Silva A1, Lafayette S1, Jaccoud AC1, Gaspari C1
1Instituto Estadual do Cerebro Paulo Niemeyer, Physical Therapy, Rio de Janeiro, Brazil
Background: Despite the evidence that early mobilization improves outcomes in post-surgical patients, bed rest remains one of the most commonly prescribed treatments in complicated pregnancies. Several studies have failed to show support that bedrest improves outcomes in obstetrics and gynecology. In addition to the lack of conclusive benefit, potential harm from bedrest can include venous thrombosis, bone demineralization, muscle atrophy, and maternal psychological adverse effects. Despite evidence supporting early mobilization to improve outcomes, specific protocols following intrauterine surgery have not been reported.
Intrauterine prenatal surgery for fetal myelomeningocele (MMC) correction is becoming more common as it has shown to reduce the need for shunting and improves motor outcomes. A form of spina bifida, MMC is characterized by the extrusion of the spinal cord into the cerebrospinal fluid filled sac, resulting in lifelong disability such as loss of movement of the lower limbs, hindbrain herniation and hydrocephalus. This type of surgery however, is associated with maternal risks including preterm labor and uterine dehiscence, as well as an increased risk of fetal or neonatal death and preterm birth.
Purpose: The purpose of this case series is to describe early mobility interventions and safety assessment of women during pregnancy in the early post-operative period following correction of fetal MMC using an intrauterine surgical approach.
Methods: This retrospective case series describes supervised physical therapy in the early post-operative period of 6 patients who underwent an intrauterine approach to correct MMC. All patients were evaluated (including assessment of ambulation) on the 1st postoperative day. Distance ambulated was measured, and safety was defined as physiologic response to exercise within normal limits by measuring vital signs (HR, BP, SpO2), and the Borg perceived exertions scale.
Results: Six consecutive patients between the ages of 15-42 and 24-26 weeks of gestation underwent mini-hysterotomy for the correction of fetal MMC. The patients ambulated with supervision of a physical therapist for safety twice per day and were discharged home by 3rd post-operative day. There were no adverse events during PT. Vital signs and the Borg scale were recorded before and after the sessions, showing minimal and expected changes. All patients tolerated walking a distance of 100m by discharge.
Conclusion(s): We described 6 cases of early mobilization in patients who underwent mini-hysterotomy for correction of fetal MMC. All patients tolerated 1st post-operative day out of bed mobilization and without adverse events during the PT sessions.
Implications: Studies involving prenatal PT generally focus on the prevention and treatment of musculoskeletal discomfort, urinary incontinence, weight gain and nonpharmacological pain relief during delivery. The effect of PT on high-risk pregnancies has been poorly explored, particularly regarding patients who are hospitalized. These patients are often kept on bedrest due to lack of evidence to be mobilized.
This study shows that early mobilization following intrauterine surgery may be indicated, rather than prolonged bedrest. Greater experience is needed to fully evaluate the safety of early mobilization following intrauterine surgery, however these initial cases provide encouraging evidence. Additional studies systematically and prospectively tracking adverse events, efficacy and patient outcomes during early mobilization are still needed.
Keywords: Early mobilization, Pregnancy, Myelomeningocele
Funding acknowledgements: None
Intrauterine prenatal surgery for fetal myelomeningocele (MMC) correction is becoming more common as it has shown to reduce the need for shunting and improves motor outcomes. A form of spina bifida, MMC is characterized by the extrusion of the spinal cord into the cerebrospinal fluid filled sac, resulting in lifelong disability such as loss of movement of the lower limbs, hindbrain herniation and hydrocephalus. This type of surgery however, is associated with maternal risks including preterm labor and uterine dehiscence, as well as an increased risk of fetal or neonatal death and preterm birth.
Purpose: The purpose of this case series is to describe early mobility interventions and safety assessment of women during pregnancy in the early post-operative period following correction of fetal MMC using an intrauterine surgical approach.
Methods: This retrospective case series describes supervised physical therapy in the early post-operative period of 6 patients who underwent an intrauterine approach to correct MMC. All patients were evaluated (including assessment of ambulation) on the 1st postoperative day. Distance ambulated was measured, and safety was defined as physiologic response to exercise within normal limits by measuring vital signs (HR, BP, SpO2), and the Borg perceived exertions scale.
Results: Six consecutive patients between the ages of 15-42 and 24-26 weeks of gestation underwent mini-hysterotomy for the correction of fetal MMC. The patients ambulated with supervision of a physical therapist for safety twice per day and were discharged home by 3rd post-operative day. There were no adverse events during PT. Vital signs and the Borg scale were recorded before and after the sessions, showing minimal and expected changes. All patients tolerated walking a distance of 100m by discharge.
Conclusion(s): We described 6 cases of early mobilization in patients who underwent mini-hysterotomy for correction of fetal MMC. All patients tolerated 1st post-operative day out of bed mobilization and without adverse events during the PT sessions.
Implications: Studies involving prenatal PT generally focus on the prevention and treatment of musculoskeletal discomfort, urinary incontinence, weight gain and nonpharmacological pain relief during delivery. The effect of PT on high-risk pregnancies has been poorly explored, particularly regarding patients who are hospitalized. These patients are often kept on bedrest due to lack of evidence to be mobilized.
This study shows that early mobilization following intrauterine surgery may be indicated, rather than prolonged bedrest. Greater experience is needed to fully evaluate the safety of early mobilization following intrauterine surgery, however these initial cases provide encouraging evidence. Additional studies systematically and prospectively tracking adverse events, efficacy and patient outcomes during early mobilization are still needed.
Keywords: Early mobilization, Pregnancy, Myelomeningocele
Funding acknowledgements: None
Topic: Women's & men's pelvic health; Critical care; Disability & rehabilitation
Ethics approval required: Yes
Institution: Instituto Estadual do Cerebro Paulo Niemeyer
Ethics committee: Centro de Etica/Pesquisa Instituto Estadual do Cerebro Paulo Niemeyer
Ethics number: 91199118.0.0000.8110
All authors, affiliations and abstracts have been published as submitted.
