Table 3. Perioperative Considerations for Open Fetal Repair of Myelomeningocele.
A detailed summary of perioperative considerations for anesthetic management of open fetal myelomeningocele repair is presented.
| Preoperative |
| Complete maternal history and physical exam |
| Complete fetal work-up to exclude other anomalies |
| Imaging studies to determine fetal lesion and placental location |
| Maternal counseling by multidisciplinary team & presurgical team meeting |
| Lumbar epidural placed and test dosed |
| Prophylactic premedication: nonparticulate antacid (aspiration), rectal indomethacin (tocolysis) |
| Blood products typed and cross matched for potential maternal and fetal transfusion; fetal blood should be type O-negative, leukocyte depleted, irradiated, CMV negative, and cross-matched against the mother |
| Obtain estimate of fetal weight to aid in medication preparation for the fetus |
| Sequential compression devices on lower extremities for thrombosis prophylaxis |
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|
| Intraoperative |
| Left uterine displacement and standard monitors |
| Preoxygenation for 3 minutes prior to induction |
| Rapid sequence induction and intubation |
| Maintain maternal FiO2 >50% and end tidal CO2 28–30 mm Hg |
| Ultrasound to determine fetal and placental positioning |
| Urinary catheter placed; additional large bore IV access placed +/− arterial line |
| Prophylactic antibiotics administered |
| Fetal resuscitation drugs and fluid transferred to scrub nurse in sterile fashion |
| Following skin incision, high concentrations of volatile anesthetic (2–3 MAC) started |
| Blood pressure maintained with IV phenylephrine, ephedrine, and/or glycopyrolate; Typical goal is to maintain mean arterial pressure within 10% of preinduction baseline |
| Consider IV nitroglycerine if uterine tone remains increased |
| IM administration of fetal opioid and neuromuscular blocking agent by surgical team following hysterotomy |
| Crystalloid restriction to <2L to reduce risk for maternal pulmonary edema, consider colloid administration |
| IV loading dose of magnesium once uterine closure begins |
| Discontinue volatile agents once magnesium load is complete |
| Administer propofol, opioids, nitrous oxide as needed |
| Activate epidural for postoperative analgesia |
| Monitor neuromuscular blockade carefully due to magnesium |
| Extubate trachea when patient is fully awake |
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|
| Early Post-operative Considerations |
| Continue tocolytic therapy |
| Patient controlled epidural analgesia |
| Monitor uterine activity and fetal heart rate |
| Ongoing fetal evaluation |
CO2=carbon dioxide, CMV=cytomegalovirus, FiO2=fraction of inspired oxygen, IM=intramuscular, IV=intravenous, and MAC=minimum alveolar concentration.