeningocele

  • Most common & severe CNS congenital anomaly

  • Affecting ~ 1500 fetuses in US annually

  • Significant morbidity and mortality

  • Life-long disabilities

  • Severity correlated with levels of the spinal cord lesion


Maternal fetal surgery for myelomeningocele

Complications

Hydrocephalus

Need for ventriculoperitoneal shunting

Motor and cognitive

impairments

Bladder and bowel incontinence

Social and emotional challenges


Maternal fetal surgery for myelomeningocele

Myelomeningocele: Fetal Sheep Model

In utero coverage of MMC

Rescues neurologic function at birth

Without prenatal coverage

With prenatal coverage


Maternal fetal surgery for myelomeningocele

Human Fetal Myelomeningocele Repair


Goal of the trial

Goal of the Trial

To compare the safety and efficacy of in utero repair of myelomeningocele (MMC) with that of the standard postnatal repair


Inclusion criteria

Inclusion criteria

  • Singleton

  • Upper MMC boundary at T1-S1

  • Evidence of hindbrain herniation

  • GA 19.0-25.9 weeks at randomization

  • Normal karyotype

  • US residency

  • Maternal age >18 years


Major exclusion criteria

Major exclusion criteria

  • Fetal anomaly unrelated to MMC

  • Severe kyphosis

  • Risk of PTB (short cervix, prior PTB)

  • Placental abruption

  • BMI >35

  • Contraindication to prenatal surgery


Screening at clinical site 2 days

Central Screening at Coordinating Center

Screening at Clinical Site (2 days)

Travel & lodging arranged

Mother and support person

Paid by MOMS center

If requirements met, offered randomization

Evaluation process

Comprehensive ultrasound

MRI of fetus

Fetal echocardiogram

Psychological testing

Meetings with evaluations team

Fetal surgeon

Neurosurgeon

Nurse

Neonatologist

Social worker

Anesthesiologist

Perinatologist


Randomization to neonatal discharge

Randomization to Neonatal Discharge

Moms and infants

go to assigned center

Postnatal group

Prenatal group

Return home

Admitted to MOMS center

Return at 37wks to MOMS

center for delivery by CD

In utero repair

Remain near center

until delivery

Postnatal closure within 48h

Deliver by CD

@ 37wks if undelivered


Primary outcome 12 months

PrimaryOutcome (12 months)

  • Death or need for ventricular decompressive shunting at 12 months defined by objective criteria

    • If shunt placed without meeting criteria – qualifies as primary outcome

  • Independent committee of neurosurgeons, blinded to treatment assignment, determines whether criteria have been met


Primary outcome 30 months

PrimaryOutcome (30 months)

  • A composite score from the Bayley Scales of Infant Development MDI and the difference between the motor level and lesion level

  • Evaluated by independent examiners blinded to treatment assignment

  • Videotapes of physical exams reviewed by independent expert


Secondary outcomes

SecondaryOutcomes

Gestational age at delivery

Hindbrain herniation

Difference between motor function and anatomic levels

Ambulation

Oligohydramnios

Blood transfusion at delivery

Placental abruption

Pulmonary edema

Hysterotomy site

Bradycardia at fetal repair


Maternal fetal surgery for myelomeningocele

L2–S4 Myelomeningocele

T12

L1

L2

L3


Maternal fetal surgery for myelomeningocele

Motor Impairment: Level of Spinal Cord Injury


Maternal fetal surgery for myelomeningocele

Secondary Outcome: Difference between motor function and anatomic levels

(Observed motor function) – (anatomic level)

(obs S1) – (anatomic L4) = + 2 levels

(obs L2) – (anatomic L4) = - 2 levels


Maternal fetal surgery for myelomeningocele

Demographics


Maternal fetal surgery for myelomeningocele

Demographics (cont’d)


Maternal fetal surgery for myelomeningocele

MOMS: Primary Outcome (12 mo)death or need for shunt

PrenatalPostnatalP value

n=78 n=80 RR (95%CI)

Primary outcome53(68%)78(98%)<0.001

0.70(0.58-0.84)

Death before shunt 2( 3%) 0

Shunt criteria met51(65%)74(92%)

Shunt placed without criteria 0 4( 5%)

Placement of shunt31(40%)66(82%)<0.001

0.48(0.36-0.64)

Two perinatal deaths in each group:

Prenatal: IUFD at 26wks, NND at 23 wks

Postnatal: NND with severe symptoms of Chiari II


Maternal fetal surgery for myelomeningocele

MOMS: Primary Outcome (30 mo)

PrenatalPostnatalP value

n=64 n=70

Primary outcome148.6+57.5122.6+57.20.007

Bayley MDI 89.7+14.087.3+18.40.53

Difference between0.58+1.94-0.69+1.990.001

motor function & anatomic level


Secondary outcome hindbrain herniation

Secondary Outcome: Hindbrain Herniation

(12 months)


Secondary outcome difference between motor function and anatomic levels

Secondary Outcome: Difference between motor function and anatomic levels

P=0.002

better

better

worse

worse


Maternal fetal surgery for myelomeningocele

Secondary Outcome: Ambulation

PrenatalPostnatalP value

n=64 n=70 RR (95%CI)

Walking independently26/62(42%)14/67(21%)0.01

2.01(1.16-3.48)

Walking status0.03

None18/62(29%)29/67(43%)

Orthotics/devices18/62(29%)24/67(36%)

