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Evidence to Inform Decisions About Maternal–Fetal Surgery: Technical Brief

Hartmann, Katherine E. MD, PhD; McPheeters, Melissa L. PhD, MPH; Chescheir, Nancy C. MD; Gillam-Krakauer, Maria MD; McKoy, J. Nikki MPH; Jerome, Rebecca MLIS, MPH; Sathe, Nila A. MA, MLIS; Meints, Laura MD; Walsh, William F. MD

doi: 10.1097/AOG.0b013e318216151d

OBJECTIVE: To summarize the state of research in maternal–fetal surgery regarding the surgical repair of abnormalities in fetuses in the womb.

DATA SOURCES: We searched MEDLINE from 1980 to 2010 for studies of maternal–fetal surgery for the following conditions: twin–twin transfusion syndrome, obstructive uropathy, congenital diaphragmatic hernia, myelomeningocele, thoracic lesions, cardiac malformations, and sacrococcygeal teratoma.

METHODS OF STUDY SELECTION: We used pilot-tested data collection forms to screen publications for inclusion and to extract data. We compiled information about how fetal diagnoses were defined, maternal inclusion criteria, type of surgery, study design, country, setting, comparators used, length of follow-up, outcomes measured, and adverse events.

TABULATION, INTEGRATION, AND RESULTS: Two reviewers independently extracted data and discordance was resolved by a third party. Of 1,341 articles located, we retained 258 (comprising 166 unique study populations). Three studies were randomized controlled trials; the majority of the evidence was observational (116 case series [70%], 36 retrospective [22%], and 11 prospective [7%] cohorts). Twin–twin transfusion is the most studied condition, with 84 studies including 2,532 pregnancies. Fewer than 500 pregnancies are represented in the literature for each of the other conditions except congenital diaphragmatic hernia (n=503). Inclusion criteria were poorly specified. Outcomes typically measured were survival to birth, preterm birth, and neonatal death. Longer-term outcomes were sparse but included pulmonary, renal, and neurologic status and developmental milestones. Maternal outcome data were rare.

CONCLUSION: Although developing rapidly, maternal–fetal surgery research has yet to achieve the typical quality of studies and aggregate strength of evidence needed to optimally inform care.

Evidence to inform decisions about maternal–fetal surgeries for seven selected conditions comes from fewer than 5,000 pregnancies reported largely in case series. SUPPLEMENTAL DIGITAL CONTENT IS AVAILABLE IN THE TEXT.

From the Vanderbilt Evidence-based Practice Center, Vanderbilt Institute for Medicine and Public Health, and the Department of Obstetrics and Gynecology, Vanderbilt Medical Center, Nashville, Tennessee; the Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of North Carolina, Chapel Hill, North Carolina; the Division of Neonatology, Vanderbilt Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee; Eskind Biomedical Library and Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee.

Selected material from the United States Agency for Healthcare Research and Quality Technical Brief on Maternal-Fetal Surgery is reprinted in this article. The full technical brief is available online at

Corresponding author: Katherine E. Hartmann, MD, PhD, Vanderbilt Evidence-based Practice Center, 2525 West End Avenue, 6th Floor, Nashville, TN 37203-1738; e-mail:

Financial Disclosure Funded by the Agency for Healthcare Research and Quality.

© 2011 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.