Hybrid fetoscopic repair reduces obstetrical complications

Hybrid fetoscopic repair reduces obstetrical complications | Image Credit: © Monkey Business - © Monkey Business - stock.adobe.com.

According to a recent study published in the American Journal of Obstetrics & Gynecology, obstetrical complications are reduced by hybrid fetoscopic repair.

About 6 to 10,000 livebirths worldwide are impacted by open neural tube defects (ONTDs), including spina bifida, which is caused by the caudal portion of the neural tube closing. This leads to neuronal elements being exposed, causing significant neuronal loss at a gestational age (GA) under 16 weeks.

Improved outcomes from fetal surgery compared to postnatal repair were indicated by the Management of Myelomeningocele Study (MOMS). Data has also indicated fetoscopic ONTD repair may be an effective alternative to open repair, with decreased risks of uterine thinning and dehiscence and the option of future vaginal delivery.

Fetoscopic ONTD repair has been linked to oligohydramnios, chorioamniotic membrane separation, preterm premature rupture of membranes, and placental abruption. There is no standardized method currently available for comparing fetoscopic ONTD repair with postnatal repair.

The Clavien–Dindo classification grades surgical complications using a 1-to-5 scale. However, this system would need to be adapted for prenatal surgeries. To investigate the Clavien–Dindo system and create a tool for evaluating maternal complications in utero repair of fetal ONTD, investigators conducted a retrospective cohort study.

The study occurred from September 2011 to July 2021 at the Texas Children’s Fetal Center. MOMS criteria were used to determine participation, with patients who met criteria and received hybrid or open fetal surgery included. 

Comparisons were made of maternal complications and GAs of patients receiving hybrid vs open fetal surgery. Evaluation was performed with 5 grades based on Clavien–Dindo classification, with specifications made based on complications only seen in pregnancy and fetal surgery.

Grade 1 complications were those needing clinical or ultrasound monitoring, but not medical or surgical intervention. Grade 2 complications were those requiring medical treatment, and grade 3 complications were those requiring surgical or minimally invasive intervention.

Grade 4 complications required intensive care after single or multiple organ failure. Grade 5 complications included maternal death. The sum of all complications weighing for severity made up the comprehensive complication index (CCI), and the final formula graded the severity of any combination of complications from 0 to 100.

There were 146 patients included in the analysis, 202 of which received hybrid fetoscopic repair and 44 received open repair. A median GA of 25.1 weeks at repair was reported in the hybrid group, compared to 24.8 weeks in the open repair group. 

The average maternal body mass index was 25.4 in the hybrid group and 27.1 in the open group. Surgery length was also significantly longer in the hybrid group compared to the open group, at 250.0±48.6 vs 164.6±42.8. All participants in the open group underwent cesarean delivery, compared to 49.5% of the hybrid group.

Grade 1 and grade 2 complications did not significantly differ between the 2 groups, but grade 3 complications were significantly more common in the open group compared to the hybrid group. Of grade 3 complications, uterine thinning was the most common, followed by placental abruptions.

One percent of the hybrid group experienced grade 4 complications compared to 4.5% of the open group. This was not considered significantly different. No grade 5 complications occurred during the analysis.

The hybrid group had a significantly lower CCI score than the open group, at 8.7 and 22.6 respectively. Grade 3 complications were significantly more common in the open-repair group after adjusting for cofounders.

One neonatal death was observed, occurring in the open group. The median GA at delivery was 38.1 weeks in the hybrid group and 35.8 weeks in the open group. Preterm birth was seen in 4.2% of the hybrid group vs 15.9% of the open group.

Overall, maternal and neonatal outcomes were improved in the hybrid fetoscopic group. Investigators recommended physicians and patients consider this information when deciding which method is most appropriate for use.

Reference

Krispin E, Hessmi K, Johnson RM. Systematic classification and comparison of maternal and obstetrical complications following 2 different methods of fetal surgery for the repair of open neural tube defects. American Journal of Obstetrics & Gynecology. 2023;229(1):53.E1-53.E8. doi:10.1016/j.ajog.2022.12.317