Cause ongoing irreversible harm to the fetus Mitigated with early treatment & Occur before gestational age at which the fetus could tolerate ex utero neonatal intervention Most fetal anomalies are amenable to therapy after birth however, sometimes therapy before birth is desirable to prevent permanent organ damage depending on the natural history and pathophysiology of malformation
Fetal surgery is a new and fast moving frontier
of medicine Procedures on the fetus or the placenta, with the aim of altering the natural history of the disease that is diagnosed in utero
The first operation on a human fetus occurred in
1981 at the University of California San Francisco Thorough maternal and fetal evaluation
Open fetal surgery : GA
Minimally invasive techniques: Local or neuraxial
anesthesia
Anesthetic considerations : assoc with
nonobstetric surgery during pregnancy, planning for fetal anesthesia & analgesia, fetal monitoring, uterine relaxation, and postop fetal monitoring & tocolysis Minimally invasive procedures FIGS-IT Fetoscopy/ Fetendo procedures
Unlike in open fetal procedures: vaginal delivery
for this and future pregnancies
Significant risk for preterm premature rupture of
membrane (PPROM), preterm labour Balancing the risks to both the mother and fetus against the potential benefit to only the fetus
Mother is the innocent bystander in the
endeavour her involvement involves only risk
Major intervention to save the life of a fetus
warranted ONLY if maternal risks minimized and good fetal outcomes assured Typical gestational ages for surgery are between 21 to 27 weeks
Mid-gestational fetal surgery is performed for
twin-twin transfusion syndrome and the twin reverse arterial perfusion syndrome (TRAP) Fetoscopic surgery: minimal insult to the uterus while obtaining access to the fetus through surgical trocar insertion or occasionally maternal minilaparotomy
LA / Epidural anaesthesia +/- IV sedation
Used to treat TTTS and TRAP; Injection of
medication into the amniotic cavity or fetal blood transfusions FIGS-IT procedures MAC with infiltration of LAs into the abdominal wall
Additional opioid, BZD, or other anesthetic : for
maternal analgesia and anxiolysis
Titrated to avoid deep sedation and the associated
increased risk for pulmonary aspiration of gastric contents EXIT Procedures involves only partially delivering the fetus, thereby uterine volume, placental perfusion and oxygenation are maintained (Placental bypass)
Allows time to perform direct laryngoscopy,
bronchoscopy, intubation and tracheostomy on the fetus For fetuses with known airway compromise or obstruction, an EXIT procedure allows continued fetal support by the intact uteroplacental unit (placental bypass) while the fetal airway is secured or other procedures completed
Minimal chances of postnatal respiratory
compromise, hypoxia, & asphyxia ECMO can be initiated during an EXIT procedure for a fetus with significant cardiopulmonary disease
Congenital lesions treated with EXIT procedures include
cystic hygroma, lymphangioma, cervical teratomas, Laryngeal webs and other congenital syndromes with potential for airway compromise Complete uterine relaxation is necessary to expose the operative fetal anatomy; additionally the fetus has to be maintained inside the uterus
Unlike open fetal surgery however, the fetus is
delivered at the end of the fetal intervention resulting in a completely flaccid uterus that must immediately involute or else massive maternal hemorrhage will occur Open Fetal Surgery: Preoperative management
Drugs and approaches used to minimize
aspiration of gastric contents
Uterine tocolytics (i.e., indomethacin) should be
given to the mother preoperatively
Left displacement of gravid uterus
Open foetal surgery: Intraoperative mgmt GA with Endotracheal intubation; GA induced with a rapid sequence technique
Before maternal skin incision, conventional
concentrations of anesthetics administered to the mother (∼1 MAC)
Before skin incision, the inspired concentration of
volatiles is increased, and before uterine incision, the concentration is further increased (≥2 MAC) to provide profound uterine relaxation IV administration of NTG in doses up to 20 μg/kg/min has been used successfully
This technique may have increased risk for
maternal pulmonary edema
Use of NTG may affect fetal vascular tone,
resulting in alterations in CBF and increased likelihood of fetal cerebral ischemia, as well as intraventricular and periventricular hge Open foetal surgery: Postoperative mgmt
Continue tocolytics (MgSO4/Indomethacin)
Patient-controlled epidural analgesia Monitor uterine activity and fetal heart rate Ongoing fetal evaluation Maternal Factors CO increases by 50-100% ;BP drops by 15%
The large uterus increases the risk of supine
hypotension syndrome
Intravascular blood volume increases by 40%;
more than the RBC volume increase (20%) which alters the plasma concentration (lower albumin levels), thus altering the PK/PD of drugs Maternal Factors Higher O2 consumption and a lower FRC results in rapid desaturation
Airway mucosa is swollen and bleeds easily
making it difficult to intubate
MAC values decrease by 40% : deeper level of
anesthesia than predicted during surgery with a relative over dosage Maternal Factors Elevated gastric acid content, delayed emptying and lower GE sphincter tone : All pregnant women treated full stomach
Epidural space is narrowed by the epidural
venous engorgement increasing the risk of intravascular catheter placement and a larger dermatomal spread of injected LAs Placental Factors Lipid soluble inhalation agents are not ionized and of low molecular weight :readily cross the placenta. Uptake slower in fetus than mother
Fortunately ,fetal MAC is less than that of the
