Bruner J P, Tulipan N, Paschall R L, Boehm F H, Walsh W F, Silva S R, Hernanz-Schulman M, Lowe L H, Reed G W
Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tenn 37232-2519, USA.
JAMA. 1999 Nov 17;282(19):1819-25. doi: 10.1001/jama.282.19.1819.
Intrauterine closure of exposed spinal cord tissue prevents secondary neurologic injury in animals with a surgically created spinal defect; however, whether in utero repair of myelomeningocele improves neurologic outcome in infants with spina bifida is not known.
To determine whether intrauterine repair of myelomeningocele improves patient outcomes compared with standard care.
Single-institution, nonrandomized observational study conducted between January 1990 and February 1999.
Tertiary care medical center.
A sample of 29 study patients with isolated fetal myelomeningocele referred for intrauterine repair that was performed between 24 and 30 gestational weeks and 23 controls matched to cases for diagnosis, level of lesion, practice parameters, and calendar time. All infants were followed up for a minimum of 6 months after delivery.
Requirement for ventriculoperitoneal shunt placement, obstetrical complications, gestational age at delivery, and birth weight for study vs control subjects.
The requirement for ventriculoperitoneal shunt placement for decompression of hydrocephalus was significantly decreased among study infants (59% vs 91%; P = .01). The median age at shunt placement was also older among study infants (50 vs 5 days; P = .006). This may be explained by the reduced incidence of hindbrain herniation among study infants (38% vs 95%; P<.001). Following hysterotomy, study patients had an increased risk of oligohydramnios (48% vs 4%; P = .001) and admission to the hospital for preterm uterine contractions (50% vs 9%; P = .002). The estimated gestational age at delivery was earlier for study patients (33.2 vs 37.0 weeks; P<.001), and the birth weight of study neonates was less (2171 vs 3075 g; P<.001).
Our study suggests that intrauterine repair of myelomeningocele decreases the incidence of hindbrain herniation and shunt-dependent hydrocephalus in infants with spina bifida, but increases the incidence of premature delivery.
在通过手术造成脊柱缺损的动物中，子宫内封闭暴露的脊髓组织可预防继发性神经损伤；然而，胎儿期脊髓脊膜膨出修补术是否能改善脊柱裂婴儿的神经学预后尚不清楚。
确定与标准治疗相比，胎儿期脊髓脊膜膨出修补术是否能改善患者预后。
1990年1月至1999年2月在单一机构进行的非随机观察性研究。
三级医疗中心。
29例孤立性胎儿脊髓脊膜膨出的研究患者样本，这些患者在妊娠24至30周时接受了子宫内修补术，另有23例对照，根据诊断、病变水平、实践参数和日历时间与病例匹配。所有婴儿在出生后至少随访6个月。
研究组与对照组患者脑室腹腔分流术的需求、产科并发症、分娩时的孕周和出生体重。
研究组婴儿因脑积水减压而进行脑室腹腔分流术的需求显著降低（59%对91%；P = 0.01）。研究组婴儿分流术的中位年龄也较大（50天对5天；P = 0.006）。这可能是由于研究组婴儿后脑疝的发生率降低（38%对95%；P<0.001）。子宫切开术后，研究组患者羊水过少的风险增加（48%对4%；P = 0.001），因早产宫缩入院的风险增加（50%对9%；P = 0.002）。研究组患者分娩时的估计孕周较早（33.2周对37.0周；P<0.001），研究组新生儿的出生体重较低（2171克对3075克；P<0.001）。
我们的研究表明，胎儿期脊髓脊膜膨出修补术可降低脊柱裂婴儿后脑疝和分流依赖性脑积水的发生率，但会增加早产的发生率。
