Fetal Anesthesia Research Articles

Anesthetic considerations for fetal interventions

Fetal therapy is a well-established but rapidly evolving field discipline. Fetal interventions require a multidisciplinary team approach that emphasizes collaboration and communication. The success of a fetal therapy program relies on the availability of a comprehensive obstetric and neonatal care team, support services, and advanced imaging. Technological advancements in prenatal fetal imaging and genetic diagnosis have improved our understanding of various fetal anomalies. Surgical techniques and anesthetic management have also advanced, leading to better outcomes. Fetal anesthesia presents unique challenges as it involves managing both the mother and the fetus. Anesthetic management focuses on ensuring maternal safety and comfort, maintaining adequate uteroplacental perfusion, optimizing surgical conditions, and minimizing risks for both the mother and the fetus. This article reviews current anesthesia practices for fetal surgery, highlighting recent advances and future directions.

Plenary A: Presidential Address: Anesthesia: A Wake-Up Call. Part 2. Developmental Risk or Resilience?

Abstract & Learning Objectives:This presentation is a clarion call to neuropsychologists to contribute their specialized knowledge to help answer a critical question: Is there a Fetal Anesthesia Syndrome that results in subtle and persistent adverse effects over an individual’s lifespan? Neuropsychologists are uniquely positioned to make substantial contributions to conceptualization, methodology, and interpretation in studies of human exposure to general anesthesia (GA). Part 1, presented at the 2022 INS Barcelona meeting, reviewed preclinical data that documented effects on the central nervous system and long-term behavioral adversities of GA exposure during an animal’s critical growth spurt developmental period. Studies of human adult exposure were also summarized, and attention directed to the absence of prospective studies from childhood to adulthood. Part 2 extends the conversation to GA exposure during the highly vulnerable in utero and early childhood developmental periods. Human retrospective study results began to be published in the early 2000s, and prospective studies only within the last decade. Reports of associations between GA and attentional problems, learning disorder, neuropsychological deficit, and neuropsychiatric disorder are emerging. Yet, due to methodological weaknesses and multiple confounders, clear evidence of causality remains lacking in this nascent literature. A 'developmentalistic’ way forward for neuropsychologists will be suggested, one using neuropsychological expertise along with the application of innovative technologies that is informed by the extensive preclinical data showing cellular, synaptic, and neural circuitry disruption during critical growth periods and short- and long-termeuropsychological effects. Upon conclusion of this course, learners will be able to: 1.Describe types of central nervous system disruption that result in animals following exposure to general anesthesia2.Identify neuropsychological domains at high potential risk following exposure to general anesthesia during the human critical growth spurt period3.Explain what is meant by 'vertical transfer'

Debatable issues of anesthesiological provision of fetal surgery

The article presents an analysis of literature data on the issues of anesthesia in fetal surgery for various interventions on the fetus. Publications containing detailed information on maternal and fetal anesthesia, published in the EMBASE, MedLine, PubMed, Google Scholar, Web of Science, Scopus databases for the period 2012–2022 were analyzed. Meta-analyses, systematic reviews, clinical guidelines, observational studies, and case series were reviewed, supplemented by a review of the literature lists in relevant publications. Our review of scientific publications showed the lack of standardized approaches when choosing anesthesia for each type of fetal intervention.

ANESTHESIA FOR FETAL SURGERY - PRINCIPLES AND CONSIDERATIONS: A CONCISE REVIEW.

Fetal surgery, an integral part of fetal therapy has undergone evolution since is conception, which was possible due to continuous renements in surgical as well as anesthetic techniques The fetal surgery can be done in various stages of the gestation for corrective treatment. Time tested criteria have been laid down for patient selection which help improve the outcome of the whole exercise. The anesthesia concerns and considerations are unique as are the ethical issues involved in this treatment modality involving two patients with contrasting physiological needs. This article reviews salient aspects of fetal physiology in detail. Anesthesia for the fetal interventions is curated as per the invasive nature of surgical interventions. The type of fetal interventions are classied as minimally invasive procedures, Open mid gestation procedures and Ex-utero intrapartum treatment (EXIT) procedures. Preoperative evaluation is dictated by extent of gestation, and invasiveness of the surgical procedure apart from medical status of mother and fetus. This review also tries to enumerate number of clinically useful pharmacological agents in fetal anesthesia including essential tocolytic agents, in addition to management of common fetal complications with a separate section on fetal bradycardia.

