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. Ó 2020 Elsevier Ltd. All rights reserved. Keywords: Percutaneous fetoscopic spina-bifida repair; Transplacental anaesthesia; Fetal monitoring; Depth of anaesthesia; Uterine tocolysis Introduction with increased rates of preterm birth (13% before 30 weeks’ gestation) and uterine dehiscence. Spina bifida results from abnormal development and In the quest to reduce maternal and fetal complica- incomplete closure of the neural tube and affects 33– tions, fetoscopic approaches have been adopted by 48 per 100 000 live births globally.1 Current practice is many centres around the world with promising surgical repair within 1–2 days of birth. Recently, sev- results.6–8 There is no published guidance on optimal eral animal and human reports have suggested that pre- modes of anaesthesia. We report our first experiences natal repair could offer better postnatal neurological of percutaneous fetoscopic spina bifida repair, including function.2,3 In 2011, the Management of optimisation strategies undertaken to ensure fetal and Myelomeningocele Study (MOMS) compared open maternal well-being under anaesthesia, shortcomings (hysterotomy) prenatal repair with the standard postna- of the current approach and directions for improvement tal technique. They found reduced rates of neurosurgical in the future. intervention for hydrocephalus in a significant propor- tion of those treated prenatally and an improved com- Case series posite score for mental development and motor function at 30 months.4,5 However, it was associated Eligibility The MOMS trial criteria were used to determine eligibil- Accepted April 2020 ity for antenatal repair. All cases had fetal spina bifida Correspondence to: C. Goonasekera, Department of Anaesthetics, recognised on antenatal ultrasound and confirmed by King’s College Hospital, Denmark Hill, London SE5 9RS, UK. E-mail address: [email protected] magnetic resonance imaging (MRI) early in the second 98 Peri-operative management of percutaneous fetoscopic spina-bifida repair trimester. None of the fetuses had any other congenital tained at 2–3 mmHg above the opening pressure. We abnormalities. The parents were counselled on the observed momentary drops in blood pressure during options available for repair and, following a multidisci- the insertion of trocars. Uterine insufflation with CO2 plinary discussion, the percutaneous fetoscopic seemed most stimulating for the mother, with a rise in approach was offered. The parents gave consent and blood pressure and BIS that was mitigated by IV mor- surgery was scheduled for the late second trimester. phine. The spinal defect was dissected by the neuro- surgeon and repaired with a bio-cellulose patch placed Operative course over the neural placode (exposed open spinal cord), cov- ered by an additional layer of a skin substitute (Neve- Extensive pre-operative planning was undertaken with Ò advice from international experts. All team members lia , Symatese, Montpelier, France) as needed (Fig. 1). participated in a simulation on the day of surgery. The uterine cavity was irrigated with warm (37 °C) Before surgery, the women were fasted, provided with Ringer’s lactate solution, antibiotic instilled (cefuroxime standard antacid premedication and anti-thrombo- 1.5 g in case 1, clindamycin 500 mg in cases 2–5) and the embolic stockings, and given rectal (PR) indomethacin cavity re-filled with 1L Ringer’s lactate solution or the 11 100 mg 12 h pre-operatively. Following pre- drained amniotic fluid if not blood-stained. Uterine oxygenation, a rapid sequence induction was carried tone was restored with termination of the GTN infusion out with intravenous (IV) fentanyl 3 mg/kg, propofol and sevoflurane inhalation 5 min before removal of the 1.5 mg/kg and rocuronium 0.8 mg/kg. This generally trocars. Intravenous anaesthesia was maintained during achieved a bispectral index (BIS) of 25–30. Following uterine port-site haemostasis and closure of abdominal intubation, positive-pressure ventilation was established wounds. The duration of the procedure ranged from with hyperventilation during intra-uterine carbon diox- 4.0 to 5.5 h. Maternal temperature was monitored