DOCSLIB.ORG

Safe Surgery Checklist in an EXIT Procedure for a Foetus with a Giant Neck Mass

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Safe Surgery Checklist in an EXIT Procedure for a Foetus with a Giant Neck Mass Safe surgery checklist in an EXIT procedure for a foetus with a giant neck mass. Centro Policlinico del Olaya (CPO)-Bogotá, Colombia G. Reyes1, R. Duque2, C. Rojas3, A. Romero4, B. Narvaez5, R. Herrera6 1. Maternal Fetal Medicine Consultant e-mail: [email protected]. 2. Obstetrics and gynaecology Consultant. 3. Neonatology Consultant. 4. Anaesthesiology Consultant. 5. Paediatric Surgery Consultant. 6. Scientific Director of CPO INTRODUCTION The ex utero intrapartum treatment (EXIT) is procedure for maintaining utero-placental circulation during caesarean section to guaranty new-born air way in a potentially obstructed fetal airway1,2. The EXIT procedure is an elective caesarean section, which the foetus is only partially delivered from the uterus with maintenance of the utero-placental circulation allowing for diagnostic and/or therapeutic procedures to the fetal airway. The foetus has been anesthetized and when the airway is secured the foetus is delivered and the umbilical cord clamped. A complete uterine relaxation by deep volatile anaesthesia in needed and uterine volume must be preserved by the foetus and warmed Ringer’s lactate solution infused into the uterine cavity1,3,4,5 . In order to maintain the uteroplacental blood flow, maternal cardiac output and blood pressure have to be kept at acceptable levels6,7. Main prerequisites during the EXIT procedure include a multidisciplinary coordinated team so we applied the WHO criteria and a check list was performed8,9. We organized a preliminary drill to prepare the final EXIT. Finally, the EXIT was performed including a team of 20 people inside the operating theater. CASE A 25-year-old primigravida patient, at 22 weeks during the anomaly scan has been detected a 60 mm foetal neck cystic mass in the left side. Its extension inside the fetal face was not clear, no other fetal malformations were detected. A fetal cervical cystic teratoma or cystic lymphangioma was diagnosed and we continued other diagnostic procedures. Fetal echocardiogram and neurosonography showed no other malformations. Fetal karyotype in amniotic fluid was normal 47 xy. Fetal growth was followed at 28, 32 and 36 weeks and the foetus was growing in a normal range, polihydramnios was Video: not showed. At 34 week a fetal MRI was performed and the neck http://www.cpo.com.co/cpo/index.php/component/k2 mass was extended to the fetal pharynx in the midline. Because /item/202-centro-policlinico-olaya-acreditada-salud there was risk of congenital high airway obstruction syndrome or https://goo.gl/Rvvr4q (CHAOS) an elective EXIT procedure was performed at 38 weeks. A successful EXIT procedure was performed and a male new-born 3630 gr., 52 cm, Ballard 38 weeks was born. The intubated new-born was moved to the NICU. MRI was very consistent with the prenatal MRI and the neonate was carried to the operating theater and the paediatric surgery consultant performed a sclerotherapy procedure with intralesional bleomycin injection. Postoperative evolution was successful and the neonate left the hospital 5 days later. DISCUSSION Prenatal diagnosis of neck masses with upper airway obstruction risk should alert the perinatal team for closed and coordinated management1,2,10. The EXIT procedure provides time for placental bypass and includes procedures such as laryngoscopy, bronchoscopy, endotracheal intubation, tracheostomy and/ or the resection of neck masses1.2.11. The team approach is really important in providing organized and coordinated surgery plan. An obstetrician and/or perinatologist, neonatologist, paediatric surgeon and anaesthesiologist should all be available in the operating theater for the birth, resuscitation and possible surgical intervention to the neonate1,2,4. Operating Theatres with the implementation of surgical checklist have great decrease in both mortality