Neurosurgery notes/Literature/Paediatric papers/MOMS

MOMS

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Paediatric papers

General

  • Prenatal surgery before 26/40 vs standard postnatal repair

Outcomes

  • 12 months:
    • composite of foetal or neonatal death or the need for shunt
  • 30 months:
    • composite of mental development and motor function
notion image
 

Results

  • Stopped after the recruitment of 183/200 patients
  • 158 patients whose children were evaluated at 12 months
  • Prenatal surgery resulted in improvement in the composite score for mental development and motor function at 30 months (P=0.007) and in improvement in several secondary outcomes, including hindbrain herniation by 12 months and ambulation by 30 months
  • Prenatal surgery increased risk of preterm delivery and uterine dehiscence at delivery
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Pre-natal Surgery
Post-natal Repair
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Primary Outcome
68%
98%
p<0.001
Shunt Placement
40%
82%
p<0.001

Conclusion

  • Prenatal surgery for myelomeningocele reduced the need for shunting and improved motor outcomes at 30 months but was associated with maternal and fetal risks

Houtrow et al 2021

  • Further analysis of the MOMS trial
  • functional mobility and motor levels are improved for children who underwent prenatal myelomeningocele repair vs standard postnatal repair.

Complications

  • Babies do better (at least in the short term) with open fetal surgery BUT
  • The mother carries an increased risk of:
    • Ruptured uterus in the current and future pregnancies
      • Uterine dehiscence
        • 35% of women who underwent prenatal surgery had an area of dehiscence or a very thin pre-natal uterine scar at the time of delivery
        • 10% of women who have a hysterotomy will rupture their uterus in their next pregnancy
        • Possibly fetoscopic repair MMC to reduce risk
          • Verbeek 2011
            • Fetoscopic group versus postnatal repair group:
              • Born earlier (32 wks [25–34] vs 39 wks [34–41])
              • More obstetric complications (chorio, PPROM, oligo)
              • More NICU ventilation and RDS
            • BUT:
              • Better neurological function preservation (mean of 2 segments better)
              • Better knee jerk and anal sphincter reflexes
    • Obligatory preterm cesarean section (usually 34–35 weeks)
    • Repeat CS for all future pregnancies
    • Increased risk of placenta percreta and death in future pregnancies
  • Maternal outcome:
    • Chorioamniotic membrane separation — 20 (26%)
    • Pulmonary edema — 5 (6%)
    • Modified biophysical profile <8 — 13 (17%)
    • Oligohydramnios — 16 (21%)
    • Placental abruption — 5 (6%)
    • Gestational diabetes — 4 (5%)
    • Chorioamnionitis — 2 (3%)
    • Preeclampsia or gestational hypertension — 3 (4%)
    • Spontaneous membrane rupture — 36 (46%)
    • Spontaneous labor — 30 (38%)
    • Blood transfusion at delivery — 7 (9%)
    • Status of hysterotomy site at delivery:
      • Intact, well-healed — 49/76 (64%)
      • Very thin — 19/76 (25%)
      • Area of dehiscence — 7/76 (9%)
      • Complete dehiscence — 1/76 (1%)
  • Fetal or neonatal outcome:
    • Bradycardia during fetal or neonatal repair — 8 (10%)
    • Perinatal death — 2 (3%)
    • Gestational age at birth — 34.1±3.1 weeks
    • Gestational age at birth (number [%]):
      • <30 wk — 10 (13%)
      • 30–34 wk — 26 (33%)
      • 35–36 wk — 26 (33%)
      • ≥37 wk — 16 (21%)