and ide (CO2) insufflation to maintain end-tidal CO2 maintained with a warm-air blanket. Women received (ETCO2) below 3.5 kPa. Antibiotic prophylaxis was IV paracetamol 1 g, IV metoclopramide 10 mg and PR administered at induction (cefuroxime 1.5 g in case 1 indomethacin 100 mg. The maternal blood loss was and clindamycin 600 mg in cases 2–5), with three further approximately 150–200 mL and total fluids during the doses postoperatively. procedure limited to Hartmann’s solution 1000– Anaesthesia was maintained with sevoflurane at a 1500 mL. Following recovery from general anaesthesia, minimum alveolar concentration (MAC) of 0.4–1, intra- the mothers and fetuses were observed in the obstetric venous propofol infusion 2–3 mg/kg/h and remifentanil high dependency unit for 24–48 h. Adequate pain con- infusion 10 mg/kg/h adjusted to maintain cardiovascular trol was achieved with regular paracetamol and doses stability. The depth of maternal anaesthesia was moni- of oral morphine (0.15 mg/kg) except in case 2, for tored using BIS and maintained at 40.9 An arterial line whom morphine patient controlled analgesia followed was inserted to assist regular sampling and cardiovascu- by epidural analgesia was required from days 2–4 lar monitoring. because of intermittent shooting postoperative pain trig- A phenylephrine infusion was titrated to maintain a gered by fetal movements impinging upon the uterine target mean maternal blood pressure (65–70 mmHg in wounds. None of the women required a blood trans- cases 1 and 2 and 80 mmHg in cases 3–5) during the pro- fusion. There were no post-procedure placental abrup- cedure. Atropine 600 mg (cases 3–5) was given if the tions or uterine dehiscences. maternal heart rate fell below 60/min. A glyceryl trini- trate (GTN) infusion was available (50 mg/50 mL) to Fetal monitoring provide additional uterine relaxation. This was required Intra-operative fetal monitoring was obstetrician led. in case 4 during which intermittent uterine contractions For case 1 this included pre- and postoperative ultra- were observed following an intraperitoneal CO2 leak sound assessment of umbilical and middle cerebral during the procedure. artery blood flow and cardiotocogram (CTG), with All women were placed in a semi-lithotomy/supine visual monitoring of the umbilical cord pulsation position, a urinary catheter inserted and PR indometha- intra-operatively. The uterine and middle cerebral artery cin 100 mg given for uterine tocolysis. An 18-gauge nee- blood flows were reported as normal before and after dle was inserted into the uterus under ultrasound surgery. The beat-to-beat variation of the fetal heart guidance and 500 mL of warm Ringer’s lactate solution on CTG was reduced postoperatively in case 1, although infused. Four percutaneous ports (in case 1) and three the baseline rate remained normal. Normal fetal move- ports (in cases 2–5) were respectively inserted into the ments were felt by the mother 48 h post-surgery. uterus under ultrasound guidance. Approximately 1 L In cases 2–5, additional intra-operative fetal monitor- of amniotic fluid was removed and humidified warm ing was instituted every 15 min using a Doppler probe CO2 insufflated. The uterine ‘opening pressure’ was placed on the maternal flank under sterile conditions measured and the maximum insufflation pressure set to gain umbilical artery signals from the umbilical cord, 10 at 4 mmHg above it. In cases 2–5, pressure was main- below the amniotic fluid level so as to avoid the CO2 C.D. Goonasekera et al. 99 Fig. 1 Completed fetoscopic patch repair of the spina-bifida (case 1) interface (Fig. 2). This fetal umbilical cord blood flow ventriculomegaly (Fig. 3). On neurological examination, study was used to calculate the pulsatility index (PI), the baby displayed good power and movement in all the systolic velocity-diastolic velocity/mean velocity, limbs and normal anal tone, and the bladder scan was which is a measure of umbilical cord forward blood within the normal range. At 48 h, there was renal flow, and placental resistance.12 The PI reduced with impairment with the s. creatinine rising to a maximum increasing gestation. A PI <1.0 was considered healthy of 289 mmol/L.