Anesthesia for In Utero Repair of Myelomeningocele

Abstract

Recently published results suggest that prenatal repair of fetal myelomeningocele is a potentially preferable alternative when compared to postnatal repair. In this article, the pathology of myelomeningocele, unique physiologic considerations, perioperative anesthetic management, and ethical considerations of open fetal surgery for prenatal myelomeningocele repair are discussed. Open fetal surgeries have many unique anesthetic issues such as inducing profound uterine relaxation, vigilance for maternal or fetal blood loss, fetal monitoring, and possible fetal resuscitation. Postoperative management, including the requirement for postoperative tocolysis and maternal analgesia are also reviewed. The success of intrauterine myelomeningocele repair relies on a well-coordinated multidisciplinary approach. Fetal surgery is an important topic for anesthesiologists to understand, as the number of fetal procedures is likely to increase as new fetal treatment centers are opened across the United States.

Incidence and Management of Umbilical Artery Flow Abnormalities during Open Fetal Surgery

“…If AREDF episodes occurred, efforts were often made to further increase maternal blood pressure and heart rate. Intraoperative intravenous fluid administration was limited to 2,000 mL in an effort to prevent postoperative pulmonary edema [18]. The surgical approach included a low transverse maternal abdominal incision followed by hysterotomy.…”

“…Anesthetic management followed an approach detailed previously [18]. Epidurals were placed for postoperative pain control, with the epidural infusion initiated at maternal abdominal closure.…”

Nesa Days 2015, Conference Report

“…Maintenance of anesthesia must be easily steerable by continuous application of short acting agents. Additionally it must be profound in order to ensure sufficient trans placental diffusion of the drugs and to provide the very essential uterine relaxation [27]. For this purpose, as a main hypnotic we use the inhaled volatile anesthetic desflurane, which is administered at a high dose of two MAC.…”

Multidisciplinary Team Approach is The Key to The Successful Assessment and Management of Complex Obstetric Patients

“…Adequate monitoring of fetal physiologic changes can decrease the intraoperative fetal demise. Fetal anesthesia during open fetal surgery is provided primarily by the placental transfer of maternally administered anesthetics such as volatile agents and intramuscular or intravenous opioid analgesics to the fetus (18).…”