Systematic assessment of maternal complications following open fetal myelomeningocele repair by Clavien-Dindo classification

Introduction:

There are undoubtable benefits of open fetal myelomeningocele (fMMC) repair, for example, reducing the need for ventriculo-peritoneal shunting and improving motoric outcomes. However, open fetal surgery and subsequent delivery by cesarean section are associated with considerable maternal risks compared to postnatal repair. The objective of the current study was to systematically describe, evaluate and categorize maternal complications after fMMC repair.

Patients and methods:

We analysed the data of 40 prenatal MMC repair cases performed between December 2010 and July 2016 at the Zurich Center for Fetal Diagnosis and Therapy for maternal complications. We classified maternal complications during and after fMMC into a 5-level severity grading system based on the therapy-oriented classification of surgical complications by Clavien and Dindo. Thereby, grade 1 are minor complications defined as events not requiring any pharmacological treatment or surgical intervention (with exception of analgesic, antipyretic and antiemetic drugs). Grade 2 calls for pharmacological treatment other than such allowed for grade 1 and grade 3 requires surgical intervention. Grade 4 are major events which are life-threatening and grade 5 is the death of a patient.

Results:

We observed no woman with grade 5 complication but twelve (30%) women with a severe complication (grade 4). During surgery or within the first 2 d we observed one case of a third-degree AV-bloc, one case of a bilateral lung embolism, and one case of an intraoperative placental abruption. In the further course of pregnany we documented three (7,5%) additional placental abruption, two (5%) chorioamnionitis, one (2,5%) uterine rupture at 36 GW, one (2,5%) urosepsis, one (2,5%) major extragenital bleeding, and one (2,5%) woman with preeclampsia. We had no case of pulmonary edema or blood transfusion. A total of 28 (70%) women had at least one but often more minor (grade 1 – 3) complications each. In more than half of the women the minor complication can be interpreted as a direct consequence of the fMMC repair such as 15 (37.5%) cases with a hematoma/seroma at the maternal incision.

Conclusion:

Our data emphasizes the crucial role of an experienced team with a dual focus on both the fetal and the maternal patient. In this study, we propose a classification system of maternal complications that supports the team in a well-structured counselling to the parents and standardizes fMMC repair results for further evaluations.