Open fetal surgery for myelomeningocele

Despite efforts at prevention through the use of preconception folic acid, spina bifida remains one of the most common congenital anomalies of the central nervous system that is compatible with life. It is, however, associated with a significant degree of lifelong morbidity. The development of open fetal surgery for myelomeningocele (MMC) has been a long process but one that serves as a model for how new procedures and technologies need to be properly evaluated before being brought into mainstream medical practice. Even so, risks and benefits need to be evaluated for each patient. The currently available studies have been carried out on a highly selected patient population where the fetal findings provided the maximum opportunity for benefit from prenatal closure of the MMC defect. There is the potential that as the surgery becomes more widely available, pressure will be brought to bear to perform surgery in cases where the likelihood for benefit is decreased and yet the risks are not. The only way to duplicate the results of the current studies is to follow the methodology and criteria that were used in the studies. This will mean that not every fetus with an MMC will be a candidate for in utero surgery. The balance of risk to benefit will continue to evolve as further technological advances are evaluated and more follow-up information is obtained. Copyright © 2011 John Wiley & Sons, Ltd.     

Managing twins discordant for fetal anomaly

An excess of structural anomalies is observed in twins compared to singletons. Approximately 1–2% of twin pregnancies may face the dilemma of expectant management versus selective termination following diagnosis of an anomaly affecting only one fetus. If the option of selective fetocide is considered, the main variable determining the technique to achieve this aim is chorionicity. In a dichorionic pregnancy, passage of substances from one twin into the circulation of the co-twin is unlikely due to the lack of placental anastomoses, hence KCl can be injected safely into the circulation of the affected twin to produce fetal asystole. In monochorionic twin pregnancies, selective termination needs to be performed by ensuring complete and permanent occlusion of both the arterial and venous flows in the umbilical cord of the affected twin, in order to avoid acute haemorrhage from the co-twin into the dying fetus, which may lead to death or organ damage. Bipolar cord coagulation under ultrasound guidance is associated with approximately 70–80% survival rates. Copyright © 2005 John Wiley & Sons, Ltd.