Open Spina Bifida: Why Not Fetal Surgery?

OBJECTIVE: The majority of patients counseled for prenatal open spina bifida repair (SBR) do not undergo fetal surgery. The aim of this study was to analyze the reasons for this phenomenon. MATERIALS AND METHODS: The data of the first 160 patients seeking counseling or referred to the Zurich Center for Fetal Diagnosis and Therapy for prenatal SBR between December 2010 and March 2017 were retrospectively analyzed. RESULTS: A total of 104 (65%) patients did not undergo prenatal SBR. Of this subgroup, 52% met the exclusion criteria, 35% decided to terminate pregnancy, 4% chose to continue pregnancy without fetal intervention, and 3% sought care in other European centers. In 6%, data about the ensuing course of pregnancy were not recorded. The main exclusion criteria were delayed presentation (30%), absence of hindbrain herniation (28%), and concomitant spinal anomalies (17%). CONCLUSION: The high percentage of patients not qualifying for prenatal SBR underscores the necessity of a standard evaluation of every single patient at a qualified referral center. To allow a higher proportion of women carrying a fetus with open spina bifida to be timely and correctly informed about a potential fetal intervention, much more effort is mandatory to spawn correct, objective, and understandable information among all groups of people potentially exposed to this topic.

Midwives' perceptions on using a fetoscope and Doppler for fetal heart rate assessments during labor: a qualitative study in rural Tanzania.

BACKGROUND: The Doppler is thought to be more comfortable and effective compared to the fetoscope for assessing the fetal heart rate (FHR) during labor. However, in a rural Tanzanian hospital, midwives who had easy access to both devices mostly used fetoscope. This study explored midwives' perception of factors influencing their preference for using either a Pinard fetoscope or a FreePlay wind-up Doppler for intermittent FHR monitoring. METHODS: Midwives who had worked for at least 6 months in the labor ward were recruited. Focus group discussion (FGD) was used to collect data. Five FGDs were conducted between December 2015 and February 2016. Qualitative content analysis was employed using NVivo 11.0. RESULTS: Three main themes emerged as factors perceived by midwives as influencing their preference; 1) Sufficient training and experience with using a device; Midwives had been using fetoscopes since their midwifery training, and they had vast experience using it. The Doppler was recently introduced in the maternity ward, and midwives had insufficient training in how to use it. 2) Ability of the device to produce reliable measurements; Using a fetoscope, one must listen for the heartbeat, count using a watch, and calculate, the Doppler provides both a display and sound of the FHR. Fetoscope measurements are prone to human errors, and Doppler measurements are prone to instrumental errors. 3) Convenience of use and comfort of a device; Fetoscopes do not need charging, and while it is possible to "personalize/hide" the measurements, and may be painful for mothers. Dopplers need charging and do not cause pain, but provide limited privacy. CONCLUSION: Midwives' preferences of FHR monitoring devices are influenced by the level of device training, experience with using a device, reliable measurements, and convenience and comfort during use. Fetoscopes and Dopplers should be equally available during midwifery training and in clinical practice.

Physician views regarding the benefits and burdens of prenatal surgery for myelomeningocele.

OBJECTIVE: Examine how pediatric and obstetrical subspecialists view benefits and burdens of prenatal myelomeningocele (MMC) closure. STUDY DESIGN: Mail survey of 1200 neonatologists, pediatric surgeons and maternal-fetal medicine specialists (MFMs). RESULTS: Of 1176 eligible physicians, 670 (57%) responded. Most respondents disagreed (68%, 11% strongly) that open fetal surgery places an unacceptable burden on women and their families. Most agreed (65%, 10% strongly) that denying the benefits of open maternal-fetal surgery is unfair to the future child. Most (94%) would recommend prenatal fetoscopic over open or postnatal MMC closure for a hypothetical fetoscopic technique that had similar shunt rates (40%) but decreased maternal morbidity. When the hypothetical shunt rate for fetoscopy was increased to 60%, physicians were split (49% fetoscopy versus 45% open). Views about burdens and fairness correlated with the likelihood of recommending postnatal or fetoscopic over open closure. CONCLUSION: Individual and specialty-specific values may influence recommendations about prenatal surgery.

