Fetal heart rate monitoring during fetoscopic repair of open spinal neural tube defects: a single-centre observational cohort study

García, Irene; Suárez, Edwin Uriel; Maíz, Nerea; Pascual, Montserrat Hernández; Perera, Remei; Arévalo, Sílvia; Giné, C; Molino, Jose Andrés; López, María Cristina Lorente; Carreras, E.; Manrique, Susana

doi:10.1016/j.ijoa.2021.103195

Cited by 4 publications

(5 citation statements)

References 28 publications

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“…20 Using the definition FHR less than 110, a previously published report found similar (3.4%) rates of bradycardia in fetoscopic repair compared to this study, but the incidence in open repairs according to this definition has not been reported to our knowledge. 32,37 Using a definition of FHR less than 100 bpm, another study demonstrated 11% of open repairs developed bradycardia, similar to 12% of open cases in our series. 19 In this study, all bradycardia events occurred during the window between hysterotomy incision and hysterotomy closure, particularly during the fetal spina bifida defect repair.…”

Section: Discussionsupporting

confidence: 82%

Fetal bradycardia in open versus fetoscopic prenatal repair of spina bifida

Papastefan,

Alhajjat,

Ott

et al. 2024

Prenatal Diagnosis

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ObjectiveTo compare the occurrence of fetal bradycardia in open versus fetoscopic fetal spina bifida surgery.MethodsThis is a single‐institution retrospective cohort study of patients undergoing open (n = 25) or fetoscopic (n = 26) spina bifida repair between 2017 and 2022. From October 2017 to June 2020, spina bifida repairs were performed via an open classical hysterotomy, and from November 2020 to June 2022 fetoscopic repairs were performed following transition to this technique. Fetal heart rate (FHR) in beats per minute (bpm) was recorded via echocardiography every 15 min during the procedure. Cohort characteristics, fetal bradycardia and maternal physiologic parameters were compared between the groups.ResultsFetuses undergoing an open repair more frequently developed bradycardia defined as <110 bpm (32% vs. 3.8%, p = 0.008), and a trend was observed for FHR decreases more than 25 bpm from baseline (20% vs. 3.8%, p = 0.073). Profound bradycardia less than 80 bpm was rare, occurring in only three operations (two in open, one in fetoscopic repair) with two fetuses (one in each group) requiring emergency cesarean delivery.ConclusionWhen compared to open fetal surgery, fetal bradycardia occurred less frequently in fetoscopic surgery despite a significantly greater anesthetic exposure and the use of the intraamniotic carbon dioxide insufflation.

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Section: Discussionsupporting

confidence: 82%

Fetal bradycardia in open versus fetoscopic prenatal repair of spina bifida

Papastefan,

Alhajjat,

Ott

et al. 2024

Prenatal Diagnosis

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“…After full-text screening against inclusion criteria, 168 articles, accounting for 6,761 procedures, were selected ( Figure 1 ) ( 11 – 178 ). Fourteen of the included studies, not providing information on the procedure outcome, were only considered for the initial description of anesthesia modality and in the summary of anesthetic drugs used ( 13 , 25 , 31 , 42 , 53 , 60 , 66 , 109 , 110 , 123 , 142 , 147 , 148 , 165 ). Characteristics of the included studies can be found in Supplementary Material .…”

Section: Resultsmentioning

confidence: 99%

“…Sixty studies, accounting for 1,524 procedures, described the anesthetic agents used to provide direct fetal anesthesia ( 14 , 16 – 20 , 30 , 32 , 34 , 36 , 37 , 41 , 43 – 45 , 47 , 49 , 50 , 52 , 54 – 57 , 59 , 62 , 63 , 66 , 68 , 70 , 83 , 85 , 86 , 88 , 95 , 98 , 100 , 104 , 106 , 108 – 110 , 118 , 121 , 125 , 127 , 135 , 140 , 141 , 143 – 148 , 153 , 158 , 163 , 170 , 176 , 177 ). The most common anesthetic agents are summarized in Table 8 .…”

Section: Resultsmentioning

confidence: 99%

“…Fifty-six studies, with a total of 1,127 patients, specified the drugs used to provide general maternal anesthesia ( 11 , 13 , 15 , 19 , 22 , 24 – 26 , 30 – 32 , 35 , 41 , 42 , 46 , 50 , 52 , 53 , 55 , 57 , 63 , 64 , 66 , 71 , 73 , 78 , 81 , 82 , 84 , 86 , 90 , 95 , 97 , 99 , 103 , 104 , 106 , 108 – 110 , 115 , 119 , 124 , 126 , 128 , 134 , 141 , 142 , 151 , 153 , 158 , 160 – 162 , 173 ). The extreme variability between the studies did not allow a specific analysis.…”