and morbidity according the WHO criterias8,9. So, an early prenatal diagnoses alerts about the fetal risk of CHAOS and them a multidisciplinary and coordinated medical team must organized a very precised EXIT proceure4,12,13. An EXIT check list was an important instrument in our team and we planned every detail before the procedure because during it has interacting different medical teams with special non day to day situations, therefore it is a challenging surgery. REFERENCES 1. Dahlgren G., Four cases of the ex utero intrapartum treatment (EXIT) procedure: anesthetic implications. International Journal of Obstetric Anesthesia. 2004; 13, 178–182. 2.Cansaran S., The EXIT for Prenatally Diagnosed Cervical Cystic Teratoma. Journal of Neonatal Surgery 2015; 4(2):18. 3. Agarwal P., Ex-utero Intrapartum Treatment (EXIT) Procedure for Giant Fetal Epignathus.Indian paediatrics. Volume 52-October 15, 2015;893-5. 4. Tuncay F., Fetal Oropharyngeal and Neck Tumors: Determination of the Need for Ex-Utero Intrapartum Treatment Procedure. Balkan Med J, Vol. 32, No. 2, 2015. 5. Thawani J., Management of Giant Cervical Teratoma with Intracranial Extension Diagnosed in Utero. J Neurol Surg Rep 2016;77:e118–e120 6.Vieira M., Anestesia para tratamento ex-útero intraparto: visão renovadasobre um procedimento raro. Rev Bras Anestesiol. 2015;65(6):525-528. 7. Torossian A. , Geburtshilfe: Anästhesie bei EXIT-Prozedur. Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 214–219. 8. WHO. Safe surgery saves lives Newsletter Nov., 2011 9. WHO: Surgical Safety Checklist 1/2009. 10. Chu GM et al. Ex-utero intrapartum treatment: a controlled approach to the management of anticipated airway problems in the new born. Hong Kong Med J 2006; 12:381-4 11. Matte G., A Modified EXIT-to-ECMO with Optional Reservoir Circuit for Use during an EXIT Procedure Requiring Thoracic Surgery. JECT. 2016;48:35–38. 12. Gupta A., CHAOS. The Journal of Obstetrics and Gynecology of India (May–June 2016) 66(3):202–208. 13. Gupta A., CHAOS: Prenatal imaging findings with post mortem contrast radiographic correlation. Radiology Case. 2016 Aug; 10(8):39-49.
Load more

Recommended publications
  • Clinical Policy: Fetal Surgery in Utero for Prenatally Diagnosed
    Clinical Policy: Fetal Surgery in Utero for Prenatally Diagnosed Malformations Reference Number: CP.MP.129 Effective Date: 01/18 Coding Implications Last Review Date: 09/18 Revision Log Description This policy describes the medical necessity requirements for performing fetal surgery. This becomes an option when it is predicted that the fetus will not live long enough to survive delivery or after birth. Therefore, surgical intervention during pregnancy on the fetus is meant to correct problems that would be too advanced to correct after birth. Policy/Criteria I. It is the policy of Pennsylvania Health and Wellness® (PHW) that in-utero fetal surgery (IUFS) is medically necessary for any of the following: A. Sacrococcygeal teratoma (SCT) associated with fetal hydrops related to high output heart failure : SCT resecton: B. Lower urinary tract obstruction without multiple fetal abnormalities or chromosomal abnormalities: urinary decompression via vesico-amniotic shunting C. Ccongenital pulmonary airway malformation (CPAM) and extralobar bronchopulmonary sequestration with hydrops (hydrops fetalis): resection of malformed pulmonary tissue, or placement of a thoraco-amniotic shunt; D. Twin-twin transfusion syndrome (TTTS): treatment approach is dependent on Quintero stage, maternal signs and symptoms, gestational age and the availability of requisite technical expertise and include either: 1. Amnioreduction; or 2. Fetoscopic laser ablation, with or without amnioreduction when member is between 16 and 26 weeks gestation; E. Twin-reversed-arterial-perfusion (TRAP): ablation of anastomotic vessels of the acardiac twin (laser, radiofrequency ablation); F. Myelomeningocele repair when all of the following criteria are met: 1. Singleton pregnancy; 2. Upper boundary of myelomeningocele located between T1 and S1; 3.
