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Objective: To assess the association between mode of delivery and 2-year motor function in children with prenatal diagnosis of myelomeningocele., Methods: A multisite retrospective cohort study of children with myelomeningocele across 14 NAFTNet (North American Fetal Therapy Network) centers born between 2007 and 2020 who had a physical examination available at 2 years of life. Exclusion criteria were in utero myelomeningocele repair, postnatal myelomeningocele diagnosis, missing data on fetal presentation at delivery, and contraindications to labor. The primary outcome was the difference between the anatomic level of the spinal lesion and functional motor level at age 2 years. A general linear model was used to determine the effect of mode of delivery on the primary outcome, and multivariable analysis was performed to control for presence of labor, gestational age at delivery, defect size and origin level, and presence of ventriculomegaly., Results: Of 566 children with myelomeningocele, 305 met inclusion criteria, with 216 (70.8%) having been delivered by cesarean and 89 (29.2%) having been delivered vaginally. Children delivered by cesarean had a mean±SE level of motor function of 0.07±0.21 segments below the anatomic level at age 2 years compared with 0.57±0.32 for children delivered vaginally (P=.19). After controlling for potential confounders, both groups improved in motor function by age 2 years compared with anatomic level. However, there was no difference in motor improvement between groups by mode of delivery (0.07 cesarean vs 0.57 vaginal delivery, adjusted difference 0.37 segments, P=.63)., Conclusion: In this multisite NAFTNet cohort, mode of delivery was not associated with lower-extremity motor function at age 2 years., Competing Interests: Financial Disclosure Jenna Miller disclosed that their institution received funding from Janssen Pharmaceuticals. She received payments from BC Platforms and UpToDate, Inc. J Newton received payment from Coplan and Crane, and Gainsburgh, Benjamin, David, Meunier, and Warshauer for providing expert opinion. The other authors did not report any potential conflicts of interest., (Copyright © 2025 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: There is an urgent need is for a regenerative patch for in utero repair of spina bifida in situations in which primary closure is difficult., Cases: We present two cases of large myeloschisis defects that underwent in utero spina bifida repair at midgestation with closure of the skin defect by using a cryopreserved human umbilical cord patch. The pregnancies were uncomplicated, and the births occurred at 37 weeks by planned cesarean delivery. The repair sites were intact with no evidence of cerebrospinal fluid leakage, with skin regenerated after delivery over a period of 3-4 weeks. The short-term outcomes after delivery showed reversal of hindbrain herniation, minimal spinal cord tethering, and normal function of the lower extremities., Conclusion: Cryopreserved human umbilical cord may be a suitable patch system for the spina bifida closure.

Objective: To assess the incidence, timing, and risk factors for death of the donor fetus after fetoscopic laser surgery, we evaluated our cohort of patients who underwent the procedure for twin-twin transfusion syndrome., Methods: This was a prospective cohort study of 166 consecutive patients with twin-twin transfusion syndrome at a single center. Fetal death was diagnosed by ultrasonography after surgery and before onset of labor. Risk factors for death of the donor twin were identified on univariate analysis and then subjected to multivariate, stepwise, logistic regression analysis., Results: Donor demise occurred in 20 (13%) cases and recipient twin death occurred in four (2.6%). The median procedure to death interval was 4 days (range 1-89 days). Risk factors for donor death were fetal growth discordance greater than 30% (odds ratio [OR] 6.7, 95% confidence interval [CI] 2-23), reverse end-diastolic velocity in the donor umbilical artery (OR 25.0, 95% CI 2-290), a marginal and velamentous cord insertion (OR 4.4, 95% CI 1-19), and an increased number of anastomoses (OR 1.2, 95% CI 1.1-1.5). All four donors with both fetal growth discordance greater than 30% and reverse end-diastolic velocity in the donor umbilical artery resulted in a demise., Conclusion: Four risk factors significantly affecting acute and delayed donor demise after fetoscopic laser surgery were identified. The presence of both fetal growth discordance greater than 30% and reverse end-diastolic velocity in the donor umbilical artery was highly predictive of donor demise in our cohort. Knowledge of these risk factors can aid in counseling and assist patients in choosing the most appropriate intervention in the management of twin-twin transfusion syndrome., Level of Evidence: III.

