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Abstract
Anesthesia for fetal and neonatal surgery requires subspecialized knowledge and expertise. Attention to important anatomic, physiologic, and metabolic differences seen in pregnancy and at birth are essential for the optimal care of these patients. Thorough preoperative evaluations tailored intraoperative strategies and careful postoperative management are critical when devising the anesthetic approach for each of these cases.
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Wilson RD, Nelson G. Maternal and fetal hypothermia: more preventive compliance is required for a mother and her fetus while undergoing cesarean delivery; a quality improvement review. J Matern Fetal Neonatal Med 2021; 35:8652-8665. [PMID: 34689687 DOI: 10.1080/14767058.2021.1993816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Cesarean delivery is common, involves two patients, has numerous multi-disciplinary health care providers involved in the delivery management, but has variable levels of anesthesia and health services implementation for decreasing maternal hypothermia and the maternal and neonatal morbidity (and mortality). Limited implementation for either of the ERAS-CD or the ERAC guidelines, for inadvertent or preventive maternal hypothermia, is likely to be occurring on labor delivery floors. This Quality Improvement (QI) review focuses on cesarean delivery and maternal hypothermia. METHODS This quality and safety initiative used SQUIRE 2.0 methodology and concurrent PubMed searches to identify systematic review, meta-analysis, topic directed studies, additional published cohorts in the topic area not included in SR/MA, limited case reports that had specific clinical outcomes related to maternal hypothermia and fetal effects. RESULTS Two quality and safety improvement guidelines have defined the hypothermia activity element differently, with ERAS-CD recommending to prevent hypothermia, while ERAC recommending to maintain normothermia. The peer-reviewed literature indicates that the knowledge associated with surgical hypothermia outcome is known but it is not implemented for maternal cesarean delivery care. Increased maternal-effect recognition, surveillance, triage, and evidenced-based protocol management is required for the maternal - neonatal dyad undergoing cesarean delivery for the clinical reduction/prevention of neonatal hypothermia that has proven evidence-based maternal morbidity and neonatal morbidity/mortality. CONCLUSION TEAM-based anesthesia, obstetrical, neonatology-pediatrics and nursing research collaboration is required through quality-safety-ERAS-ERAC directed processes. Healthcare system recognition and financial support is required for maternal-fetal-neonatal hypothermia prevention protocols implementation.
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Affiliation(s)
- R Douglas Wilson
- Department of Obstetrics and Gynecology, Cumming School of Medicine University of Calgary, Calgary, Canada
| | - Gregg Nelson
- Department of Obstetrics and Gynecology, Cumming School of Medicine University of Calgary, Calgary, Canada
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3
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Abstract
Nonobstetric surgery during pregnancy occurs in 1% to 2% of pregnant women. Physiologic changes during pregnancy may have an impact when anesthesia is needed. Anesthetic agents commonly used during pregnancy are not associated with teratogenic effects in clinical doses. Surgery-related risks of miscarriage and prematurity need to be elucidated with well-designed studies. Recommended practices include individualized use of intraoperative fetal monitoring and multidisciplinary planning to address the timing and type of surgery, anesthetic technique, pain management, and thromboprophylaxis. Emergency procedures should be performed immediately and elective surgery should be deferred during pregnancy.
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4
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Olutoye OA. Anesthesia for fetal procedures: From unique to mainstream. Paediatr Anaesth 2021; 31:744-745. [PMID: 34137127 DOI: 10.1111/pan.14190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/22/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Olutoyin A Olutoye
- Department of Anesthesiology, Peri-operative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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6
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Sastry AC, Gandhi M, Clark SL, Whitehead WE, Mann DG, Sutton CD. Fetal heart rate mirrors maternal temperature during posterior fossa craniotomy: a case report. Int J Obstet Anesth 2021; 47:103193. [PMID: 34144352 DOI: 10.1016/j.ijoa.2021.103193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/27/2021] [Accepted: 05/19/2021] [Indexed: 11/15/2022]
Abstract
While it is well known that maternal temperature affects fetal heart rate, the exact relationship is not well described. The circumstances accompanying most cases of maternal hypothermia and rewarming (e.g. a drowning event) have precluded a precise quantitative description of this relationship. We describe hypothermia and controlled rewarming during resection of a maternal brain stem tumor in the early third trimester. Continuous electronic fetal heart rate and core temperature monitoring demonstrated a near linear relationship during the development of hypothermia and rewarming. Recognition of the close relationship between maternal temperature and fetal heart rate can help safeguard maternal and fetal health, and prevent unnecessary delivery during non-obstetric surgery in pregnancy.