Maternal and Fetal Anaesthesia for Fetal Surgery

(Anaesthesia. 2021;76(suppl 4):63–68) Over the past 3 decades, great advances have been made in fetal surgery. While many procedures require only local anesthesia, additional maternal and/or fetal anesthesia can be needed. Multidisciplinary planning is needed to ensure success in these procedures. This article reviews three fetal surgical procedures and the anesthetic considerations for each.

The myth and half-truths of fetal pain decrypted: A metaverse

Fetal pain is one of the most controversial topics in medicine because of the disagreement between people whether the fetus can perceive pain or not and the absence of any direct objective method for the assessment of fetal pain. Although fetus is incapable of declaring pain, various studies have shown that the mere experience of pain without the aptitude of self-contemplation is worth paying attention to, and that the pain in fetus need not be comparable to that of a mature adult to matter. Furthermore, refusing to acknowledge fetal pain in late preterm fetuses would jeopardize the advances in neonatal care because it would question the use of analgesia in neonates of similar gestational age. This systematic review article examines the neuroanatomical and physiological evidence of nociception in the fetus and its implications, which compel the need for its alleviation. It looks into the adequacy of International Association for the Study of Pain definition of pain to define fetal pain. The article also provides a brief overview of the existing literature on whether safe analgesia and anesthesia techniques exist for abortions and therapeutic fetal procedures. We performed a literature search for English-language articles using the electronic database with keywords: controversy in fetal pain, fetal anaesthesia, fetal analgesia, fetal pain, fetus, neuroanatomy of fetal pain, neurophysiology of fetal pain, nociception, and recent advances in understanding of fetal pain

Society for Maternal-Fetal Medicine Consult Series #59: The use of analgesia and anesthesia for maternal-fetal procedures

Pain is a complex phenomenon that involves more than a simple physical response to external stimuli. In maternal-fetal surgical procedures, fetal analgesia is used primarily to blunt fetal autonomic responses and minimize fetal movement. The purpose of this Consult is to review the literature on what is known about the potential for fetal awareness of pain and to discuss the indications for and the risk-benefit calculus involved in the use of fetal anesthesia and analgesia. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we suggest that fetal paralytic agents be considered in the setting of intrauterine transfusion, if needed, for the purpose of decreasing fetal movement (GRADE 2C); (2) although the fetus is unable to experience pain at the gestational age when procedures are typically performed, we suggest that opioid analgesia should be administered to the fetus during invasive fetal surgical procedures to attenuate acute autonomic responses that may be deleterious, avoid long-term consequences of nociception and physiological stress on the fetus, and decrease fetal movement to enable the safe execution of procedures (GRADE 2C); and (3) due to maternal risk and a lack of evidence supporting benefit to the fetus, we recommend against the administration of fetal analgesia at the time of pregnancy termination (GRADE 1C).

Society for Maternal-Fetal Medicine Consult Series #59: The use of analgesia and anesthesia for maternal-fetal procedures

Pain is a complex phenomenon that involves more than a simple physical response to external stimuli. In maternal-fetal surgical procedures, fetal analgesia is used primarily to blunt fetal autonomic responses and minimize fetal movement. The purpose of this Consult is to review the literature on what is known about the potential for fetal awareness of pain and to discuss the indications for and the risk-benefit calculus involved in the use of fetal anesthesia and analgesia. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we suggest that fetal paralytic agents be considered in the setting of intrauterine transfusion, if needed, for the purpose of decreasing fetal movement (GRADE 2C); (2) although the fetus is unable to experience pain at the gestational age when procedures are typically performed, we suggest that opioid analgesia should be administered to the fetus during invasive fetal surgical procedures to attenuate acute autonomic responses that may be deleterious, avoid long-term consequences of nociception and physiological stress on the fetus, and decrease fetal movement to enable the safe execution of procedures (GRADE 2C); and (3) due to maternal risk and a lack of evidence supporting benefit to the fetus, we recommend against the administration of fetal analgesia at the time of pregnancy termination (GRADE 1C).

