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• W4207029151 abstract "This multicenter study describes the pregnancy outcomes in subsequent pregnancies following a pregnancy in which in utero open spina bifida closure without a stapled hysterotomy was performed. All patients who underwent in utero open spina bifida closure at 5 referral centers in Latin America from 2005 to 2020 were included. During surgery, the initial hysterotomy was performed in the uterine fundus at least 3 to 5 cm away from the placental edge, which was identified using ultrasonography. The incision was made using a surgical scalpel or with electrocautery and it was extended to a length of 4 to 7 cm using a scalpel, electrocautery, or a bipolar clamping device. The chorioamniotic membranes were then sutured to the myometrium using running or interrupted synthetic absorbable 2-0 polyglactin or 2-0 polydioxanone sutures. The hysterotomy was closed in 2 or 3 layers with running 2-0, 0, and/or 1 polyglactin or polydioxanone sutures. The medical records were reviewed. This study was approved by the Baylor College of Medicine Institutional Review Board (approval number H-38479). A total of 222 consecutive patients underwent in utero, open, spina bifida closure without stapled hysterotomy, with 7.2% (n=16) of them being lost to follow-up. Of the remaining 206 patients, 24.8% (n=51) had subsequent pregnancies, 16.5% (n=34) had subsequent deliveries via repeat cesarean delivery (Table), and there are 3 ongoing pregnancies. Subsequent pregnancies were complicated by abortions (n=12), ectopic pregnancies (n=2), postpartum hemorrhage requiring blood transfusions (n=2), and placental abruption (n=1). One pregnancy was complicated by prelabor uterine rupture, which required a hysterectomy at 33 weeks’ gestation; the neonate developed grade 4 intraventricular hemorrhage and death occurred at 7 days of age after care was redirected. Of note, the patient’s previous spina bifida closure was complicated by fetal death on day 1 after surgery, the patient was delivered via cesarean delivery using the same hysterotomy and the patient recovered well after surgery.TableDemographic and clinical characteristics of the study populationDemographicsn=34Maternal age (y)29 (19–34)Parity1 (1–3)Ethnicity White (%)41.2 (14/34) Hispanic (%)58.8 (20/34)GA at open spina bifida closure (wk)25 (23–27)GA at delivery following spina bifida closure (wk)34 (23–37)Birthweight (g) following spina bifida closure2045 (510–2879)GA at delivery in subsequent pregnancy (wk)37 (33–39)Birthweight (g) in subsequent pregnancy2750 (1900–4200)Small for GA neonatesaSmall for gestational age neonate is a neonate with a birthweight below the 10th percentile for GA at delivery in subsequent pregnancies (%)11.8 (4/34)Interval between deliveriesbInterval between deliveries is the time period from the pregnancy with in utero surgery to the subsequent pregnancy (mo)27 (11–82)Respiratory distress syndrome (%)15 (5/34)Grade 4 intraventricular hemorrhage (%)2.9cThe case in which neonatal death associated with uterine rupture occurred, also had respiratory distress syndrome and grade 4 intraventricular hemorrhage. (1/34)Neonatal death (%)2.9cThe case in which neonatal death associated with uterine rupture occurred, also had respiratory distress syndrome and grade 4 intraventricular hemorrhage. (1/34)Data are presented as median and range, or proportion and percentage.GA, gestational age.Blair. Uterine rupture after nonstapled hysterotomy in a previous pregnancy. Am J Obstet Gynecol 2022.a Small for gestational age neonate is a neonate with a birthweight below the 10th percentile for GA at deliveryb Interval between deliveries is the time period from the pregnancy with in utero surgery to the subsequent pregnancyc The case in which neonatal death associated with uterine rupture occurred, also had respiratory distress syndrome and grade 4 intraventricular hemorrhage. Open table in a new tab Data are presented as median and range, or proportion and percentage. GA, gestational age. Blair. Uterine rupture after nonstapled hysterotomy in a previous pregnancy. Am J Obstet Gynecol 2022. Our uterine rupture rate in subsequent pregnancies following fetal surgery without a stapled hysterotomy (2.9% [1/34]) is lower than that after a stapled hysterotomy in a previous pregnancy (9.6% [5/52]) reported by Goodnight et al.1Goodnight W.H. Bahtiyar O. Bennett K.A. et al.Subsequent pregnancy outcomes after open maternal-fetal surgery for myelomeningocele.Am J Obstet Gynecol. 