Neurological outcomes by mode of delivery for fetuses with open neural tube defects: a systematic review and meta-analysis

Background: Controversy exists regarding the optimal mode of delivery for fetuses with open neural tube defects. Objective: To compare neurological outcomes among infants with open neural tube defects who underwent vaginal compared with caesarean delivery. Search strategy: Electronic databases MEDLINE, EMBASE, Scopus, and Clinicaltrials.gov were searched from inception to November 2017. Selection criteria: Eligible studies included observational or randomised studies comparing vaginal and caesarean delivery in pregnancies with fetal open neural tube defects who did not undergo prenatal repair. Data collection and analysis: Two reviewers independently reviewed abstracts and full-text articles. Outcomes were compared between vaginal and caesarean delivery and prelabour caesarean versus exposure to labour. The primary outcome was motor–anatomic level difference. Secondary outcomes included shunt requirement, sac disruption, meningitis, and ambulation at 2 years. Meta-analysis was performed and mean difference or odds ratios with 95% CI were calculated. Main results: Of 201 abstracts identified in the primary search, nine studies (672 women) met the eligibility criteria. Comparing vaginal and caesarean delivery, there was no significant difference in motor–anatomic level difference (mean difference –0.10, 95% CI −0.58 to 0.38; I² = 57%). The vaginal delivery group was less likely to require a shunt or have sac disruption [odds ratio (OR) 0.37, 95% CI 0.14–0.95 and OR 0.46, 95% CI 0.23–0.90, respectively]. Comparisons by prelabour caesarean versus exposure to labour showed no significant difference in motor–anatomic level difference (OR 1.29, 95% CI 0.63–3.21) or ambulation at 2 years (OR 2.13, 95% CI 0.35–13.12). Conclusion: Caesarean delivery was not associated with improved neurological outcomes among fetuses with open neural tube defects. Tweetable abstract: Available evidence does not support routine caesarean delivery for fetuses with open neural tube defects.