ACOG has recently released its updated guidance on Neural Tube Defects (NTDs) and includes guidelines about prevention, screening, antenatal management and delivery in pregnancies with such defects. The practice bulletin No.187 is published in December issue of Journal Obstetrics and Gynecology.
In contrast
to other malformations, NTDs are preventable by supplementation of folic acid.
The recommendations:
ACOG along
with other professional organizations like CDC, AAFP, AAP, ACMG and AAN: Women
in the reproductive age group, having the capacity to become pregnant should
take at least 0.4 mg (400 µg) of folic acid daily.
USPSTF: all women who are planning or capable of pregnancy take a daily
supplement containing 0.4 to 0.8 mg (400-800 µg) of folic acid.
ACOG, CDC
other organization suggests a higher dose of 4 mg (4000 μg) of folic acid for
women who are at high risk of having a baby with NTD. These factors are:
Previous
history of pregnancy with NTD
Having a
partner with NTDs or a partner who previously has had a child with NTD
Patients
with a second or third degree relative with NTD
Patient
herself was born with NTD
History of
taking anti-epileptic medication Valproic acid
Type 1
Diabetes Mellitus
Obesity.
ACOG has also made additional recommendations in the recent 2017 updates.
With Advancements
in Ultrasound techniques, Maternal Serum Alpha Feto Protein (MSAFP) has become
less important in diagnosing NTDs, when high quality, second trimester
ultrasound is routinely used.
MSAFP is
more important for screening for other anomalies and placental complications in
such cases.
If MSAFP
value is ≥ 2.5 MoMs, the detection rate for anencephaly is 95% and 65-80% for
other open NTDs.
2D
ultrasound has a detection rate of 96% and if structural abnormalities are seen
on Ultrasound, they can be considered diagnostic.
3D
ultrasound is not superior to 2D in diagnosing NTDs; however, it may be more helpful
in delineating the upper limit of spinal defects.
The rates of
diagnosing NTDs in first trimester are lower than that of 2nd
trimester sonography.
MRI is not
mandatory if NTD has already been identified in sonography.
Pregnancy and delivery management:
After a
pregnancy with NTD is diagnosed options should be individualized according to
each pregnancy:
Pregnancy
termination
In Utero fetal
surgery for repair
Expectant
management with neonatal surgical repair.
Studies on
In-Utero repairs have demonstrated that such neonates have functional level two
or more times better than expected, and reduce the neonatal mortality and
morbidity.
Delivery:
Regarding
the timing of delivery, term delivery is preferred. Elective late preterm or early
term cesarean is only considered if fetal repair has been done or other
obstetric indication for surgery exists.
Retrospective
studies with not very long-term follow-up have demonstrated no increased risk
of vaginal delivery, but each case needs to be individualized.
Media: Univision.com
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