Objective Partial amniotic carbon dioxide (CO 2 ) insufflation (PACI) is used to improve visualization and facilitate complex fetoscopic surgery. However, there are concerns about fetal hypercapnic acidosis and postoperative fetal membrane inflammation. We assessed whether using heated and humidified, rather than cold and dry, CO 2 might reduce the impact of PACI on the fetus and fetal membranes in sheep. Methods Twelve fetal lambs of 105 days' gestational age (term = 145 days) were exteriorized partially, via a midline laparotomy and hysterotomy, and arterial catheters and flow probes were inserted surgically. The 10 surviving fetuses were returned to the uterus, which was then closed and insufflated with cold, dry (22 °C at 0–5% humidity, n = 5) or heated, humidified (40 °C at 100% humidity, n = 5) CO 2 at 15 mmHg for 180 min. Fetal membranes were collected immediately after insufflation for histological analysis. Physiological data and membrane leukocyte counts, suggestive of membrane inflammation, were compared between the two groups. Results After 180 min of insufflation, fetal survival was 0% in the group which underwent PACI with cold, dry CO 2 , and 60% ( n = 3) in the group which received heated, humidified gas. While all insufflated fetuses became progressively hypercapnic (PaCO 2 > 68 mmHg), this was considerably less pronounced in those in which heated, humidified gas was used: after 120 min of insufflation, compared with those receiving cold, dry gas ( n = 3), fetuses undergoing heated, humidified PACI ( n = 5) had lower arterial partial pressure of CO 2 (mean ± standard error of the mean, 82.7 ± 9.1 mmHg for heated, humidified CO 2 vs 170.5 ± 28.5 for cold, dry CO 2 during PACI, P < 0.01), lower lactate levels (1.4 ± 0.4 vs 8.5 ± 0.9 mmol/L, P < 0.01) and higher pH (pH, 7.10 ± 0.04 vs 6.75 ± 0.04, P < 0.01). There was also a non‐significant trend for fetal carotid artery pressure to be higher following PACI with heated, humidified compared with cold, dry CO 2 (30.5 ± 1.3 vs 8.7 ± 5.5 mmHg, P = 0.22). Additionally, the median (interquartile range) number of leukocytes in the chorion was significantly lower in the group undergoing PACI with heated, humidified CO 2 compared with the group receiving cold, dry CO 2 (0.7 × 10 –5 (0.5 × 10 –5 ...
Partial amniotic carbon dioxide insufflation (PACI) involves insufflating the amniotic sac with carbon dioxide (CO2) and, in some cases, draining some of the amniotic fluid. The creation of a gaseous intra‐amniotic compartment improves visualization, even in the presence of limited bleeding, and creates the work space required for complex fetoscopic procedures. Clinically, PACI is mostly used to perform fetoscopic myelomeningocele (MMC) repair, enabling a minimally invasive alternative to open fetal surgery. However, evidence of the fetal safety of PACI is limited. Previous animal experiments in sheep demonstrate that PACI induces fetal hypercapnia and acidosis with largely unknown short and longer term implications. In this review, we examine the literature for the physiological effects of intrauterine insufflation pressure, duration, humidity, and the role of maternal hyperventilation on fetal physiology and well‐being.
Iatrogenic preterm premature rupture of the fetal membranes (iPPROM) remains the Achilles’ heel of keyhole fetal surgery (fetoscopy) despite significant efforts in preclinical models to develop new therapies. This limited success is partially due to incomplete understanding why the fetal membranes rupture early after fetoscopy and notable differences in membrane physiology between humans and domestic species. In this review, we summarize aspects of fetoscopy that may contribute to iPPROM, the previous efforts to develop new therapies, and limitations of preclinical models commonly used in fetal membrane research.
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