Maternal and fetal anaesthesia for fetal surgery.

Over the last three decades, advances in early diagnosis of fetal anomalies, imaging and surgical techniques have led to a huge expansion in fetal surgery. A small number of specialist centres perform fetal surgery, which involves high-risk anaesthesia for the mother and fetus. The anaesthetist plays an integral role within the large multispecialty and multidisciplinary team, involved in planning and delivering care for complex surgical procedures. This article reviews three fetal surgical procedures, congenital diaphragmatic hernia, myelomeningocele repair and ex-utero intrapartum treatment for airway obstruction. The underlying fetal pathology, surgical management, anaesthetic considerations and risks for both the mother and fetus are described for each. Fundamental to this is the understanding that clear communication and collaboration between all team members is vital to ensure successful outcomes of patients, the mother and the fetus.

The Choice of Anesthesia During Organ-Saving Operations Concerning Patients With Placenta Accreta Spectrum Disorders

Abstract Placenta accreta (PAS-disorders) is one of the most serious complications of pregnancy, associated with the risk of massive uterine bleeding, massive hemotransfusion and maternal mortality. Peripartum hysterectomy is a common treatment strategy for patients with placenta accreta. Currently, there is a clear trend of changing surgical tactics in favor of organ-saving operations, but there are no studies devoted to anesthesiological support of such operations.The aim of the study is to substantiate an effective and safe method of anaesthesia in organ-saving operations for placenta accreta spectrum disorders.Materia l and methods The study involved 80 patients with a diagnosis of placenta accreta spectrum disorders, confirmed intraoperatively, who underwent organ-saving operations. The patients were randomized depending on the method of anesthesia into 3 groups: general anesthesia, spinal anesthesia with planned conversion to general after fetal extraction and epidural anesthesia with planned conversion to general also after fetal extraction. The comparison of intraoperative hemodynamics, efficiency of tissue perfusion, efficiency of antinociceptive protection at the stages of surgery was performed. A comparative analysis of the volume of blood loss and blood transfusion, time of patients activation in the postoperative period, severity of pain on the first day after surgery, duration of hospital stay before discharge and comparison of the assessment of the newborn according to Apgar score at first and fifth minute after extraction.Conclusion The study shows that the optimal method of anesthesia in organ-saving operations for placenta accreta spectrum disorders is epidural anesthesia with its planned conversion to general anesthesia with an artificial lung ventilation after fetal extraction. Such an approach to anesthesia allows to maintain stable hemodynamic profile with minimal vasopressor support, sufficient heart performance, providing effective tissue perfusion and a high level of antinociceptive protection at the intraoperative stage and reduce the volume of intraoperative blood loss and hemotransfusion. In the current study there were no differences in neonatal outcomes and duration of hospitalization depending on the method of anesthesia. The advantage of epidural anesthesia with its conversion to general anesthesia was earlier activation after surgery and lower intensity of postoperative pain syndrome.

Fetal anesthesia: intrauterine therapies and immediate postnatal anesthesia for noncardiac surgical interventions.

This review describes maternal and fetal anesthetic management for noncardiac fetal surgical procedures, including the management of lower urinary tract obstruction, congenital diaphragmatic hernia (CDH), myelomeningocele, sacrococcygeal teratoma, prenatally anticipated difficult airway and congenital lung lesions. Fetal interventions range from minimally invasive fetoscopic procedures to mid-gestation open surgery, to ex-utero intrapartum treatment procedure. Anesthetic management depends on the fetal intervention and patient characteristics. Anesthesia for most minimally invasive procedures can consist of intravenous sedation and local anesthetic infiltration in clinically appropriate maternal patients. Open fetal and ex-utero intrapartum treatment procedures require maternal general anesthesia with volatile anesthetic and other medications to maintain uterine relaxation. Tracheal balloons are a promising therapy for CDH and can be inserted via minimally invasive techniques. Management of the prenatally anticipated difficult airway during delivery and removal of tracheal balloons from patients with CDH during delivery can be clinically dynamic and require flexibility, seamless communication and a high-functioning, multidisciplinary care team. Maternal and fetal anesthetic management is tailored to the fetal intervention and the underlying health of the fetus and mother.