    [Show full text]
  • Guide to Learning in Maternal-Fetal Medicine
    GUIDE TO LEARNING IN MATERNAL-FETAL MEDICINE First in Women’s Health The Division of Maternal-Fetal Medicine of The American Board of Obstetrics and Gynecology, Inc. 2915 Vine Street Dallas, TX 75204 Direct questions to: ABOG Fellowship Department 214.871.1619 (Main Line) 214.721.7526 (Fellowship Line) 214.871.1943 (Fax) [email protected] www.abog.org Revised 4/2018 1 TABLE OF CONTENTS I. INTRODUCTION ........................................................................................................................ 3 II. DEFINITION OF A MATERNAL-FETAL MEDICINE SUBSPECIALIST .................................... 3 III. OBJECTIVES ............................................................................................................................ 3 IV. GENERAL CONSIDERATIONS ................................................................................................ 3 V. ENDOCRINOLOGY OF PREGNANCY ..................................................................................... 4 VI. PHYSIOLOGY ........................................................................................................................... 6 VII. BIOCHEMISTRY ........................................................................................................................ 9 VIII. PHARMACOLOGY .................................................................................................................... 9 IX. PATHOLOGY .........................................................................................................................
    [Show full text]
  • (EXIT), a Resuscitation Option for Intra-Thoracic Foetal Pathologies
    Original article SWISS MED WKLY 2007;137:279–285 · www.smw.ch 279 Peer reviewed article Ex utero intrapartum treatment (EXIT), a resuscitation option for intra-thoracic foetal pathologies Christian Kerna, Michel Ange, Moralesb, Barbara Peiryc, Riccardo E. Pfisterc a Anaesthesia, University Hospital Geneva, Switzerland b Gynaecology and Obstetrics, University Hospital Geneva, Switzerland c Paediatrics, University Hospital Geneva, Switzerland Summary The ex utero intrapartum treatment (EXIT) requires a caesarean section that specifically differs procedure is designed to guarantee sufficient oxy- from the traditional caesarean section during genation for a foetus at risk of airway obstruction. which uterine tone is maintained to minimize ma- This is achieved by improving lung ventilation, ternal bleeding. To guarantee foetal oxygenation usually by establishing an airway during caesarean during the EXIT procedure, profound uterine delivery whilst preserving the foetal-placental cir- relaxation is desired. To gain time with optimal culation temporarily. Indications for the EXIT placental oxygenation in order to safely perform an procedure have extended from its original use in airway intervention in a baby at risk of hypoxia may reversing iatrogenic tracheal obstruction in con- require deep inhalation anaesthesia and/or to- genital diaphragmatic hernia to naturally occur- colytic agents. We review the EXIT procedure and ring upper airway obstructions. We report our present a case series from the University Hospital experience with a new and rarely mentioned indi- of Geneva that contrasts with the common indica- cation for the EXIT procedure, intra-thoracic tion for the EXIT procedure usually based on volume expansions. The elaboration of lowest risk upper airway obstruction by its exclusive indica- scenarios through balancing risks with alternative tion for intra-thoracic malformations/diseases.
    [Show full text]
  • Techniques of Fetal Intervention What Is Fetal Intervention?