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Affiliation(s)
- A C Sastry
- Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - M Gandhi
- Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - S L Clark
- Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - W E Whitehead
- Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - D G Mann
- Department of Anesthesiology, Perioperative, and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - C D Sutton
- Department of Anesthesiology, Perioperative, and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
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Anesthesia for Maternal-Fetal Interventions: A Consensus Statement From the American Society of Anesthesiologists Committees on Obstetric and Pediatric Anesthesiology and the North American Fetal Therapy Network. Anesth Analg 2021; 132:1164-1173. [PMID: 33048913 DOI: 10.1213/ane.0000000000005177] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Maternal-fetal surgery is a rapidly evolving specialty, and significant progress has been made over the last 3 decades. A wide range of maternal-fetal interventions are being performed at different stages of pregnancy across multiple fetal therapy centers worldwide, and the anesthetic technique has evolved over the years. The American Society of Anesthesiologists (ASA) recognizes the important role of the anesthesiologist in the multidisciplinary approach to these maternal-fetal interventions and convened a collaborative workgroup with representatives from the ASA Committees of Obstetric and Pediatric Anesthesia and the Board of Directors of the North American Fetal Therapy Network. This consensus statement describes the comprehensive preoperative evaluation, intraoperative anesthetic management, and postoperative care for the different types of maternal-fetal interventions.
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Ferschl MB, Rollins MD, Chatterjee D. Error traps in anesthesia for fetal interventions. Paediatr Anaesth 2021; 31:275-281. [PMID: 33394561 DOI: 10.1111/pan.14120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/27/2020] [Accepted: 12/28/2020] [Indexed: 11/27/2022]
Abstract
A wide range of fetal interventions are being performed worldwide to save the fetus's life, prevent permanent fetal organ damage, and allow a successful transition to extrauterine life. However, these are invasive procedures and can be associated with serious complications. This article focuses on promoting a culture of safety by highlighting five common error traps while anesthetizing patients for fetal interventions. They include failure to preserve uteroplacental perfusion and gas exchange, failure to achieve adequate uterine relaxation prior to hysterotomy, failure to monitor the fetus and prepare for fetal/neonatal resuscitation, failure to prepare for maternal hemorrhage, and failure to promptly treat uterine atony. Practical tips for avoiding these serious complications will also be discussed.
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Affiliation(s)
- Marla B Ferschl
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| | - Mark D Rollins
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Debnath Chatterjee
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
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9
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Abstract
BACKGROUND Fetal tachycardia can occur with maternal fever (hyperthermia); therefore, a low maternal temperature (hypothermia) might produce fetal bradycardia. CASES Five cases of fetal bradycardia are presented in gestations complicated by maternal hypothermia. The fetal heart rate (FHR) tracings demonstrated stable baselines of 88-96 beats per minute with moderate variability and accelerations. All baselines returned to normal after maternal warming measures. CONCLUSION A possible cause for fetal bradycardia with a stable baseline and moderate variability is maternal hypothermia, a pattern not indicative of fetal hypoxia. Delivery is not indicated, and maternal warming results in FHR baseline normalization.
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Patel S, Wali A. Airway Management of the Obstetric Patient. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00422-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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11
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Goonasekera CD, Skelton VA, Zebian B, Nicolaides K, Araujo Lapa D, Santorum-Perez M, Bleil C, Hickey A, Bhat R, Oliva Gatto BE. Peri-operative management of percutaneous fetoscopic spina-bifida repair: a descriptive review of five cases from the United Kingdom, with focus on anaesthetic implications. Int J Obstet Anesth 2020; 43:97-105. [PMID: 32386991 DOI: 10.1016/j.ijoa.2020.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 03/15/2020] [Accepted: 04/13/2020] [Indexed: 11/16/2022]
Abstract
We present a case-based review of the first five percutaneous fetoscopic in-utero spina bifida repair procedures undertaken in the UK. Our focus is on implications of anaesthesia and analgesia for the mother and fetus, provision of uterine relaxation and fetal immobilisation while providing conditions conducive to surgical access. Minimising risks for fetal acidosis, placental and fetal hypoperfusion, maternal and fetal sepsis and maternal fluid overload were the foremost priorities. We discuss optimisation strategies undertaken to ensure fetal and maternal well-being under anaesthesia, shortcomings in the current approach, and possible directions for improvement.
