Maternal and fetal anaesthesia for fetal surgery

Abstract

Summary Over the last three decades, advances in early diagnosis of fetal anomalies, imaging and surgical techniques have led to a huge expansion in fetal surgery. A small number of specialist centres perform fetal surgery, which involves high‐risk anaesthesia for the mother and fetus. The anaesthetist plays an integral role within the large multispecialty and multidisciplinary team, involved in planning and delivering care for complex surgical procedures. This article reviews three fetal surgical procedures, congenital diaphragmatic hernia, myelomeningocele repair and ex‐utero intrapartum treatment for airway obstruction. The underlying fetal pathology, surgical management, anaesthetic considerations and risks for both the mother and fetus are described for each. Fundamental to this is the understanding that clear communication and collaboration between all team members is vital to ensure successful outcomes of patients, the mother and the fetus.

Recent advances in anaesthesia for intrauterine and foetal surgery

“…These procedures include repair of MMC, excision of lesions such as sacrococcygeal teratoma, congenital cystic adenomatoid/pulmonary malformation (CCAM/CPAM)[ 2 ] and temporary tracheal occlusion for CDH. [ 7 ]…”

“…Originally performed for CDH foetuses with tracheal plugging, it is now performed for other causes of airway obstruction. [ 4 , 7 ] The head and upper chest of the foetus are delivered, and airway is secured before clamping the cord. EXIT procedure can also facilitate transition to extracorporeal membrane oxygenation (ECMO).…”

Multiple sevoflurane exposures during mid‐trimester induce neurotoxicity in the developing brain initiated by 15LO2‐Mediated ferroptosis

“…Fetal surgery has become an acceptable option for certain neonatal ailments owing to advancements in prenatal diagnosis 1 . Fetuses with severe abnormalities may require open mid‐gestation operations, which demand varying degrees of analgesia, sedation, or anesthesia for both mother and fetus to optimize surgical conditions and obtain beneficial outcomes 2 . However, mid‐gestational anesthetics exposure has been demonstrated to induce prolonged neurocognitive deficits in offspring, suggesting the potential neurotoxicity of anesthetics on developing brain 3–6 .…”

Immediate postdelivery airway management of neonates with prenatally diagnosed micrognathia: A retrospective observational study

“…3,7,10,12,13 General anesthesia for the mother and profound uterine relaxation are commonly required to facilitate partial delivery, vascular access, and airway management of the neonate. [13][14][15][16] The neonate receives volatile anesthetic through the placental circulation supplemented with an intramuscular injection of fentanyl and a non-depolarizing neuromuscular blocker prior to any intervention. 13,16,17 There are significant maternal risks to the EXIT procedure intraoperatively, including hemorrhage, 1,[13][14][15][16]18 hypotension, 13,16 and placental abruption, which may threaten the life of the mother and compromise the success of the EXIT procedure.…”

“…[13][14][15][16] The neonate receives volatile anesthetic through the placental circulation supplemented with an intramuscular injection of fentanyl and a non-depolarizing neuromuscular blocker prior to any intervention. 13,16,17 There are significant maternal risks to the EXIT procedure intraoperatively, including hemorrhage, 1,[13][14][15][16]18 hypotension, 13,16 and placental abruption, which may threaten the life of the mother and compromise the success of the EXIT procedure. 13,16,18 Ex-utero intrapartum treatment may not be indicated for all cases of micrognathia, however.…”