Objective: To estimate the response in lung growth and vascularity after fetal endoscopic tracheal occlusion for severe congenital diaphragmatic hernia in the prediction of neonatal survival., Methods: Between January 2006 and December 2010, fetal lung parameters (observed-to-expected lung-to-head ratio; observed-to-expected lung volume; and contralateral lung vascularization index) were evaluated before fetal tracheal occlusion and were evaluated longitudinally every 2 weeks in 72 fetuses with severe isolated congenital diaphragmatic hernia. Thirty-five fetuses underwent fetal endoscopic tracheal occlusion and 37 cases did not., Results: Survival rate was significantly higher in the fetal endoscopic tracheal occlusion group (54.3%) than in the no fetal endoscopic tracheal occlusion group (5.4%, P<.01). Fetal endoscopic tracheal occlusion resulted in a significant improvement in fetal lung size and pulmonary vascularity when compared with fetuses that did not go to the fetal intervention (increase of the observed-to-expected lung-to-head ratio, observed-to-expected total lung volume, and contralateral pulmonary vascularization index 56.2% compared with 0.3%, 37.9% compared with 0.1%, and 98.6% compared with 0.0%, respectively; P<.01). Receiver operating characteristic curves indicated that the observed-to-expected total fetal lung volume was the single best predictor of neonatal survival before fetal endoscopic tracheal occlusion (cutoff 0.23, area under the curve [AUC] 0.88, relative risk 5.3, 95% confidence interval [CI] 1.4-19.7). However, the contralateral lung vascularization index at 4 weeks after fetal endoscopic tracheal occlusion was more accurate in the prediction of neonatal outcome (cutoff 24.0%, AUC 0.98, relative risk 9.9, 95% CI 1.5-66.9) with the combination of observed-to-expected lung volumes and contralateral lung vascularization index at 4 weeks being the best predictor of outcome (AUC 0.98, relative risk 16.6, 95% CI 2.5-112.3)., Conclusion: Fetal endoscopic tracheal occlusion improves survival rate by increasing the lung size and pulmonary vascularity in fetuses with severe congenital diaphragmatic hernia. The pulmonary response after fetal endoscopic tracheal occlusion can be used to predict neonatal survival.

Objective: To compare the outcomes in chorioamnion membrane separation with nonchorioamnion membrane separation cases after fetoscopic laser photocoagulation of placental anastomoses for the treatment of twin to twin transfusion syndrome., Methods: We performed a retrospective cohort study of twin to twin transfusion syndrome cases that underwent laser ablation at the Texas Children's Fetal Center from October 2007 to March 2009. The cases were identified from our database. We excluded triplet pregnancies. Chorioamnion membrane separation was identified by ultrasound examination performed within 24 hours of intervention. Preterm premature rupture of membranes (PROM) was defined as rupture of the membranes before 34 weeks of gestation., Results: Ninety-seven cases were included in the analysis; 19 (19.6%) had chorioamnion membrane separation. There were no significant differences in preoperative and intraoperative variables, except for a lower recipient maximum vertical pocket (10.3+/-2.1 compared with 12.6+/-3.4; P<.01), and higher rate of iatrogenic septostomy (21% compared with 2.5%; P=.01) in the chorioamnion membrane separation group. Postoperatively, the incidence of preterm PROM was 74% in chorioamnion membrane separation group compared with 23% in the nonchorioamnion membrane separation group (relative risk 3.2, 95% confidence interval 1.9-4.4). The procedure-to-delivery interval was reduced by 20 days in the chorioamnion membrane separation group (P<.01). The neonatal survival rate was 63.2% in the chorioamnion membrane separation group compared with 84% in the nonchorioamnion membrane separation group (P=.016)., Conclusion: A low preoperative recipient maximum vertical pocket is associated with increased risk of chorioamnion membrane separation. Postoperative chorioamnion membrane separation after laser surgery for twin to twin transfusion syndrome is a major risk factor for preterm PROM, early delivery, and an increase in perinatal mortality., Level of Evidence: II.

Objective: To estimate the accuracy of the protein/creatinine ratio in predicting 300 mg of protein in 24-hour urine collection in pregnant patients with suspected preeclampsia., Data Sources: Articles were identified through electronic databases (MEDLINE, CINHAL, and Cochrane) using the terms "preeclampsia," "protein/creatinine ratio," and "diagnosis," during the period January 1966 to October 2007. The relevant citations were hand searched., Methods of Study Selection: Included studies evaluated patients for suspected preeclampsia with a 24-hour urine sample and a protein/creatinine ratio. Only English-language articles were included. Studies including patients with only chronic illness such as chronic hypertension, diabetes mellitus, or renal impairment were excluded. Using the Quality Assessment of Diagnostic Accuracy Studies questionnaire, we created group 1 satisfying all the required criteria and group 2 not satisfying all of it. Two researchers independently extracted the accuracy data. A graph comparing six receiver operating characteristic curves was plotted., Tabulation, Integration, and Results: Twenty-one studies were identified, but only seven met our inclusion criteria (1,717 total patients). Group 1, with three studies, had 510 patients. The studies evaluated different cut points for positivity of protein/creatinine ratio from 130 mg/g to 700 mg/g. For protein/creatinine ratio 130-150 mg/g, sensitivity ranged from 90-99%, and specificity ranged from 33-65%; for protein/creatinine ratio 300 mg/g, sensitivity ranged from 81-98% and specificity ranged from 52-99%; for protein/creatinine ratio 600-700 mg/g, sensitivity ranged from 85-87%, and specificity ranged from 96-97%., Conclusion: Random protein/creatinine ratio determinations are helpful primarily when they are below 130-150 mg/g, in that 300 mg or more proteinuria is unlikely below this threshold. Midrange protein/creatinine ratio (300 mg/g) has poor sensitivity and specificity, requiring a full 24-hour urine for accurate results. Higher thresholds have not been adequately studied.