Section: Resultsmentioning

confidence: 99%

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Anesthesia for fetal operative procedures: A systematic review

et al. 2022

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ObjectiveThe anesthetic management of fetal operative procedures (FOP) is a highly debated topic. Literature on fetal pain perception and response to external stimuli is rapidly expanding. Nonetheless, there is no consensus on the fetal consciousness nor on the instruments to measure pain levels. As a result, no guidelines or clinical recommendations on anesthesia modality during FOP are available. This systematic literature review aimed to collect the available knowledge on the most common fetal interventions, and summarize the reported outcomes for each anesthetic approach. Additional aim was to provide an overall evaluation of the most commonly used anesthetic agents.MethodsTwo systematic literature searches were performed in Embase, Medline, Web of Science Core Collection and Cochrane Central Register of Controlled Trials up to December 2021. To best cover the available evidence, one literature search was mostly focused on fetal surgical procedures; while anesthesia during FOP was the main target for the second search. The following fetal procedures were included: fetal transfusion, laser ablation of placental anastomosis, twin-reversed arterial perfusion treatment, fetoscopic endoluminal tracheal occlusion, thoraco-amniotic shunt, vesico-amniotic shunt, myelomeningocele repair, resection of sacrococcygeal teratoma, ligation of amniotic bands, balloon valvuloplasty/septoplasty, ex-utero intrapartum treatment, and ovarian cyst resection/aspiration. Yielded articles were screened against the same inclusion criteria. Studies reporting anesthesia details and procedures’ outcomes were considered. Descriptive statistical analysis was performed and findings were reported in a narrative manner.ResultsThe literature searches yielded 1,679 articles, with 429 being selected for full-text evaluation. A total of 168 articles were included. Overall, no significant differences were found among procedures performed under maternal anesthesia or maternal-fetal anesthesia. Procedures requiring invasive fetal manipulation resulted to be more effective when performed under maternal anesthesia only. Based on the available data, a wide range of anesthetic agents are currently deployed and no consistency has been found neither between centers nor procedures.ConclusionsThis systematic review shows great variance in the anesthetic management during FOP. Further studies, systematically reporting intraoperative fetal monitoring and fetal hormonal responses to external stimuli, are necessary to identify the best anesthetic approach. Additional investigations on pain pathways and fetal pain perception are advisable.

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“…Whether hhCO 2 insufflation exacerbates these intraoperative physiological cardiac changes is unclear 33,34 . Using hhCO 2 (3-5 mmHg) for fetoscopy was safer than cold CO 2 in pregnant sheep, but was associated with hypercapnia, acidosis and fetal demise in sheep fetuses 35 .…”

Section: Discussionmentioning

confidence: 99%

Fetal cardiovascular changes during open and fetoscopic in‐utero spina bifida closure

Backley,

Bergh,

Garnett

et al. 2024

Ultrasound in Obstet & Gyne

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ObjectiveLaparotomy‐assisted fetoscopic closure of spina bifida utilizing heated‐humidified carbon dioxide gas has been associated with less maternal morbidity than open in‐utero spina bifida closure. Fetal cardiovascular changes during these surgical interventions are not well defined. Our objective was to compare fetal bradycardia (defined as fetal heart rate (FHR)<110 bpm over 10 minutes) and changes in umbilical artery Doppler parameters throughout open in‐utero closure with those observed during laparotomy‐assisted fetoscopic closure.MethodsWe conducted a prospective cohort study of 22 open and 46 fetoscopic consecutive in‐utero closures between 2019 and 2023. Both cohorts had similar preoperative counseling and clinical management. FHR and umbilical artery velocimetry were systematically obtained during preoperative assessment, every 5 minutes during the intraoperative period, and in the postoperative assessment. FHR, pulsatility indexes and end‐diastolic flows were segmented into hourly periods during surgery, and the lowest values were averaged for analysis. Umbilical vein maximum velocities were measured in the fetoscopic cohort. Each fetal heart rate recording time point was correlated to maternal parameters, including heart rate, systolic and diastolic blood pressures.ResultsFetal bradycardia occurred in 4/22 cases (18.2%) of open in‐utero closure and in 21/46 cases (45.7%) of fetoscopic closure. FHR gradually decreased in both cohorts after general anesthesia and decreased further during surgery. FHR were significantly lower after two hours of surgery in the fetoscopic closure than in the open in‐utero closure group. In addition, the FHR (BPM) change in the final stages of the fetal surgery from the baseline FHR was significantly lower in the fetoscopic cohort (‐32.3 (‐35.7, ‐29.1)) compared to the open cohort (‐23.5 (‐28.1, ‐18.8)) (p=0.002). Abnormal end‐diastolic flow (defined as absent or reversed end‐diastolic flow) in the umbilical artery Doppler velocity occurred in 3/22 (13.6%) of the open closure cohort and in 23/46 (50%) of the fetoscopic closure cohort (p=0.004). There were no differences in umbilical artery end‐diastolic flow and pulsatility index between closure techniques during the various stages of assessment.ConclusionsWe observed a decrease in the FHR and abnormalities in umbilical artery Doppler parameters in both open in‐utero and fetoscopic closure groups. Fetal bradycardia was more prominent during fetoscopic closure following heated‐humidified carbon dioxide insufflation, but the FHR recovered after cessation of the heated‐humidified carbon dioxide. Changes in FHR and umbilical artery Doppler parameters during in‐utero spina bifida closure were observed to be transient, no cases required emergency delivery and no fetoscopic closure were converted to open closure. These observations should inform algorithms for perioperative management of fetal bradycardia associated with in‐utero spina bifida closure.This article is protected by copyright. All rights reserved.

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Fetal heart rate monitoring during fetoscopic repair of open spinal neural tube defects: a single-centre observational cohort study

Cited by 4 publications

References 28 publications

Fetal bradycardia in open versus fetoscopic prenatal repair of spina bifida

Fetal bradycardia in open versus fetoscopic prenatal repair of spina bifida

Anesthesia for fetal operative procedures: A systematic review

Fetal cardiovascular changes during open and fetoscopic in‐utero spina bifida closure

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