The impact of mode of delivery on infant neurologic outcomes in myelomeningocele

• Published in: American journal of obstetrics and gynecology Vol. 215; no. 4; pp. 495.e1 - 495.e11
• Main Authors: Greene, Stephanie, Lee, Philip S., Deibert, Christopher P., Tempel, Zachary J., Zwagerman, Nathan T., Florio, Karen, Bonfield, Christopher M., Emery, Stephen P.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.10.2016
• Subjects: cesarean; Cesarean Section; delivery; Delivery, Obstetric - methods; Evidence-Based Medicine; Female; Follow-Up Studies; function; Humans; Infant, Newborn; labor; Labor, Obstetric; Meningomyelocele - diagnosis; Meningomyelocele - physiopathology; motor; Motor Activity - physiology; myelomeningocele; neurologic; Obstetrics and Gynecology; Pregnancy; Pregnancy Outcome; Prenatal Diagnosis; Retrospective Studies; spina bifida; Trial of Labor; vaginal; delivery; motor; cesarean; myelomeningocele; spina bifida; function; neurologic; vaginal; labor
• ISSN: 0002-9378; 1097-6868; 1097-6868
• DOI: 10.1016/j.ajog.2016.05.028

Controversy exists regarding the optimal route of delivery for fetuses who are diagnosed prenatally with myelomeningocele. Current recommendations are based partly on antiquated studies with questionable methods. All studies that have been published to date suffer from nonstandardized outcome measures, selection bias, and small sample size. The larger studies are >15 years old. The purpose of this study was to provide information for evidence-based decision-making regarding the impact of route of delivery on motor outcomes for pediatric patients with prenatally were diagnosed myelomeningocele in a well-defined retrospective cohort. Medical records were reviewed retrospectively for all neonates who had been diagnosed with a myelomeningocele at birth from 1995-2015 within the University of Pittsburgh Medical Center system, as identified through the Children’s Hospital of Pittsburgh Neurosurgery Department operative database. Records were matched with maternal records with the use of the Center for Assistance in Research that used eRecord. Data from 72 maternal-neonatal pairs were analyzed for multiple variables. The primary outcome measure was the difference between the functional and anatomic motor levels in the child at the age of 2 years, stratified by mode of delivery and presence or absence of labor. The sample size necessary to detect a difference between the groups with power of 0.8 and significance of .05 was calculated to be 52 subjects total (26 per group). Functional levels were slightly better than predicted by anatomic levels for all pediatric patient groups, regardless of mode of delivery or presence of labor. Anatomic levels were slightly lower (better), and defects were smaller for those infants who underwent vaginal delivery or a trial of labor, likely attributable to selection bias. Attempts to correct for this selection bias did not change the results. No other outcomes that were analyzed were associated significantly with mode of delivery or presence of labor. No benefit to motor function from delivery by cesarean section or avoidance of labor was demonstrated statistically in this mother-infant cohort.