Anesthesia for fetal surgery

https://doi.org/10.1016/S1055-8586(03)00025-8Get rights and content

Abstract

Fetal surgery is a rapidly growing and evolving area. Fetal surgery is based on years of animal and clinical research. In contrast, anesthesia techniques for fetal surgery are based on clinical experience. The techniques that have emerged are safe for mother and fetus. In this review, the authors describe current techniques for anesthetic management of fetal surgery patients. General anesthesia is the primary technique used for hysterotomy based surgical correction of midgestation fetuses and ex utero interpartum corrections of end-gestation fetuses. Epidural analgesia, with general anesthesia as back-up, is the primary technique used for fetoscopic cases in which anesthetic care is required. Because of the myriad of anesthetic and surgical issues these cases generate, it is essential to have good communication and cooperation between surgeons and anesthesiologists from the preoperative period to the postoperative period. This will allow development of a cohesive anesthetic and surgical plan that can be used for the safe perioperative management of the fetal surgery patient.

Section snippets

Maternal anesthetic considerations

In contrast to nonsurgical therapy of the fetus or midgestation nonobstetric surgery, fetal surgery involves the simultaneous treatment of 2 patients. It is therefore incumbent on the anesthesiologist to monitor and treat both the fetus and the mother. The physiology of the parturient contributes to increased anesthetic risk for both the mother and fetus.

Unlike obstetric anesthetic practice, general anesthesia is the technique of choice for open fetal surgery. The major organ systems

Fetal anesthetic considerations

Fetal diseases amenable to surgical correction often compromise or disturb cardiovascular function. The combination of immature organ function and cardiovascular disease predispose the fetus to anesthetic-related difficulty.

Maintenance of fetal cardiovascular stability is the primary concern of anesthetic management. The fetal cardiovascular system is less able to compensate for hypoxia and hypovolemia than a full-term infant. Lacking a functional pulmonary system to increase oxygen tension,

Utero-placental anesthetic consideration

Fetal survival depends on transfer of oxygen from the mother to the fetus. Uterine and umbilical artery blood flow and placental barriers to diffusion influence fetal oxygenation. Maternal systemic blood pressure and myometrial tone affect uterine artery blood flow. Volatile anesthetics decrease myometrial tone and also tend to decrease both maternal blood pressure and placental blood flow. This can result in a decrease in fetal oxygenation.19, 20, 21 Thus, maintenance of maternal arterial

Open fetal surgery

Open fetal surgeries usually are performed on the midgestation fetus with myelomeningocele, congenital cystic adenomatoid malformation, or sacrococcygeal teratoma. To qualify as a surgical candidate, a mother must undergo extensive medical and psychosocial screening, have a fetus with disease that merits intervention, and be at low maternal risk for anesthesia and surgery. This surgery is contraindicated for mothers with serious medical diseases or fetuses with other disabling/lethal congenital

Conclusion

Anesthesia for fetal surgery is an evolving field. The anesthetic techniques that have emerged are safe for mother and fetus. Because of the myriad of anesthetic and surgical issues these cases generate, it is essential to have good communication and cooperation between surgeons and anesthesiologists from the preoperative period to the postoperative period. This will allow development of a cohesive anesthetic and surgical plan that can be used for the safe perioperative management of the fetal

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