Fetal Surgery: Coming to a Center Near You?

Olutoye, Oluyinka O.

doi:10.1177/0885066607310238

Cited by 2 publications

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“…These hospitals are often in close proximity to or affiliated with maternal obstetric units and involve a multidisciplinary team approach to provide care for both mother and baby. However, these types of procedures are increasingly being performed in diverse hospital settings 1 ; therefore, adequate knowledge about the related intricacies of these cases is warranted.…”

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Case Scenario: Anesthesia for Maternal-Fetal Surgery

et al. 2011

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FETAL anomalies such as giant neck masses can result in perinatal death or hypoxia and anoxic brain injury due to inability to secure an airway in a timely fashion after delivery. Modern technology, ultrasound, and ultrafast magnetic resonance imaging have enabled intrauterine diagnosis and fetal interventions as a mode of therapy, thereby giving such affected fetuses a chance at survival.Initially, the Ex Utero Intrapartum Therapy (EXIT) procedure was exclusively performed in large tertiary children's hospitals because of the easy availability of pediatric practitioners who can adequately manage the baby-related issues. These hospitals are often in close proximity to or affiliated with maternal obstetric units and involve a multidisciplinary team approach to provide care for both mother and baby. However, these types of procedures are increasingly being performed in diverse hospital settings 1 ; therefore, adequate knowledge about the related intricacies of these cases is warranted.We present the case of a mother carrying a fetus of 37 weeks' gestation with a giant cervical teratoma who underwent the EXIT procedure for fetal airway access. This discussion will focus on the multiple management issues and concerns to be contemplated before embarking on the care of a pregnant mother whose child may need surgery shortly before delivery to ensure neonatal survival. Case ReportA 35-yr-old healthy, uniparous woman, gravida 2, was referred to our institution's fetal center at 21 weeks' gestation after diagnosis of a giant neck mass with associated moderate polyhydramnios on a routine obstetric ultrasound examination. Fetal magnetic resonance imaging revealed findings consistent with a cervical teratoma and significant airway compromise ( fig. 1). Given the degree of airway compromise and distortion of the fetus' anatomy, a multidisciplinary meeting that included anesthesiologists, pediatric surgeons, maternal-fetal medicine specialists, obstetricians, neonatologists, cardiologists, operating room nurses, and labor and delivery room nurses was organized to discuss the fetal anomaly and management approach to delivery of the fetus. Conventional delivery followed by airway maneuvers to intubate the trachea or place a tracheostomy after delivery were thought to be the least favorable options for management given the gross anatomic distortion and potential for hypoxia associated with prolonged attempts at intubation. The EXIT procedure offered the ability to maintain neonatal oxygenation via placental support while trying different approaches to secure a definitive airway, and therefore seemed most favorable after reviewing the fetus' anatomy. Once the plan was concluded by the specialties involved, the family was invited to the meeting for an update on the deliberations and concerns and also to meet members of the team. The questions the family had were

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confidence: 99%