Laparotomy Versus Percutaneous Endoscopic Correction of Myelomeningocele

Launched by USFETUS · Feb 25, 2019

Keywords

ClinConnect Summary

This clinical trial is studying two different surgical techniques to correct a serious birth defect called myelomeningocele, which is a type of spina bifida that affects the spinal cord and nerves. The trial aims to see if a less invasive approach, called percutaneous endoscopic correction, can be done safely for certain patients, while another method called laparotomy will be offered to others. This study is designed for pregnant women who are between 19 to 27 weeks along in their pregnancy and have a confirmed diagnosis of myelomeningocele.

To participate, women must be at least 18 years old, have the right type of myelomeningocele, and have good support from a social worker and pediatric neurologist. They also need to live within a reasonable distance from specific hospitals for follow-up visits after the surgery. Participants can expect to receive care from a team of specialists throughout the process and will need to come back for follow-up evaluations at various times after giving birth. It is important to note that certain health conditions or complications in the pregnancy may prevent someone from participating in this trial.

Gender

FEMALE

Eligibility criteria

• Inclusion Criteria:
• • 1. Myelomeningocele (including myeloschisis) at level T1 through S1 with hindbrain herniation. Lesion level and hindbrain herniation will be confirmed by MRI and ultrasonography.
• • 2. Maternal age ≥18 years.
• • 3. Gestational age of 19 to 27 6/7 weeks' gestation as determined by clinical information and evaluation of first ultrasound.
• • 4. Balanced karyotype with written confirmation of culture results. Results by fluorescence in situ hybridization (FISH) will be acceptable if the patient is at 24 weeks or more.
• • 5. Positive evaluation of social work consult indicating the patient is capable of consenting to the procedure and has the appropriate social support system to participate in the study.
• • 6. Positive evaluation from pediatric neurology consult.
• • 7. Willing to remain in the greater Wellington or Pasadena area (within a 30-minute car ride) for remainder of the pregnancy and deliver at Wellington Regional Medical Center or Huntington Memorial Hospital for postnatal management. The participants must be willing to return to our center for the 12, 24, 30, 48, and 60 months for follow-up evaluation.
• Exclusion Criteria:
• • 1. Multiple gestation
• • 2. Insulin-dependent pregestational diabetes
• • 3. Presence of a fetal anomaly not related to myelomeningocele. A fetal echocardiogram will be conducted before surgery and if the finding is abnormal, the patient will be excluded.
• • 4. Fetal kyphosis of 30 degrees or more, assessed by ultrasound or MRI.
• • 5. Presence of uterine cervical cerclage or history of incompetent cervix.
• • 6. Placenta previa or placental abruption.
• • 7. Short cervix \< 25 mm measured by cervical ultrasound.
• • 8. Obesity as defined by body mass index (BMI) of 35 or greater.
• • 9. History of previous spontaneous singleton delivery prior to 37 weeks.
• • 10. Maternal-fetal Rh isoimmunization, Kell sensitization or a history of neonatal alloimmune thrombocytopenia.
• • 11. Maternal HIV or Hepatitis-B status positive because of the increased risk of transmission to the fetus during maternal-fetal surgery. If the patient's HIV or Hepatitis B status is unknown, the patient must be tested and found to have negative results before she can be enrolled.
• • 12. Known Hepatitis-C positivity. If the patient's Hepatitis C status is unknown, she does not need to be screened.
• • 13. Uterine anomaly such as large (greater than 6 cm) fibroids, cervical fibroids or multiple fibroids or Mullerian duct abnormality.
• • 14. Other maternal medical condition which is a contraindication to surgery or anesthesia.
• • 15. Patient does not have a support person (e.g., husband, partner, parents).
• • 16. Inability to comply with the travel and follow-up requirements of the study.
• • 17. Patient does not meet psychosocial criteria as determined by the social worker evaluation.
• • 18. Participation in another intervention study that influences maternal and fetal morbidity and mortality.
• • 19. Maternal hypertension as determined by the investigator, which would increase the risk of preeclampsia or preterm delivery (including, but not limited to: uncontrolled hypertension, chronic hypertension with end organ damage and new onset hypertension in current pregnancy).
• • 20. Bicornuate uterus or any other uterine malformation the PI decides is not safe for surgery.
• • 21. Nickel allergy.
• • 22. Maternal request to undergo open fetal surgery for the antenatal correction of open spina bifida at our institution primarily or after failed fetoscopic approach.
• • 23. Known maternal hypersensitivity to bovine collagen or chondroitin materials.