    Techniques of Fetal Intervention What is fetal intervention? Fetal intervention is reaching inside the uterus to help a fetus who has a problem. Our ability to detect fetal problems has advanced so rapidly over the last few decades. While many diseases can now be accurately diagnosed before birth by genetic and imaging techniques, only a few require intervention before birth. These are generally simple anatomic problems that cause ongoing damage to the developing fetus and can be corrected using the techniques described below. All fetal intervention is really maternal-fetal intervention, and the most important consideration in all fetal intervention is the safety of the mother: her current health and her furture reproductive potential. The intervention is designed to benefit the fetus who has a problem, but the mother is an innocent bystander who assumes some risk for the sake of her unborn fetus. In weighing the risks versus the benefits of an intervention, the most important consideration is the mother, her health, her family, and her ability in the future to have other children. What are the techniques of fetal intervention? There are three general approaches to fetal intervention, all of which have been developed in the last few decades. The most definitive and most invasive is open fetal surgery. Open Fetal Surgery Open Fetal Surgery Michael Harrison, MD In open fetal surgery, the mother is anesthetized, an incision is made in the lower abdomen to expose the uterus, the uterus is opened using a special stapling device to prevent bleeding, the surgical repair of the fetus is completed, the uterus followed by the maternal abdominal wall are closed, and the mother awakened.
    [Show full text]
  • The EXIT (Ex-Utero Intrapartum Treatment) Procedure
    ACTA OTORHINOLARYNGOLOGICA ITALICA 2018;38:480-484; doi: 10.14639/0392-100X-1261 OPEN ACCESS Case series and reports The EXIT (ex-utero intrapartum treatment) procedure – from the paediatric ENT perspective Procedura EXIT (ex-utero intrapartum treatment) – prospettive otorinolaringoiatriche pediatriche B. PUCHER1, J. SZYDLOWSKI1, K. JONCZYK-POTOCZNA2, J. SROCZYNSKI1 1 Department of Paediatric Otolaryngology, Poznan University of Medical Sciences; 2 Department of Paediatric Radiology, Poznan University of Medical Sciences, Poland SUMMARY The main principle of the EXIT procedure is to maintain uteroplacental circulation with neonatal anaesthesia by controlled uterine hypoto- nia. This enables securing the foetal airways and decompress or resect large neck and mediastinal foetal masses. The authors present their experience with use of the EXIT procedure in 7 foetuses in whom evaluation and management of the airways were performed. In 4 patients, the neck mass was surgically removed in the neonatal period, in 1 the propranolol treatment was introduced. Two newborns died shortly af- ter the EXIT procedure. The EXIT procedure allows the paediatric otolaryngologist to provide airway patency of newborns during delivery. Both ultrasound and MR imaging are crucial in the prenatal assessment of foetal head and neck masses. Their application in the evaluation of any foetal anomaly is essential for proper prognosis and treatment. Maternal monitoring for complications such as polyhydramnios and preterm labour are important in planning and desirability of the EXIT procedure. KEY WORDS: EXIT procedure • Foetal neck masses • Foetal airways • Prenatal imaging • Teratoma • Lymphatic malformation RIASSUNTO L’obiettivo principale della procedura EXIT è sfruttare la circolazione uteroplacentare inducendo una anestesia nel neonato e controllan- do l’ipotonia uterina.
