Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita, using continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation

Anesthesia for fetal operative procedures: A systematic review

Objective

The anesthetic management of fetal operative procedures (FOP) is a highly debated topic. Literature on fetal pain perception and response to external stimuli is rapidly expanding. Nonetheless, there is no consensus on the fetal consciousness nor on the instruments to measure pain levels. As a result, no guidelines or clinical recommendations on anesthesia modality during FOP are available. This systematic literature review aimed to collect the available knowledge on the most common fetal interventions, and summarize the reported outcomes for each anesthetic approach. Additional aim was to provide an overall evaluation of the most commonly used anesthetic agents.

Methods

Two systematic literature searches were performed in Embase, Medline, Web of Science Core Collection and Cochrane Central Register of Controlled Trials up to December 2021. To best cover the available evidence, one literature search was mostly focused on fetal surgical procedures; while anesthesia during FOP was the main target for the second search. The following fetal procedures were included: fetal transfusion, laser ablation of placental anastomosis, twin-reversed arterial perfusion treatment, fetoscopic endoluminal tracheal occlusion, thoraco-amniotic shunt, vesico-amniotic shunt, myelomeningocele repair, resection of sacrococcygeal teratoma, ligation of amniotic bands, balloon valvuloplasty/septoplasty, ex-utero intrapartum treatment, and ovarian cyst resection/aspiration. Yielded articles were screened against the same inclusion criteria. Studies reporting anesthesia details and procedures’ outcomes were considered. Descriptive statistical analysis was performed and findings were reported in a narrative manner.

Results

The literature searches yielded 1,679 articles, with 429 being selected for full-text evaluation. A total of 168 articles were included. Overall, no significant differences were found among procedures performed under maternal anesthesia or maternal-fetal anesthesia. Procedures requiring invasive fetal manipulation resulted to be more effective when performed under maternal anesthesia only. Based on the available data, a wide range of anesthetic agents are currently deployed and no consistency has been found neither between centers nor procedures.

Conclusions

This systematic review shows great variance in the anesthetic management during FOP. Further studies, systematically reporting intraoperative fetal monitoring and fetal hormonal responses to external stimuli, are necessary to identify the best anesthetic approach. Additional investigations on pain pathways and fetal pain perception are advisable.

Neuraxial anesthesia in ex utero intrapartum therapy for parturients with fetal congenital diaphragm hernia: a prospective observational study

BACKGROUND

Congenital diaphragmatic hernia (CDH) is characterized by defects in the fetal diaphragm and thoracic herniation of the abdominal viscera. The ex utero intrapartum treatment (EXIT) procedure is used to establish the fetal airway while on placental support. These EXIT procedures are commonly performed under general anesthesia, which increases maternal bleeding and the risk of insufficient placental perfusion subsequently. This study investigated the feasibility of performing neuraxial anesthesia for the EXIT procedure for fetal congenital diaphragmatic hernia to improve outcomes.

METHODS

Parturients with fetal CDH who underwent an EXIT procedure between January 2019 and May 2021 in our institution were recruited. Variables evaluated included gestational age, surgical time, intra-operative blood loss, peri-operative hemoglobin, maternal complications, fetal lung-to-head ratio, time on placental bypass, and postnatal outcome.

RESULTS

Twenty-two cases were included. All procedures were performed under neuraxial anesthesia. The median gestational age at the time of the EXIT procedure was 37 weeks. The median estimated blood loss was 200 mL. There was no report of an adverse maternal event. The placental bypass time was 142.9 ± 72.6 s, and access to the airway was successfully established within the bypass time. Twenty-one neonates reached an Apgar score of 9 at 5 min. In the first two hours after birth, the average pH of neonatal peripheral arterial blood was 7.35 ± 0.07 (n=19), and lactate level 1.85 ± 0.71 mmol/L (n=19).

CONCLUSIONS

In the EXIT procedure to establish an airway for fetal CDH, neuraxial anesthesia proved a feasible technique for maternal anesthesia.

International Pediatric Otolaryngology Group (IPOG): Consensus recommendations on the prenatal and perinatal management of anticipated airway obstruction

OBJECTIVE

To make recommendations on the identification, routine evaluation, and management of fetuses at risk for airway compromise at delivery.

METHODS

Recommendations are based on expert opinion by members of the International Pediatric Otolaryngology Group (IPOG). A two-iterative Delphi method questionnaire was distributed to all members of the IPOG and responses recorded. The respondents were given the opportunity to comment on the content and format of the survey, which was modified for the second round. "Consensus" was defined by >80% respondent affirmative responses, "agreement" by 51-80% affirmative responses, and "no agreement" by 50% or less affirmative responses.

RESULTS

Recommendations are provided regarding etiologies of perinatal airway obstruction, imaging evaluation, adjunct evaluation, multidisciplinary team and decision factors, micrognathia management, congenital high airway obstruction syndrome management, head and neck mass management, attended delivery procedure, and delivery on placental support procedure.