Feticide in second‐ and third‐trimester termination of pregnancy for fetal anomalies: Results of a national survey

To conduct an audit of the practice of feticide in second- and third-trimester termination of pregnancy for fetal anomalies (TOPFA) in prenatal diagnosis (PD) centers in France. A questionnaire was sent out to the 49 French PD centers and completed by 39/49 centers; 5350 TOPFAs were performed. The gestational age after which feticide was performed was 20 weeks in two centers (5%), 22 weeks in 28 centers (72%), 23 weeks in four centers (10%), and 24 weeks in five centers (13%). Fifteen of 39 centers reported that feticide was not performed in all cases, because of a fetal abnormality associated with a high probability of rapid neonatal death (13 centers), pregnant woman's refusal (11 centers), and technical impossibility of performing feticide (one center). Feticide was done using xylocaine in 38 of the 39 centers and using KCl in the remaining center. All but one of the centers before feticide used fetal anesthesia. Feticide was done on the day of induction of labor in 35/39 centers (90%), after maternal epidural analgesia in 33 centers, or after maternal subcutaneous local anesthesia in two centers. Feticide was done the day before induction of labor in two centers. In France, most TOPFAs performed in second and third trimesters are associated with feticide, which is most often done after fetal anesthesia.

The first national survey of anesthesia techniques for fetal therapies in Japan.

The aim of this study was to survey the frequency of various anesthetic techniques used in the anesthetic management of both the mother and fetus during fetal therapies in Japan. We sent a postal survey to the institutions with physicians who held membershipof the Japan Society of Fetal Therapy to describe maternal and fetal anesthetic management during fetal therapies performed from January 2016 to March 2017. The therapies included were thoracoamniotic shunting (TAS), intrauterine transfusion (IUT), radiofrequency ablation (RFA), fetoscopic laser photocoagulation (FLP), fetoscopic endotracheal occlusion (FETO), and ex utero intrapartum treatment (EXIT). Survey respondents were asked to specify the standard anesthetic technique used in each of these procedures done during the study period. The most common anesthetic techniques used in each therapy were sedation/analgesia with local anesthesia in TAS (31%), local anesthesia alone in IUT (47%), neuraxial anesthesia in RFA (50%), FLP (66%) and FETO (100%), and general endotracheal anesthesia in EXIT. Fetal analgesia was utilized in 61% of TAS, 33% of IUT, 10% of RFA, 22% of FLP, 100% of FETO, and 50% of EXIT. In all fetal therapies, the most common route of administration for fetal anesthesia was maternal administration. In this first published description of the frequency of various anesthetic techniques used during fetal therapies in Japan, we found that anesthetic techniques varied depending on the degree of invasiveness to the mother and fetus. Fetal anesthesia was not always performed, and the most common route for fetal anesthesia was maternal administration.

Maternal anesthesia for EXIT procedure: A systematic review of literature.

The ex utero intrapartum treatment (EXIT) procedure is performed in cases of fetal congenital malformation. The anesthetic management is much more challenging and involves providing profound uterine relaxation, maintenance of Uteroplacental blood flow and fetal anesthesia. The aim of the article is to review the literature and compare the efficacy of both the anesthetic techniques with respect to maternal and fetal outcomes. The literature source for this review was obtained via PubMed, Medline, Google scholar and Cochrane database of systematic reviews until January 2017. In our literature review we found that both GA and Regional anesthesia were successfully described for EXIT procedure but GA was performed in the majority of cases. Consideration for anesthetic technique should be done on a case-by-case basis.

