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Management of Labor and Delivery After Fetoscopic Repair of an Open Neural Tube Defect

Kohn, Jaden, R., MD, MPH; Rao, Vibha, MD; Sellner, Allison, A., MD; Sharhan, Dina, BS; Espinoza, Jimmy, MD, MSc; Shamshirsaz, Alireza, A., MD; Whitehead, William, E., MD, MPH; Belfort, Michael, A., MD, PhD; Sanz Cortes, Magdalena, MD, PhD

doi: 10.1097/AOG.0000000000002577
Contents: Maternal-Fetal Medicine: Original Research

OBJECTIVE: To report labor, delivery, and neonatal outcomes in a cohort of women delivering neonates who had undergone fetoscopic neural tube defect repair.

METHODS: We conducted a retrospective cohort study from April 2014 to January 2018. All patients met Management of Myelomeningocele Study eligibility criteria. We included patients with completed second-trimester fetoscopic neural tube defect repair (laparotomy, uterine exteriorization, and minimally invasive access through two or three uterine ports) followed by standardized management of labor and delivery at our institution. Outcomes included rates of vaginal delivery, term delivery, and intrapartum cesarean delivery as well as obstetric and neonatal outcomes after oxytocin. Complications of interest included preterm prelabor rupture of membranes, chorioamnionitis, uterine dehiscence or rupture, 5-minute Apgar score less than 7, and neonatal acidosis (umbilical artery pH less than 7.15).

RESULTS: Thirty-four patients had fetoscopic repair, followed by 17 vaginal deliveries (50%, 95% CI 32–68%). Median gestational age was 38 1/7 weeks at vaginal delivery (range 26 0/7–40 2/7 weeks of gestation) and 37 1/7 weeks of gestation at cesarean delivery (range 25 5/7–40 5/7 weeks of gestation); 62% of deliveries occurred at term. Eight patients had prelabor cesarean delivery: three nonurgent and five urgent (for nonreassuring fetal heart tracings). Twenty-six patients labored; six were induced and 20 labored spontaneously. Of the latter, five were augmented. Of 26 laboring patients, 17 delivered vaginally and nine underwent urgent cesarean delivery (35%, 95% CI 17–56%; seven nonreassuring fetal heart tracings and two breech). There were no cases of uterine rupture or dehiscence. Most (94%, 95% CI 80–99%) had normal 5-minute Apgar scores; one neonate (3%, 95% CI 0–15%) had acidosis but normal Apgar scores.

CONCLUSION: Our data regarding trial of labor, use of low-dose oxytocin, and vaginal delivery after prenatal fetoscopic neural tube defect repair are reassuring. Importantly, fetoscopic repair may permit delivery at advanced gestational ages.

Labor, low-dose oxytocin, and vaginal delivery appear to be well–tolerated in patients with prenatal fetoscopic neural tube defect repair; fetoscopic repair permits delivery at more advanced gestation.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, and the Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; the University of Maryland, Baltimore, Maryland; and Texas Children’s Hospital Fetal Center, Houston, Texas.

Corresponding author: Magdalena Sanz Cortes, MD, PhD, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, 6651 Main Street, Suite 420, Houston, TX 77030; email: Magdalena.SanzCortes@bcm.edu.

Development and evaluation of our fetoscopic procedure is financially supported by grants from the Sterling Turner Foundation, O'Quinn Foundation, Fondren Foundation, and Tramuto Foundation; these organizations did not contribute to the content or preparation of the manuscript.

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented as a poster at the American College of Obstetricians and Gynecologists’ Annual Clinical and Scientific Meeting, April 27–30, 2018, Austin, Texas.

Each author has indicated that he or she has met the journal's requirements for authorship.

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.