Reproductive outcomes following open maternal–fetal surgery for myelomeningocele closure: analysis of MOMS trial participants

BACKGROUND

In utero closure of myelomeningocele has become an accepted alternative in the management of prenatally diagnosed spina bifida. Maternal reproductive risk has been previously described on the basis of registry data and institutional outcomes. Herein we aim to provide maternal reproductive outcomes from participants in the Management of Myelomeningocele Study.

OBJECTIVE

Open maternal–fetal surgery for in utero closure of myelomeningocele is associated with childhood benefits through school age; however, obstetrical and maternal reproductive risks are also factors to consider. The objective of this analysis was to evaluate reproductive outcomes after open maternal–fetal surgery compared with standard postnatal myelomeningocele closure.

STUDY DESIGN

The Management of Myelomeningocele Study was a randomized trial comparing prenatal vs postnatal closure of myelomeningocele. Women in the prenatal closure arm underwent open maternal–fetal surgery at 21 to 26 weeks of gestation and underwent cesarean delivery at 37 weeks if they were not delivered before that. In the postnatal closure arm, cesarean delivery was performed at 37 weeks and neonates underwent surgical closure soon after birth. Families returned for follow-up at 30 months and again at school age between 6 and 10 years. Maternal reproductive questionnaires were administered at the time of the follow-up visits to assess menstruation, fertility, gynecologic issues, and subsequent pregnancy outcomes. We compared continuous variables using the Wilcoxon test and categorical variables using the chi-square or Fisher exact test, as appropriate.

RESULTS

A total of 174 randomized women (86 in the prenatal closure group and 88 in the postnatal closure group) completed reproductive questionnaires, with 91 women reporting no subsequent pregnancies since the Management of Myelomeningocele Study. In the prenatal closure group, 36 women reported 60 subsequent pregnancies, of which 45 (75%) progressed ≥20 weeks. In the postnatal closure group, 43 women reported 71 pregnancies, of which 50 (70%) progressed ≥20 weeks. The prenatal closure group was more likely to deliver at <37 weeks (P<.001). One uterine rupture (2.2%) and 2 uterine dehiscence cases (4.4%) were reported in the prenatal closure group; none were reported in the postnatal closure group (P<.001). The use of fertility treatments or gynecologic surgeries was not different between the groups.

CONCLUSION

Preterm delivery was more common in subsequent pregnancies after open maternal–fetal surgery. The risk for uterine rupture and dehiscence was higher in the prenatal group than in the postnatal group, but lower than what has been previously reported with open maternal–fetal surgery. Reproductive outcomes were otherwise similar between women undergoing open maternal–fetal surgery for myelomeningocele closure and the postnatal closure group in the Management of Myelomeningocele Study.