2019; 220: 494.e1-494.e7Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar The difference did not reach statistical significance (P=.4); however, this comparison requires a cohort of at least 335 individuals with subsequent deliveries after open spina bifida closure to have 80% power with an alpha of 0.05 to detect a significant difference. The authors reported a similar proportion of missing outcome data. Goodnight et al1Goodnight W.H. Bahtiyar O. Bennett K.A. et al.Subsequent pregnancy outcomes after open maternal-fetal surgery for myelomeningocele.Am J Obstet Gynecol. 2019; 220: 494.e1-494.e7Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar concluded that “the risk of uterine rupture [after stapled hysterotomy]…is similar to that of prior classical uterine incisions.” However, the uterine rupture rate reported by these authors was 15-fold higher than that reported by Chauhan et al2Chauhan S.P. Magann E.F. Wiggs C.D. Barrilleaux P.S. Martin Jr., J.N. Pregnancy after classic cesarean delivery.Obstet Gynecol. 2002; 100: 946-950Crossref PubMed Scopus (0) Google Scholar (0.6%; relative risk [RR], 15.1; 95% confidence interval [CI], 1.8–126.3; P=.004) among 157 patients who underwent classical cesarean delivery and 5-fold higher than that reported in a Maternal-Fetal Medicine Units Network study (1.9%; RR, 5.1; 95% CI, 1.01–25.1; P=.04), involving 105 patients with a previous classical cesarean delivery.3Landon M.B. Hauth J.C. Leveno K.J. et al.Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery.N Engl J Med. 2004; 351: 2581-2589Crossref PubMed Scopus (967) Google Scholar The pregnancy outcomes of open fetal spina bifida closure in the index pregnancy in several Latin American centers were reported elsewhere.4Sepulveda W. Cruz-Martinez R. Etchegaray A. et al.Open intrauterine repair of spina bifida aperta: historical aspects, current availability, and clinical outcomes from the Latin American Spina Bifida Consortium.Prenat Diagn. 2021; 41: 933-941Crossref PubMed Scopus (4) Google Scholar In our study, participating centers did not use surgical staples because of unavailability or prohibitive local costs. Absorbable surgical staples may interfere with adequate uterine wound healing processes; histologic evaluation of 25 cases with stapled hysterotomy scars excised at the time of cesarean delivery following open spina bifida closure demonstrated that the intact layer of myometrium was <1 mm thick in 56% of cases.5Ochsenbein-Kölble N. Brandt S. Bode P. et al.Clinical and histologic evaluation of the hysterotomy site and fetal membranes after open fetal surgery for fetal spina bifida repair.Fetal Diagn Ther. 2019; 45: 248-255Crossref PubMed Scopus (9) Google Scholar The authors proposed that “In order to prevent uterine rupture in subsequent pregnancies, we recommend the hysterotomy site to be completely excised after birth.”5Ochsenbein-Kölble N. Brandt S. Bode P. et al.Clinical and histologic evaluation of the hysterotomy site and fetal membranes after open fetal surgery for fetal spina bifida repair.Fetal Diagn Ther. 2019; 45: 248-255Crossref PubMed Scopus (9) Google Scholar Absorbable staples help in extending the hysterotomy while achieving hemostasis and membrane preservation. However, adequately powered studies are required to determine if hemostatic suturing of the myometrium and chorioamniotic membranes in open fetal surgery is associated with a lower risk for uterine rupture in subsequent pregnancies when compared with a stapled hysterotomy following in utero surgery." @default.
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• W4207029151 date "2022-05-01" @default.
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• W4207029151 title "Uterine rupture in subsequent pregnancies following in utero spina bifida closure without stapled hysterotomy" @default.
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