ANAESTHESIA FOR INTRAUTERINE FETAL SURGERY PRESENTED BY- Dr. Anupam MODERATOR- Dr. Yashwant.
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Transcript of ANAESTHESIA FOR INTRAUTERINE FETAL SURGERY PRESENTED BY- Dr. Anupam MODERATOR- Dr. Yashwant.
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ANAESTHESIA FOR INTRAUTERINE FETAL SURGERY
PRESENTED BY- Dr. Anupam
MODERATOR- Dr. Yashwant
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Fetal surgery is ………..Indicated in conditions which interfere
with the normal development of the fetus in-utero but
Which when corrected will allow the development of the fetus normally.
It is contraindicated in conditions that are incompatible with lifemedical condition in the mother
precluding surgery.
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3 types of fetal surgery :-EXIT (Ex-Utero Intrapartum
Treatment Procedure)Mid gestation Open Surgery Minimally invasive mid gestation
procedures FETENDO (Fetal Endoscopic
Surgery)FIGS (Fetal Image Guided
Surgery)
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EXIT ( Ex-utero intrapartum treatment ) :- Also know as OOPS.It is the intervention that occurs at
the time of deliveryIt is primarily used in cases where
baby’s airway requires surgical intervention
It starts as a routine LSCS but under GA
Head of the baby is delivered, but the placenta is in situ
The baby gets oxygen from placenta via umbilical cord
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Bronchoscopy of the fetal airwayEndotracheal intubation
attemptedIf unsuccessful then
tracheostomy is doneO2 delivery to lungs confirmedCord is cut & Baby is delivered
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Indications:- Giant cervical neck mass.CHAOS (Congenital High Airway
Obstruction Syndrome- tracheal atresia)
Removal of balloon after CDHCCAM (Congenital Cystic
Adenomatoid Malformation)
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Mid gestational open fetal surgery:-Surgery performed between 18-26
weeks through hysterotomy.Fetus exteriorized for surgery then
placed back in uterus to mature. Indications :- CCAM (Congenital Cystic Adenomatoid
Malformation of Lung)- LobectomySCT (Sacro-coccygeal Teratoma)-
ResectionMMC (Meningo Myelocoele)- Repair
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FIGS (Fetal Image Guided Surgery) :-
Ultrasound image guided procedure
Least invasiveLeast risk of
amniotic fluid leak
Least risk of PT labour
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Indications :-Diagnostic :-
Chorion Villus Sampling
AmniocentesisCordocentesisFetal skin Biopsy
Therapeutic :-
RFA (Radio Frequency Ablation) of anomalous Twins
Cord cauterization in Twins
Vesical / Pleural Shunts
Balloon Dilatation of Aortic Stenosis
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FETENDO (Fetal Endoscopic Surgery) :-Fetoscopic access
to the FetusThe fetal
visualisation is a combination of endoscopic and sonographic on two different screens
Less invasive Less risk of
amniotic fluid leakLess risk of PT
labour
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Indications :-CDH (Congenital Diaphragmatic
Hernia)-Balloon Occlusion of trachea
TTTS (Twin to Twin Transfusion Syndrome)- Laser coagulation of vessels
Cord ligation in cases of acardiac Twins
Amniotic bands division
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ANAESTHESIA FOR FETAL SURGERY
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ANAESTHETIC CHALLENGESThose related to any anaesthetic
technique in a pregnant femaleTechniques used to prevent
preterm labourMaintenance of maternal
hemostasis in face of tocolytic techniques
Maintenance of fetal hemostasisProvision of fetal analgesia.
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Anaesthetic considerations :- Maternal FetalUteroplacentalPreoperative assessmentType of anaesthesiaIntraoperative managementPost operative carecomplications
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Maternal anesthetic considerations:-
Risk of aspiration pneumonitis Risk of pulmonary edema Risk of hypoxia Risk of supine hypotension
syndrome Risk of massive hemorrhage Myocardial depression,
hypotension
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Fetal anaesthetic considerations:-
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Fetal anaesthetic considerations:Fetal Cardiac Output is sensitive to heart
rate changesFetus has high vagal tone & low
barorecepter sensitivity ,hence responds to stress with precipitous bradycardia.
Fetal circulating volume is low( 110ml/kg), hence little intra-operative bleeding can cause hypovolemia.
Inhalational agents depressess fetal circulation as well-direct myocardial depression, vasodilatation, changes in arterio-venous shunting.
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Fetus tends to lose heat much easily from the exposed skin resulting in hypothermia
Immature coagulation system predispose the fetus to bleeding and difficulty in achieving hemostasis.