Middle Cerebral Artery Doppler Changes following Fetal Transfusion Performed with and without Fetal Anesthesia.

The objective of this study was to test the association between fetal intravenous anesthesia and the change in middle cerebral artery peak systolic velocity (MCA-PSV) in patients undergoing intrauterine transfusion (IUT) for suspected fetal anemia. We retrospectively examined data from all patients who underwent IUT via umbilical cord route from 2007 to 2016. We calculated the change of the MCA-PSV multiple of median (MoM) as the difference in MCA-PSV MoM between the pre- and immediate postoperative measurements for the first IUT. The change in MCA-PSV MoM was compared between those who did and did not receive fetal anesthesia using Kruskal-Wallis' testing. Of 62 patients, 37 (59.7%) received intravenous fetal anesthesia and 25 (40.3%) did not. The change in MCA-PSV MoM did not differ between those who did and did not receive fetal anesthesia (median: 0.57 [interquartile range, IQR: +0.42 to +0.76] vs. median 0.57 [IQR: +0.40 to +0.81], p = 1.000). The relationship remained insignificant when stratifying by gestational age, length of procedure, initial MCA-PSV, and when excluding hydropic fetuses. Among women undergoing IUT, there was no evidence that the use of fetal anesthesia was associated with a change in the pre- versus postoperative change in MCA-PSV MoM.

Anesthetic Management for Percutaneous Minimally Invasive Fetoscopic Surgery of Spina Bifida Aperta: A Retrospective, Descriptive Report of Clinical Experience.

Minimally invasive fetoscopic surgery for spina bifida aperta is a new therapeutic approach to preserve neurologic function by protecting exposed neural tissue. The anesthetic management is of paramount importance for the success of the procedure. Therefore, our protocol was developed with particular attention to safe and adequate maternal and fetal anesthesia, sufficient uterine relaxation as well as prevention of pulmonary edema, placental abruption, and spontaneous labor. As illustrated by this retrospective analysis of 61 cases, these goals can be reliably achieved. The clinical protocol is presented as a supplemental digital content to this manuscript (Supplemental Digital Content 1, http://links.lww.com/AA/B733).

Fetoscopic tracheal occlusion for severe congenital diaphragmatic hernia: retrospective study

The temporary fetal tracheal occlusion performed by fetoscopy accelerates lung development and reduces neonatal mortality. The aim of this paper is to present an anesthetic experience in pregnant women, whose fetuses have diaphragmatic hernia, undergoing fetoscopic tracheal occlusion (FETO). Retrospective, descriptive study, approved by the Institutional Ethics Committee. Data were obtained from medical and anesthetic records. FETO was performed in 28 pregnant women. Demographic characteristics: age 29.8±6.5; weight 68.64±12.26; ASA I and II. Obstetric: IG 26.1±1.10 weeks (in FETO); 32.86±1.58 (reversal of occlusion); 34.96±2.78 (delivery). Delivery: cesarean section, vaginal delivery. Fetal data: Weight (g) in the occlusion and delivery times, respectively (1045.82±222.2 and 2294±553); RPC in FETO and reversal of occlusion: 0.7±0.15 and 1.32±0.34, respectively. Preoperative maternal anesthesia included ranitidine and metoclopramide, nifedipine (VO) and indomethacin (rectal). Preanesthetic medication with midazolam IV. Anesthetic techniques: combination of 0.5% hyperbaric bupivacaine (5-10mg) and sufentanil; continuous epidural predominantly with 0.5% bupivacaine associated with sufentanil, fentanyl, or morphine; general. In 8 cases, there was need to complement via catheter, with 5 submitted to PC and 3 to BC. Thirteen patients required intraoperative sedation; ephedrine was used in 15 patients. Fetal Anesthesia: fentanyl 10 to 20mg·kg-1 and pancuronium 0,1-0,2mg·kg-1 (IM). Neonatal survival rate was 60.7%. FETO is a minimally invasive technique for severe congenital diaphragmatic hernia repair. Combined blockade associated with sedation and fetal anesthesia proved safe and effective for tracheal occlusion.