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Affiliation(s)
- C D Goonasekera
- Department of Anaesthesia, King's College Hospital, London, UK.
| | - V A Skelton
- Department of Anaesthesia, King's College Hospital, London, UK
| | - B Zebian
- Department of Neurosurgery, King's College Hospital, London, UK
| | - K Nicolaides
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - D Araujo Lapa
- Department of Obstetrics and Fetal Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - M Santorum-Perez
- Department of Obstetrics and Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - C Bleil
- Department of Neurosurgery, King's College Hospital, London, UK
| | - A Hickey
- Department of Neonatology, King's College Hospital, London, UK
| | - R Bhat
- Department of Neonatology, King's College Hospital, London, UK
| | - B E Oliva Gatto
- Department of Anaesthesia, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
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12
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Abstract
One percent to 2% of pregnant women undergo nonobstetric surgery during pregnancy. Historically, there has been a reluctance to operate on pregnant women based on concerns for teratogenesis, pregnancy loss, or preterm birth. However, a careful review of published data suggests four major flaws affecting much of the available literature. Many studies contain outcomes data from past years in which diagnostic testing, surgical technique, and perioperative maternal-fetal care were so different from current experience as to make these data of limited utility today. This issue is further compounded by a tendency to combine experience from vastly disparate types of surgery into a single report. In addition, reports in nonobstetric journals often focus on maternal outcomes and contain insufficient detail regarding perinatal outcomes to allow distinction between complications associated with surgical disease and those attributable to surgery itself. Finally, most series are either uncontrolled or use the general population of pregnant women as controls rather than women with surgical disease who are managed nonsurgically. Consideration of these factors as well as our own extensive experience suggests that when the risks of maternal hypotension or hypoxia are minimal, or can be adequately mitigated, indicated surgery during any trimester does not appear to subject either the mother or fetus to risks significantly beyond those associated with the disease itself or the complications of surgery in nonpregnant individuals. In some cases, reluctance to operate during pregnancy becomes a self-fulfilling prophecy in which delay in surgery contributes to adverse perinatal outcomes traditionally attributed to surgery itself.
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13
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Po' G, Olivieri C, Rose CH, Saccone G, McCurdy R, Berghella V. Intraoperative fetal heart monitoring for non-obstetric surgery: A systematic review. Eur J Obstet Gynecol Reprod Biol 2019; 238:12-19. [PMID: 31082738 DOI: 10.1016/j.ejogrb.2019.04.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 03/11/2019] [Accepted: 04/18/2019] [Indexed: 02/02/2023]
Abstract
Limited data are available on fetal monitoring during non-obstetric surgery in pregnancy. We performed a systematic review to evaluate the incidence of emergent cesarean delivery performed for non-reassuring fetal heart rate patterns during non-obstetric surgery. Electronic databases were searched from their inception until October 2018 without limit for language. We included studies evaluating at least five cases of intraoperative fetal heart rate monitoring -either with ultrasound or cardiotocography- during non-obstetric surgery in pregnant women at ≥22 weeks of gestation. The primary outcome was the incidence of intraoperative cesarean delivery performed for non-reassuring fetal heart rate monitoring. Non-reassuring fetal heart rate monitoring was defined by attendant personnel, meeting NICHD criteria for category II or III patterns. Data extracted regarded type of study, demographic characteristics, maternal and perinatal outcomes. Statistical analysis was performed for continuous outcomes by calculating mean and standard deviations for appropriate variables. Of 120 studies identified, 4 with 41 cases of intraoperative monitoring met criteria for inclusion and were analyzed. Most (66%) surgeries were indicated for neurological or abdominal maternal issues and were performed under general anesthesia (88%) at a mean gestational age of 28 weeks. Minimal or absent fetal heart variability was noted in most cases and a 10-25 beats per minutes decrease in fetal heart rate baseline was observed in cases with general anesthesia. No intraoperative cesarean deliveries were needed. The incidence of non-reassuring fetal heart rate monitoring was 4.9% (2/41) and were limited to fetal tachycardia during maternal fever. Two (4.9%) cases of non-reassuring fetal heart rate monitoring were noted within the immediate 48 h after surgery, necessitating cesarean delivery. A single case of intrauterine fetal demise occurred four days postoperatively in a woman who had neurosurgery and remained comatose. In conclusion, limited data exist regarding the clinical application of fetal heart rate monitoring at viable gestational ages during non-obstetric surgical procedures. Fetal heart rate monitoring during non-obstetric surgery at ≥22 weeks was not associated with need for intraoperative cesarean delivery, but two (4.9%) cesarean deliveries were performed for non-reassuring fetal heart rate monitoring within 48 h after surgery.
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Affiliation(s)
- Gaia Po'
- Obstetrics and Gynecology Unit, Mother-Infant and Adult Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Carl H Rose
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Science and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Rebekah McCurdy
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Vincenzo Berghella
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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