    [Show full text]
  • Curriculum for Subspecialty Training in Maternal and Fetal Medicine
    Maternal and Fetal Medicine Curriculum Curriculum for Subspecialty Training in Maternal and Fetal Medicine Module 1 Medical Complications of Pregnancy Module 2 Genetics Module 3 Structural Fetal Abnormalities Module 4 Antenatal Complications Module 5 Intrapartum Complications Module 6 Infectious Diseases 1 Last updated February 2013 Maternal and Fetal Medicine Curriculum Module 1 Medical complications of pregnancy 1.1 Hypertension Objectives Manage a case of chronic hypertension, including: Counsel regarding fetal and maternal risks 1. To be able to carry out appropriate assessment (including long-term health implications. and management of women with chronic hypertension. Arrange appropriate investigations. 2. To be able to carry out appropriate assessment institute and modify drug therapy. and management of women with pregnancy- Plan delivery and postnatal care. induced hypertension, pre-eclampsia and Refer, where appropriate, for further assessment associated complications. and treatment. Chronic hypertension Professional skills and attitudes Knowledge criteria Ability to take an appropriate history and conduct an examination to screen for secondary causes and Definition and diagnosis: complications of chronic hypertension. Measurement of blood pressure in pregnancy, including validated devices. Ability to perform and interpret appropriate Impact of pregnancy on blood pressure. investigations. Superimposed pre-eclampsia. Prevalence (primary and secondary causes). Ability to formulate, implement and, where appropriate, modify a multidisciplinary management Pathophysiology: plan. Acute hypertension. Chronic hypertension (including end-organ Ability to manage antihypertensive drug therapy in damage). antenatal and postnatal periods. Management: Ability to liaise with primary care and physicians in Screening for common causes of secondary management of hypertension. hypertension. Ability to counsel women about: Pregnancy management, including fetal monitoring.
    [Show full text]
  • Anesthesia for Ex Utero Intrapartum Treatment (EXIT Procedure) in Fetus with Prenatal Diagnosis of Oral and Cervical Malformations: Case Reports
    Rev Bras Anestesiol CLINICAL INFORMATION 2012; 62: 3: 411-423 CLINICAL INFORMATION Anesthesia for Ex Utero Intrapartum Treatment (EXIT procedure) in Fetus with Prenatal Diagnosis of Oral and Cervical Malformations: Case Reports Daniel Corrêa Helfer 1, Jefferson Clivatti 2, Américo Massafuni Yamashita, TSA 3, Antonio Fernades Moron 4 Abstract: Helfer DC, Clivatti J, Yamashita AM, Moron AF – Anesthesia for Ex Utero Intrapartum Treatment (EXIT procedure) in Fetus with Prenatal Diagnosis of Oral and Cervical Malformations: Case Reports. Background and objectives: Fetus prenatally diagnosed with neck tumors, or with any other disease that obstructs the airways, should not be treated conventionally, as the assistant physician has to face two challenges right after the infant’s delivery: the limited time to establish the access to the potentially difficult airways and the lack of anesthesia of the neonate in case of instrumentation of the airways. The ex utero intrapartum treatment, i.e., the EXIT procedure consists of maintaining the fetoplacental circulation during the cesarean section, until the airways of the fetus be secured. Case Reports: Female patient, 37 years old, G3P2, 38 weeks pregnant, having polyhydramnios and fetus diagnosed with large cervical masses by prenatal ultrasound. A cesarean section was performed using the EXIT procedure to enable safe access to the infant’s airways. After hystero- tomy, the fetus was intubated by direct laryngoscopy. The neonate was immediately transferred to another operating room, where cervical tumor resection of the neck tumor and tracheostomy were successfully performed. Female patient, 27 years old, G3P1A1, 32 weeks pregnant, whose fetus was prenatally diagnosed with a large oral tumor.