CONCLUSIONS

Thorough evaluation and thoughtful decision making are required to optimally balance fetal and maternal risks/benefits.

Use of nitroglycerin for parallel transverse uterine cesarean section in patients with pernicious placenta previa and placenta accrete and predicted difficult airway: A case report and review of literature

RATIONALE

The incidence of obstetric hemorrhage due to pernicious placenta previa (PPP) and placenta accreta is currently increasing in China. Parallel transverse uterine incision (PTUI) cesarean section (CS) is a novel technique designed to avoid transecting the placenta and control postpartum hemorrhage during CS in these patients in our hospital. A key point of anesthesia management related to PTUI CS involves keeping the uterus relaxed. General anesthesia (GA) has often been performed, and inhaled volatile anesthetics have traditionally been recommended for this purpose; however, GA may be contraindicated in patients with difficult airways.

PATIENT CONCERNS

The patient was predicted to have a difficult airway, and GA may have resulted in potentially life-threatening complications. An alternative and safer method of achieving uterine relaxation during PTUI CS was thus required.

DIAGNOSES

The patient was diagnosed with PPP, and a predicted difficult airway was suspected preoperatively.

INTERVENTIONS

PTUI CS was planned to control postpartum hemorrhage and preserve fertility during CS. Uterine relaxation during PTUI CS was achieved with intravenous nitroglycerin under combined spinal-epidural anesthesia.

OUTCOME

Intravenous nitroglycerin and combined spinal-epidural anesthesia achieved uterine relaxation during the time from delivery of the neonate to making the second transverse incision in the lower segment of the uterus during PTUI CS. Both the parturient and neonate were well and were discharged 4 days later.

LESSIONS

Intravenous nitroglycerin and combined spinal-epidural anesthesia may offer an alternative to GA for achieving uterine relaxation in patients with PPP and a predicted difficult airway undergoing PTUI CS to control postpartum hemorrhage.

Regional anesthesia with a single spinal anesthesia using hyperbaric bupivacaine in a child with arthroglyposis multiplex congenita

Arthrogryposis multiplex congenita (AMC) consists of complex congenital anomalies characterized by multiple contractures. Anesthetic management of these patients requires special care: as this disease often progresses until dysfunction of multiple organ systems occur, it may have an impact on the anesthetic management. Here, we report a case of AMC undergoing urgent surgery for open tibia fracture who had difficult airway management because of limited mouth opening. The anesthetic management of this patient is represented in light of the literature.

[Continuous spinal anesthesia in obstetrics]

Despite the theoretical advantages of continuous anesthesia in obstetric patients (good-quality blockade at low doses, good hemodynamic stability, rapid onset of effect, and no risk of toxicity), little has been published on this technique and its use in pregnancy. Moreover, few descriptive studies or comparative trials have evaluated the efficacy and safety of continuous spinal anesthesia, probably because of concerns about potential adverse effects-principally neurologic complications and postdural puncture headache. We review the literature on the use of continuous spinal anesthesia in obstetric patients, analyzing the advantages and disadvantages, indications, and adverse effects of this technique.

Current world literature

This bibliography is compiled by clinicians from the journals listed at the end of this publication. It is based on literature entered into our database between 1 February 2008 and 31 January 2009 (articles are generally added to the database about two and a half months after publication). In addition, the bibliography contains every paper annotated by reviewers; these references were obtained from a variety of bibliographic databases and published between the beginning of the review period and the time of going to press. The bibliography has been grouped into topics that relate to the reviews in this issue.

Obstetric hemorrhage during an EXIT procedure for severe fetal airway obstruction

PURPOSE

To report a case of massive obstetric hemorrhage occurring during Cesarean delivery for an ex utero intrapartum treatment (EXIT) procedure. Methods to optimize the anesthetic, obstetric, and perinatal management are discussed.

CLINICAL FEATURES

A healthy parturient underwent an urgent EXIT procedure at 32 weeks gestation for a giant fetal neck mass. During the intraoperative period, severe intraoperative hemorrhage occurred from the site of the uterine incision. No evidence of placental bleeding, premature placental separation, or inadequate uterine relaxation was observed during the perioperative period. Placement of a uterine stapling device was unsuccessful in achieving adequate surgical hemostasis. Initial attempts with laryngoscopy and rigid bronchoscopy to secure the fetal airway on placental support were unsuccessful, and early termination of placental support was deemed necessary due to the severity of maternal blood loss. After full delivery of the neonate and termination of placental support, neonatal ventilation with bag-mask ventilation was achieved and successful endotracheal intubation occurred during repeat bronchoscopy.

CONCLUSIONS

The risk of obstetric hemorrhage due to uterine relaxation and inadequate surgical hemostasis in patients undergoing EXIT procedures is poorly reported. To reduce adverse maternal and neonatal outcomes, the premature termination of placental support during EXIT procedures may be required in the setting of severe obstetric hemorrhage.