Maternal anesthesia reduces placental blood flow, this reduces the amount of O2
delivered to the fetus( hypoxia)Normal Fetal oxygen saturation is 60-70%
and the aim is to maintain it above 40%Intra-operative fetal distress is
manifested by bradycardia, decreased fetal oxygen saturation and reduced stroke output.
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Uteroplacental considerations:-
Maternal hyperventilation is avoided as maternal hypocapnia causes fetal placental vasoconstriction and fetal hypoxia.
Maternal BP & myometrial tone correlates with uterine artery blood flow.
Maintenance of patent UA & maintenence of maternal BP with in 10% of baseline is critical.
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Pre-operative assessment:-Assessment of the mother for fitness
for anaesthesiaAssessment of the fetus
◦Detailed USG to r/o other malformations◦3D and 4D examination-Detailed
examination of affected organ system◦Detailed Fetal Echocardiography,
Amniocentesis, Localization of placenta◦Fetal MRI Maternal blood cross matched- arrange
blood for mother and fetus.
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Anaesthesia for open fetal surgery:- Pre-operative preparation-1. OT warmed2. Blood arranged3. Monitors and syringes4. Prophylaxis for Aspiration 5. Lumber epidural inserted &
tested6. Indomethacin suppository
administered7. Positioning done
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The fetus is monitored with Fetal
Echocardiography
Pulse OximetryPO2 from Cord
BloodFetal Hb from
Cord Blood
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TYPES OF MATERNAL ANAESTHESIA :-
Regional Anaesthesia-Lumbar Epidural
Deep GA-(Sodium Pentothal + Scoline) + (Isoflurane + Fentanyl+O2 + Vecuronium)
GA with N2O- (Sodium Pentothal + Scoline) + (Isoflurane + N2O + Vecuronium)
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Intraoperative management:-
Rapid sequence induction with thiopentone & Sch.
Maintenence – Nitrous plus oxygen plus 0.5 MAC (isoflurane, desflurane)
Invasive arterial line, secure 2nd venous catheter, NG tube & Foley's catheter insertion.
Fetal status monitored by sterile intraop echocardiography.
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Restrict fluids in mother ( post op PE )Before hysterotomy, nitrous turned off
& deepen the patient by increasing inhalational agents to 2 MAC
Maintain maternal BP – ephedrine/PEFetus is given I/M opioids b4 incision.Fetal monitoring with Miniature pulse
oximeter & echocardiography done.Blood gas samples help guide therapy
during period of fetal distress.Following closure of uterus, anaesthesia
converted to regional based technique.( LA,opioids through epidural catheter)
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Tocolysis instituted via MgSo4 loading dose followed by infusion.
Patient extubated and shifted to recovery.
Post-op management:-Tocolysis for at least 18-24 hours.Adequate maternal pain relief
with epidural.
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Anaesthesia for EXIT :-No tocolysisOne additional OT for possible fetal sugeryDesflurane inhalational agent of choice.During hysterotomy, only partial exposure
of fetus done.DL / intubation done by surgeon or
anaesthesiologist.If baby cant be intubated , tracheostomy
done.After assuring adequate fetal oxygenation
cord clamped & fetus delivered.
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The timing of cord clamping with respect to administration of oxytocin, methergin and carboprost as well as decreasing volatile agents must be coordinated between anaesthesiologist and surgeon .
Blood loss is monitored and cross matched blood is administered if needed.
If surgery is not required immediately, a neonatology team resuscitates and transports the neonate to NICU.
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Fetoscopic surgery:-Epidural anaesthesia:- less effect on fetal
hemodynamics & UP circulation & post op uterine activity but lack of uterine relaxation, lack of fetal anesthesia hence, difficulty manipulating the uterus & cord while baby is still moving.
Balanced inhalation-opioid anaesthesia:- it eliminates anxiety, nausea, emesis and allows immobile anaestheized fetus, less CV effects than deep inhalational, but provides no uterine relaxation.
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Deep inhalational anaesthesia:- provides profound uterine relaxation but affect fetal hemodynamics & UPBF
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Maternal complications: -Tocolytic therapy can cause pulmonary
edemaSubsequent delivery by LSCSMassive hemorrhageAmniotic fluid leakWound infectionIntra uterine infection“Maternal Mirror Syndrome” in cases of
fetal Hydrops ( mother mirrors the symptoms that fetus is experiencing)
Chorio-amniotic membrane separation
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Fetal complications:- PrematurityIntra Uterine InfectionFetal vascular embolic events
◦ Intestinal atresia
◦Renal agenesis
Premature closure of Ductus ArteriosusCNS injuries due to maternal hypoxia or
fetal circulatory disturbanceBleeding
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