    [Show full text]
  • Anaesthesia for Fetal Surgery
    Anaesthesia for fetal surgery Dr.M.Păpurică, Dr.O.Bedreag UMF”V.Babes” Timișoara History of fetal surgery 1965 - first intrauterine transfusion for hydrops due to Rh incompatibility by A.W.Liley 1974 - fetoscopy to obtain fetal samples by Hobbin 1981- fetoscopic transfusion by Rodeck 1982 - first open fetal surgery for obstructive uropathy by Dr. Michael Harrison, University of California, San Francisco What is fetal surgery? It is application of established surgical techniques to the unborn baby - during gestation - at the time of delivery fetal intervention is reaching inside the uterus many diseases can now be accurately diagnosed before birth by genetic and imaging techniques maternal - fetal intervention the safety of the mother Contraindication for fetal surgery conditions incompatible with life chromosomal and genetic disorders other associated life threatening abnormalities usually performed between 24-29 weeks gestation Requires combined expertise of Obstetrician Anaesthesiologist Neonatologist Pediatric surgeon Indications For Fetal Surgery 1. Anatomic lesions that interfere with development: - Bilateral obstructive hydronephrosis or lower urinary tract obstruction - Obstructive hydrocephalus - Congenital diaphragmatic hernia(CDH) - Cardiac anomalies-complete heart block, AS, PS - Neural tube defects –spina bifida, sacrococcygeal teratoma, myelomeningocele - Skeletal defects - Gastroschisis - Thoracic space occupying lesions - Giant neck masses - Tracheal atresia-stenosis - Congenital cystic pulmonary adenomatoid
    [Show full text]
  • (EXIT) Procedure: Anesthetic Implications
    International Journal of Obstetric Anesthesia (2004) 13, 178–182 Ó 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijoa.2004.01.007 CASE REPORT Four cases of the ex utero intrapartum treatment (EXIT) procedure: anesthetic implications G. Dahlgren, D. C. Tornberg,€ K. Pregner, L. Irestedt Department of Anesthesia and Intensive Care, Karolinska Hospital and Institute, SE 171 76 Stockholm, Sweden SUMMARY. The ex utero intrapartum treatment (EXIT) procedure is a method of maintaining utero-placental cir- culation during cesarean section to gain time to secure a potentially obstructed fetal airway. Four cases of the EXIT procedure are described with special reference to the maternal anesthetic technique. Deep volatile anesthesia (ap- proximately 2 MAC) with isoflurane or sevoflurane for a prolonged period of time, in three cases in combination with an intravenous nitroglycerin infusion, was used to ensure a fully relaxed uterus during the procedure. All mothers were maintained hemodynamically stable with preserved utero-placentary perfusion. It was possible to intubate the tracheas of two fetuses, whereas in the other two tracheostomies had to be performed. Fetal gas exchange was not negatively affected during the EXIT procedure as evidenced by normal blood gas values in the umbilical artery at the time of delivery. After reducing the concentration of volatile anesthetic, delivery of the neonate and administration of oxytocin, uterine contractility was promptly re-established and there were no signs of uterine atony in the post- operative period. All four neonates survived the procedure without complications. Ó 2004 Elsevier Ltd. All rights reserved. INTRODUCTION The EXIT procedure is performed in conjunction with an elective cesarean section.
    [Show full text]
  • Intrauterine Fetal Surgery – Commercial Medical Policy
    UnitedHealthcare® Commercial Medical Policy Intrauterine Fetal Surgery Policy Number: 2021T0035V Effective Date: September 1, 2021 Instructions for Use Table of Contents Page Community Plan Policy Coverage Rationale ....................................................................... 1 • Intrauterine Fetal Surgery Applicable Codes .......................................................................... 1 Description of Services ................................................................. 2 Benefit Considerations .................................................................. 4 Clinical Evidence ........................................................................... 4 U.S. Food and Drug Administration ........................................... 