Does website-based information add any value in counseling mothers expecting a baby with severe congenital diaphragmatic hernia?

OBJECTIVE: We aimed to measure whether website-provided information about congenital diaphragmatic hernia (CDH) and fetal therapy for severe cases provides added value compared with clinical counseling of parents. METHODS: This is a single center study in 102 couples who earlier opted for fetoscopic endoluminal tracheal occlusion (FETO) because of isolated severe CDH. They were asked to fill out an anonymized web-based survey of 12 questions. Then, they were offered access to information on the web pages of the randomized Tracheal Occlusion to Accelerate Lung Growth (TOTAL) trial. One week later, their appreciation was measured again by a second questionnaire. RESULTS: Eighty-two (80%) parents completed the first questionnaire, and 48 (47%) completed the entire survey. Several items became more clear to the parents after reading the website, such as the length of hospital stay (23.2% prior to web information, 60.4% after; P = 0.004), maternal risk, or the requirement of fetal anesthesia for FETO (43.9% resp. 79.2%; P = <0.001). CONCLUSION: Complementing prenatal counseling on CDH and FETO by standardized information via website is perceived by parents as of added value. Maternal risks and the need for fetal medication need more clarification during the verbal counseling prior to prenatal interventions.

Role of psychological intervention in fetoscopic laser surgery of twin-to-twin transfusion syndrome.

OBJECTIVE: This study aims to investigate the influence of application of psychological intervention in fetoscopic laser surgery of twin-to-twin transfusion syndrome (TTTS) on perinatal outcome. MATERIALS AND METHODS: A total of ten cases of pregnant women diagnosed with TTTS from January 2007 to December 2009 in the present hospital were selected. Their gestational weeks ranged from 16 to 29 weeks. Under the location of B ultrasound, the method of intra-amniotic fetoscopic laser occlusion of chorioangiopagous vessels (FLOC) plus amnioreduction was conducted for treatment. Contemporarily, psychological intervention was also carried out. RESULTS: Preoperative, intraoperative, and postoperative behavior controls of all pregnant women were good, and all operations were successfully completed to achieve the desired purpose of rehabilitation discharge. CONCLUSION: Fetoscopic laser surgery is an effective treatment for TTTS and competent psychological intervention is one of important measures for successful operation and pregnant woman rehabilitation discharge.

Short-term outcomes of fetoscopic laser surgery for severe twin-twin transfusion syndrome from Taiwan single center experience: demonstration of learning curve effect on the fetal outcomes.

OBJECTIVE: To evaluate the learning curve effect on fetal outcomes while using fetoscopic laser photocoagulation (FLP) for twin-twin transfusion syndrome (TTTS) as managed by a newly established single center in Taiwan. MATERIALS AND METHODS: Between October 2005 and October 2010, women diagnosed to have TTTS before 26 weeks of gestation were offered FLP surgery. Cases were divided into first-half and second-half groups to evaluate the learning effect on fetal outcomes including at least one survival rate, two survival rate, and gestational age of delivery. RESULTS: A total of 44 cases with a median gestational age of 20.1 weeks (range 16-25) at operation were included in the study. Overall, both twins survived in 22 (50.0%) cases, whereas only one twin was born alive in 13 (29.5%), and neither was born alive in the remaining nine cases (20.5%). The total survival rate was 64.8%. When comparing the first-half 22 cases and the second-half 22 cases, there were significant improvements in total survival rate (54.7% vs. 75.0%, p = 0.045), a prolonged interval between operation and delivery (62.1 vs. 89.1 days, p = 0.042), and more advanced gestational age of delivery (28.3 vs. 33.0 weeks, p = 0.008) in the second-half 22 cases. CONCLUSIONS: With increasing experience in using fetoscopic guide laser therapy for TTTS, the fetal survival rate could be improved with advanced gestational age at delivery.