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

Abstract

Introduction: Umbilical artery (UA) Doppler ultrasound is used to assess uteroplacental insufficiency. Absent or reversed end diastolic flow (AREDF) in the UA is associated with increased perinatal mortality in fetuses with intrauterine growth restriction. We describe the incidence of UA Doppler abnormalities during open fetal surgery. Methods: We conducted a retrospective review of patients undergoing open in utero myelomeningocele (MMC) repair between 2008 and 2015. Intermittent UA Dopplers were performed during key portions of all cases. Our primary outcome was the rate of any AREDF. Secondary outcomes included analysis of absent versus reversed end diastolic flow (EDF), vasopressor use, and volatile anesthetic and clinical outcomes. Results: Thirty-four of 47 fetuses developed UA Doppler abnormalities intraoperatively. Nineteen had absent EDF and 15 had reversed EDF. No AREDF was present before induction, and all AREDF resolved by postoperative day 1. Ten of 19 (52.6%) patients who received sevoflurane had reversed EDF, versus 5/28 (17.9%) for desflurane, odds ratio (95% CI) 5.11 (1.36-19.16), p = 0.02. One intraoperative fetal death occurred in the AREDF group. Discussion: AREDF is a common phenomenon during open MMC repair. Anesthetic agent choice may influence this risk. Future studies of UA flow during fetal surgery are needed to further evaluate the impact of intraoperative AREDF on fetal well-being.

Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta‐analysis

“…For example, a letter to a journal editor describing maternal convulsions during general anaesthesia was excluded as a case report according to our criteria. In this circumstance, it appears that the patient was also part of the cohort of a study that was included, but it is possible that other rare events published as case reports have been missed. An international, prospective registry of fetal and fetoscopic surgery, such as the Eurofoetus and NAFTNet registries, would be the best way to accurately determine complication types and rates and avoid missing rare complications.…”

Fetal modified left myocardial performance index monitoring during open surgery for myelomeningocele repair

“…This study provides an interesting proposal for the quantitative and practical evaluation of fetal heart function. This may be added to other echocardiographic protocols already described and above all may increase the safety of the procedure when combined with traditional monitoring of intraoperative fetal cardiac frequency . It is clear that among other limitations, this study does not consider a high number of cases; this topic should certainly be studied in greater detail.…”

“…This may be added to other echocardiographic protocols already described and above all may increase the safety of the procedure when combined with traditional monitoring of intraoperative fetal cardiac frequency. 3,4,7,10,11 It is clear that among other limitations, this study does not consider a high number of cases; this topic should certainly be studied in greater detail. We also emphasize that it is often difficult to achieve adequate images within a limited window of time because the intraoperative echocardiogram should not hinder the surgery.…”

Advanced ultrasound for prenatal interventions

“…In patients with an anterior placenta, hysterotomy is either fundal or posterior. Some authors have suggested the use of intermittent umbilical artery Doppler ultrasonography during open fetal surgery, but the short-term impact of absent/reversed end-diastolic flow on fetal well-being remains elusive [ 18 ].…”