286: Middle cerebral artery doppler changes following fetal transfusion performed with and without fetal anesthesia

286: Middle cerebral artery doppler changes following fetal transfusion performed with and without fetal anesthesia

Fetoscopic tracheal occlusion for severe congenital diaphragmatic hernia: retrospective study

Background and objectivesThe temporary fetal tracheal occlusion performed by fetoscopy accelerates lung development and reduces neonatal mortality. The aim of this paper is to present an anesthetic experience in pregnant women, whose fetuses have diaphragmatic hernia, undergoing fetoscopic tracheal occlusion (FETO). MethodRetrospective, descriptive study, approved by the Institutional Ethics Committee. Data were obtained from medical and anesthetic records. ResultsFETO was performed in 28 pregnant women. Demographic characteristics: age 29.8±6.5; weight 68.64±12.26; ASA I and II. Obstetric: IG 26.1±1.10 weeks (in FETO); 32.86±1.58 (reversal of occlusion); 34.96±2.78 (delivery). Delivery: cesarean section, vaginal delivery. Fetal data: Weight (g) in the occlusion and delivery times, respectively (1045.82±222.2 and 2294±553); RPC in FETO and reversal of occlusion: 0.7±0.15 and 1.32±0.34, respectively. Preoperative maternal anesthesia included ranitidine and metoclopramide, nifedipine (VO) and indomethacin (rectal). Preanesthetic medication with midazolam IV. Anesthetic techniques: combination of 0.5% hyperbaric bupivacaine (5–10mg) and sufentanil; continuous epidural predominantly with 0.5% bupivacaine associated with sufentanil, fentanyl, or morphine; general. In 8 cases, there was need to complement via catheter, with 5 submitted to PC and 3 to BC. Thirteen patients required intraoperative sedation; ephedrine was used in 15 patients. Fetal anesthesia: fentanyl 10–20mg.kg−1 and pancuronium 0.1–0.2mg.kg−1 (IM). Neonatal survival rate was 60.7%. ConclusionFETO is a minimally invasive technique for severe congenital diaphragmatic hernia repair. Combined blockade associated with sedation and fetal anesthesia proved safe and effective for tracheal occlusion.

Fetal cardiac interventions - are we ready for them?

The aim of the study was to analyze types and methods of intrauterine fetal cardiac interventions performed between June 2011 and December 2013, and to assess the perinatal management of the neonates. The program was developed after analysis of the available literature, practical individual training in Linz, Austria, and simulation of the procedure in a dissecting-room. The rules for anesthesia in pregnant women and their fetuses were developed. The interventions were performed in fetuses with critical cardiac defects, in the operating room, under ultrasonographic control. The protocol was approved by the Local Bioethics Committee at the Centre of Postgraduate Medical Education. We included fetuses with critical aortic stenosis (n=29), critical pulmonary stenosis (n=2), and closed or extremely restricted foramen ovale (n=7). Between June 2011 and December 2013, the team comprised of JD, MD and AK conducted 42 interventions in 35 fetuses, including 32 balloon aortic valvuloplasties (in 29 fetuses), 2 pulmonary valvuloplasties, 4 balloon atrial septostomies and 4 atrial septal stent placement. Three fetuses required both, aortic valvuloplasty and fenestration of the atrial septum. Out of the 42 procedures, 41 (97%) were technically successful. We recorded 3 cases of fetal demise associated with the intervention. We modulated the protocol of anesthesia given to pregnant women, switching from general to local anesthesia with intravenous sedation. We always provided additional fetal anesthesia with fentanyl and atracurium via the umbilical vein. Based on our 2.5-year experience, it seems safe to conclude that all types of fetal cardiac interventions may be successfully conducted at Polish centers. The procedures are safe for the pregnant women and improve fetal status. Most of the neonates treated prenatally were referred in good general condition to a tertiary pediatric cardiology and cardiac surgery center