Variability in fetal resuscitation between care centers

Variability in fetal resuscitation between care centers | Image Credit: © Konstantin Yuganov - © Konstantin Yuganov - stock.adobe.com.

There is no standard practice for managing fetal resuscitation or neonatal resuscitation during open spina bifida repair, according to a recent study published in JAMA Network Open.

Medical advances have allowed fetal surgery to be used for more diagnosed fetal anomalies, including open spina bifida, which can be treated through fetal repair. Open spina bifida is the most common neural tube defect diagnosed during pregnancy, reported in 4.72 per 10,000 births in the European Union in 2017.

Myelomeningocele and myeloschisis are the most common forms of open spina bifida treated through fetal repair. Myelomeningocele is a condition where the spinal cord extrudes into a sac with cerebrospinal fluid, and myeloschisis is a condition where the neural tissue does not extrude, being level with the surrounding skin.

Long-term effects of open spina bifida include cognitive disabilities, paralysis, and hydrocephalus. However, hysterotomy may improve outcomes, with research about using mini-hysterotomy and fetoscopy ongoing. As surgery may lead to fetal compromise, it is vital to follow globally accepted evidence-based practice.

To assess current policy and practice for fetal resuscitation during fetal surgery and neonatal resuscitation after emergency delivery, investigators conducted a survey containing 33 questions of either multiple-choice or open-ended format. 

There were 4 sections in the survey: fetal surgery center information, in utero fetal resuscitation, emergency delivery during surgery and subsequent neonatal resuscitation, and neonatal palliative care. Participants could also add additional comments through a final open-ended question.

Data collection occurred througheligible fetal surgery centers from January 15 to May 31, 2021. Participants received an email containing information about the study aims and linking to the survey. Participation was further encouraged through a follow-up email sent to potential participants after 2 weeks.

Eligible centers were currently performing or had previously performed fetal surgery for open spina bifida, and eligible participants were involved in organizing or conducting fetal surgery for open spin bifida. One survey was administered per center.

There were 28 eligible centers that responded to the survey, 13 in North America, 7 in Europe, 5 in South America, and 3 in Asia. Of individual participants, 75% reported being fetal medicine specialists. Of the centers, 43% only offered open fetal surgery, 14% only fetoscopic fetal surgery, and 43% both modalities.

Annually, a median 8 cases of open fetal century were performed in available centers. For fetoscopic fetal surgery, there were 16 available centers, 15 of which provided information. Among these, a median 10 cases of fetoscopic fetal surgery were performed.

Across 10 centers, there were 20 cases requiring fetal resuscitation during fetal surgery in the past 5 years. Measures against fetal cardiac compromise included uterine or fetal repositioning, pausing procedures, administration of epinephrine, bicarbonate, or atropine, and warm saline uterine infusions.

Of the 15 centers which responded to questions about fetal resuscitation policy, 11% had a specific policy in place. Twenty of the 24 centers which responded to questions about parental counseling related to potential fetal complicationsprovided counseling on the potential need for fetal resuscitation either during the initial consultation or immediately prior to surgery.

Twenty-four centers discussed sharing information among health care professionals prior to surgery, 19 of which reported discussion of fetal resuscitation with a surgical team before surgery. Input was provided by fetal surgeons in 16 centers, fetal medicine specialists in 15, anesthesiologists in 13, and parents or patient representatives in 3.

Necessity of emergency delivery 4 times in the past 5 years was reported by 3 of 20 centers, 2 each during open or fetoscopic surgery and all at 23- to 26-weeks’ gestation. One center reported the death of an infant at 23-weeks’ gestation.

Discussion of a plan for neonatal palliative care with parents was reported by 12 of 22 centers. Policies to support practice after fetal death were reported by 12 centers, while 10 did not have policies in place.

These results indicate variability in many areas of practice, such as seeking parental consent, the gestational age when resuscitating, policy provision, and mortality management. This showed a need for further collaborative work between centers.

Reference

Gallagher K, Crombag N, Prashar K, et al. Global policy and practice for intrauterine fetal resuscitation during fetal surgery for open spina bifida repair. JAMA Netw Open. 2023;6(4):e239855. doi:10.1001/jamanetworkopen.2023.9855