Walking independently26/62(42%)14/67(21%)


Maternal outcomes

Maternal Outcomes


Maternal outcome hysterotomy site

Maternal Outcome: Hysterotomy site

Prenatal

n=76

35.5%


Maternal fetal surgery for myelomeningocele

Fetal and Neonatal Outcomes

15%

80%


Maternal fetal surgery for myelomeningocele

Neonatal Outcomes (cont’d)


Summary

Summary

Prenatal surgery for myelomeningocele reduces the need for a shunt or death and improves motor outcomes at 30 months but is associated with maternal and fetal risks


Summary1

Summary

Prenatal surgery is associated with other favorable secondary outcomes:

Reduces hindbrain herniation at 12 months

No evidence of herniation in 36% vs 4%

Doubles ability to walk without orthotics42% vs 21%

More likely to have a level of function that was two or more levels better than expected according to anatomic levels 32% vs 12%


Summary2

Summary

  • Prenatal surgery associated with maternal and fetal risks

    • Preterm birth: 80% vs 15%

      • RDS in 21% vs 6%

    • Bradycardia

    • Oligohydramnios

    • Placental abruption

    • Transfusion at delivery

    • Uterine dehiscence at surgical site (35%)


Many thanks to

Many thanks to:

  • Radiology Review committee: Dorothy Bulas, M.D., Charles Fitz, M.D. and Gilbert Vezina, M.D.

  • Shunt Outcome Review Committee: D. Douglas Cochrane, M.D., James Drake, M.D., John Kestle, M.D. and Jerry Oakes, M.D.

  • Pediatrician and psychologist examiners: Alex Espinosa, M.D., Julia Hayes, M.D., Elizabeth Higley, Ph.D., Rita Jeremy, Ph.D., Rowena Korobkin, M.D., David Kube, M.D., Leanne Pollard, Jonathan Rowland, Elizabeth Saslow, Ph.D. and Toni Whitaker, M.D.

  • Training and QA monitoring: Mario Petersen, M.D., Melissa Fallone, Ph.D., Theresa Leach, M.Ed. and Susan Anderson,M.D.

  • The Data and Safety Monitoring Committee: George Macones, M.D., Michael Ross, M.D., Donald Stablein, Ph.D., Alessandro Ghidini, M.D., Michele Prince, MS, C.G.C., Barbara Schmidt, M.D., Antoine Khoury, M.D., Sonya Oppenheimer, M.D., John McLaughlin, M.D., Reverend Phillip Cato, Ph.D., Kellie Murphy, M.D., M.Sc., Dale Phelps, M.D., Keith Aronyk, M.D., William Hay, Jr., M.D., Mary E. Hannah, M.D., M.Sc., Jeremy Sugarman, M.D.


And at the sites many thanks to

And at the sites, many thanks to

  • The Children’s Hospital of Philadelphia, Philadelphia, PA– Alan Flake, M.D., Holly Hedrick, M.D., Jamie Koh, R.N., M.S.N., Jack Rychik, M.D., David Cohen, M.D., Natalie Rintoul, M.D., Beverly Coleman, M.D., Patrick Pasquariello, M.D., Enrico Danzer, M.D., Larissa Bilaniuk, M.D., Martha Hudson, M.S.W., Michael Carr, M.D., Ph.D., Michael Bebbington, M.D., M.H.Sc., Julie Moldenhauer, M.D., and R. Douglas Wilson, M.D.

  • University of California San Francisco, San Francisco, CA– Michael Harrison, M.D., Hanmin Lee, M.D., Larry Rand, M.D., Tamara Ryan, R.N., Cindy Lazzaretti, R.N., Rachel Perry, R.N., Stephanie Berman, L.C.S.W., Vicki Feldstein, M.D., Ruth Goldstein, M.D., Peter Callen, M.D., Orit Glenn, M.D., Larry Baskin, M.D., Mark Rosen, M.D., Charles Cauldwell, Ph.D., M.D., and Vilma Zarate, Ph.D.

  • Vanderbilt University Medical Center, Nashville, TN– Katharine Wenstrom, M.D., Lisa Trusler, R.N., M.S.N., Joseph Bruner, M.D., Bill Walsh, M.D., Edmund Yang, M.D., Ph.D., Ann Kavanaugh-McHugh, M.D., Tracy Perry, Jennifer Anderson, R.N., Mark Bliton, Ph.D. and Denise Pepin, M.S.W., L.C.S.W.

  • The George Washington University Biostatistics Center, Washington, DC– Jessica Ratay, M.S., C.G.C., Erin Greenbaum Musok, M.A., Kristen Holloway, Catherine Shaer, M.D., Shanika Gregory, Julia Zachary, Lucy Leuchtenburg, Jeremy Drehmer, M.P.H. and Megan Mitchell, M.P.H.

  • The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD– Susan Tolivaisa, Nancy Chescheir, M.D. and Marian Willinger, Ph.D.


Maternal fetal surgery for myelomeningocele

  • Thanks to:

  • The women, their children and families who have taken part and continue to take part in the MOMS trial

  • The fetal therapy community

  • The perinatal community

  • The Society for Maternal Fetal Medicine

  • MOMS Centers

    • The Children’s Hospital Of Philadelphia

    • University Of California-San Francisco

    • Vanderbilt University Medical Center

  • Coordinating Center

    • The George Washington University Biostatistics Center

  • NICHD

    • Pregnancy and Perinatology Branch


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