13 References ................................................................................... 13 Policy History/Revision Information ........................................... 16 Instructions for Use ..................................................................... 16 Coverage Rationale See Benefit Considerations Intrauterine fetal surgery (IUFS) is proven and medically necessary for treating the following conditions: Congenital Cystic Adenomatoid Malformation (CCAM) and Extralobar Pulmonary Sequestration (EPS): Fetal lobectomy or thoracoamniotic shunt placement for CCAM and thoracoamniotic shunt placement for EPS Pleural Effusion: Thoracoamniotic shunt placement Sacrococcygeal Teratoma (SCT): SCT resection Urinary Tract Obstruction (UTO): Urinary decompression via vesicoamniotic
    [Show full text]
  • AOGD Bulletin May 2019.Indd
    AOGDAOGD BULLETINBULLETIN Volume 19 I May 2019 I Monthly Issue 1 I Price `30 Only Enlightening the Path for Next Generation of Gynaecologists Dedicated Issue: Urogynaecology AOGD SECRETARIAT Department of Obstetrics & Gynaecology, 3076, Teaching Block, IIIrd Floor, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029 Tel.: 011-26546603, 26593221 E-mail: [email protected] Vol.19, No.1; May, 2019 1 Website: www.aogd.org AOGD Offi ce-Bearers 2019-20 Dr Sunesh Kumar Dr Ashok Kumar President Vice President Dr Vatsla Dadhwal Dr K Aparna Sharma Dr Rohini Sehgal Hon. Secretary Joint Secretary Treasurer Dr Dipika Deka Dr Neerja Bhatla Dr K K Roy Dr Neena Malhotra Scientifi c Advisors Editorial Board Dr J B Sharma Dr Reeta Mahey Dr Vanamail Dr Juhi Bharti Editor Co-Editors Web Editor Dr Neeta Singh Dr Garima Kachhawa Dr Seema Singhal Dr Jyoti Meena Dr Vidushi Kulshreshtha Dr Rajesh Kumari Scientifi c Committee Clinical Secretaries 2 AOGD Bulletin AOGD Bulletin Volume 19 • Monthly Issue 1 • May 2019 AOGD Executive Committee 2019-20 President Vice President Hon. Secretary Dr Sunesh Kumar Dr Ashok Kumar Dr Vatsla Dadhwal President Patrons Dr Sunesh Kumar Dr D Takkar Dr Kamal Buckshee Vice President Dr Neera Agarwal Dr Ashok Kumar Dr Sheila Mehra Contents Hony. Secretary Dr S K Bhandari Dr Vatsla Dadhwal Dr S N Mukherjee Dr Swaraj Batra • Basic Statistical Methods for Obstetricians and Gynaecologists 8 Scientifi c Advisors Dr Urmil Sharma Vanamail Perumal Dr Dipika Deka Dr V L Bhargava Dr Neerja Bhatla Dr K K Roy Advisors
    [Show full text]
  • Peri-Operative Management of Percutaneous Fetoscopic Spina
    International Journal of Obstetric Anesthesia (2020) 43, 97–105 0959-289X/$ - see front matter Ó 2020 Elsevier Ltd. All rights reserved. https://doi.org/10.1016/j.ijoa.2020.04.005 REVIEW ARTICLE www.obstetanesthesia.com Peri-operative management of percutaneous fetoscopic spina-bifida repair: a descriptive review of five cases from the United Kingdom, with focus on anaesthetic implications C.D. Goonasekera,a V.A. Skelton,a B. Zebian,b K. Nicolaides,c D. Araujo Lapa,d M. Santorum-Perez,e C. Bleil,b A. Hickey,f R. Bhat,f B.E. Oliva Gattog aDepartment of Anaesthesia, King’s College Hospital, London, UK bDepartment of Neurosurgery, King’s College Hospital, London, UK cFetal Medicine Research Institute, King’s College Hospital, London, UK dDepartment of Obstetrics and Fetal Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil eDepartment of Obstetrics and Fetal Medicine, Fetal Medicine Research Institute, King’s College Hospital, London, UK fDepartment of Neonatology, King’s College Hospital, London, UK gDepartment of Anaesthesia, Hospital Israelita Albert Einstein, Sao Paulo, Brazil ABSTRACT We present a case-based review of the first five percutaneous fetoscopic in-utero spina bifida repair procedures undertaken in the UK. Our focus is on implications of anaesthesia and analgesia for the mother and fetus, provision of uterine relaxation and fetal immobilisation while providing conditions conducive to surgical access. Minimising risks for fetal acidosis, placental and fetal hypoperfusion, maternal and fetal sepsis and maternal fluid overload were the foremost priorities. We discuss optimisation strate- gies undertaken to ensure fetal and maternal well-being under anaesthesia, shortcomings in the current approach, and possible directions for improvement.
    [Show full text]