mother this is well below that needed to obtain uterine relaxation: Adequate maternal anesthesia and uterine relaxation results in adequate fetal anesthesia Techniques used to prevent preterm labor Avoidance of intraoperative and postoperative uterine contraction
Open fetal surgery and the EXIT procedures profound
uterine relaxation required for optimal surgical exposure
Volatile anesthetic agents at 2 MAC concentrations are
potent uterine relaxants
These high concentrations leads to reduction in cardiac
output & hypotension Decreased uteroplacental perfusion and fetal hypoxia
Appropriate maternal hemodynamic monitoring & use of
fluid boluses or vasopressors may be required
To avoid high concentrations of volatile anesthetic
agents, short acting but profound uterine relaxants like IV nitroglycerin
Intravenous infusion of MgSO4 towards the end of
surgery, subcutaneously turbutaline and indomethacin postoperatively Adequate post operative maternal analgesia results in lower plasma oxytocin levels and also decreases uterine tone
Placement of an epidural catheter preoperatively
and local anesthetic initiated postoperatively is an important measure to prevent preterm labor Opioids can be transferred to the fetus by maternal administration or direct IM or IV umbilical cord administration using USG guidance
Fetal intramuscular administration of fentanyl 10
to 20 μg/kg (invasive procedures)
Prophylactic IM atropine 20 μg/kg with opioids to
minimize the risk for fetal bradycardia Fetal movement can be prevented by IM or umbilical vessel administration of muscle relaxant using USG-guidance
Vecuronium with doses of 0.3 mg/kg IM or 0.1 to
0.25 mg/kg IV
Maternal administration and placental transfer of
IV remifentanil provides adequate fetal immobility during fetoscopic interventions that involve only the umbilical cord or placenta For open fetal procedures, placental transfer of maternally administered general anesthesia with volatile anesthetics provides fetal anesthesia
Echocardiography, pulse oximetry, and
ultrasound imaging of umbilical artery flow are the primary methods for fetal assessment EXIT procedure: insertion of a fetal scalp electrode has been used successfully for FHR monitoring
Echocardiography, pulse oximetry, and USG
imaging of umbilical artery flow are the primary methods for fetal assessment
Intraoperative USG allows imaging of FHR,
cardiac contractility, and cardiac filling, as well as Doppler assessment of umbilical cord flow In utero, the fetus is unable to thermoregulate & depends on maternal body temperature
Induction of GA, surgical exposure, and
hysterotomy can reduce fetal temperature
Monitoring of temperature and maintenance of
maternal euthermia with use of forced air warming likely improves fetal well-being during minimally invasive procedures During open fetal surgery, use of warmed fluid for intrauterine irrigation & maternal core and amniotic fluid temperature monitoring Intrauterine transfusion for Anemia 18-20 weeks gestational age Umbilical vein access Intraperitoneal transfusion LA, with minimal maternal sedation and analgesia FIGS-IT Aortic balloon valvuloplasty for treatment of critical AS & evolving HLHS: most common
improve renal development and reduce the pulmonary hypoplasia associated with oligohydramnios Monozygotic twins
Nonviable twin perfused with retrograde blood from
other twin with no share in placenta
Inadequate perfusion of recipient twin: acardia &
acephalus
High-output congestive heart failure and preterm birth
secondary to the increased uterine volume from polyhydramnios and increased size of the hydropic nonviable twin Treatment : Cessation of flow in the recipient twin’s umbilical artery & death of nonviable fetus
Endoscopic laser photocoagulation of vascular
anastomoses/RFA at the base of umbilical cord within abdomen of the acardiac twin
Share the same placenta & have intertwin vascular
connections creating shared blood flow between the two fetuses
Chorionic vascular anastomoses can result in
unequal placental blood flow between the two monochorionic twins, creating a significant degree of intertwin discordance that can lead to twin-to-twin transfusion syndrome (TTTS) Recipient twin: increased blood flow leads to polycythemia, polyuria, polyhydramnios & can cause hypertrophic cardiomyopathy, hydrops fetalis, & fetal death
Donor or “pump” twin: typically
hypovolemic,IUGR, & oligohydramnios; primarily at risk for renal failure, cardiac failure, and hydrops fetalis secondary to the high cardiac output state Treatment: Selective fetoscopic laser photocoagulation (SFLP) of the vascular anastomoses between the two twins
Serial Amnioreductions
Maternal neuraxial blockade or local anesthesia
infiltration from maternal skin to myometrium During early gestation, abdominal contents herniate into the thoracic cavity and compress the fetal lungs
Fetal intervention for CDH aims to improve fetal
lung development and prevent the morbidity of pulmonary hypoplasia Fetal lungs secrete over 100 mL/kg/day of fluid that exits the trachea and mouth into the amniotic cavity
Minimally invasive approach includes reversible
fetal tracheal occlusion which restricts the normal outflow of the fetal lung fluid and provides an increase in pulmonary hydrostatic pressure This increased pressure pushes the viscera out of the thorax, promotes expansion of the hypoplastic lung, & thereby improves lung growth & development
Percutaneous endoscopic endotracheal
intubation used to place a small detachable occlusive balloon in the fetal trachea ; Later it is deflated and removed before term with a second fetal endoscopic surgical techniques procedure Preoperative: Complete maternal history, examination & Complete fetal workup to exclude other anomalies