Fetal surgeries present unique challenges for providing anesthesia to both the mother and fetus. Pioneers in the field performed some of the first fetal surgeries in the 1960s-1980s. There are three main types of fetal surgeries: EXIT/OOPS procedures which are done during a cesarean section to address airway issues; minimally invasive mid-gestation procedures like shunt placements guided by ultrasound; and open midgestation surgeries. Anesthesiologists must consider the physiological differences of the fetus and risks to both the mother and fetus. Careful planning and coordination is needed between all specialists involved to balance these risks and potentially interrupt conditions that would otherwise progress.

1. ANAESTHESIA FOR
FETAL SURGERIES
DR NANDINI DESHPANDE
GUIDE- DR ASHISH PAREEK

2. INTRODUCTION
 The allure of fetal surgery is the possibility of
interrupting the in utero progression of an
otherwise treatable condition.
 The concept of fetus as a patient who is able to
undergo surgery or medical intervention has
evolved from prenatal diagnosis and serial
observation of fetuses with anatomical
abnormalities.
 The challenge of an anaesthesiologist lies with
providing anaesthesia to both the mother and
the fetus and ensuring safety for both of them at
the same time.

3. PIONEERS OF FETAL SURGERY
 Sir Albert William Liley in 1965 was the first
to successfully treat erythroblastosis fetalis
with an intraperitoneal blood transfusion.
 In 1982, Dr Michael Harrison performed the
first successful human surgery by creating a
vesicostomy in a fetus with obstructive
uropathy.
 In 1970, Liggins administered corticosteroids
to the fetus via the maternal circulation to
increase the surfactant production in preterm
fetuses at the risk for respiratory distress
syndrome.

4. TYPES OF FETAL SURGERIES
 Ex Utero Intrapartum Treatment [EXIT]/
Operations on placental support[OOPS].
 Minimally invasive mid-gestation
procedures like FIGS-IT[Fetal image guided
surgery for intervention and therapy] and
FETENDO procedures.
 Midgestational open surgeries

5. 1] EXIT/OOPS PROCEDURE
 Done in fetuses with known airway
compromise or obstruction.
 These interventions are performed on
vaginal delivery or caesaerian section.
 Only a portion of fetus is delivered and
procedures such as endotracheal
intubation or examination of neck
masses is done while the fetus is still
connected to the placenta by umbilical
cord.

6.  The fetal airway is secured without the
concern for postnatal respiratory
compromise, hypoxia and asphyxia.
 The EXIT is an extension of a standard
classical Caesarean section, where an
opening is made on the midline of the
anesthetized mother's abdomen and uterus.
Then comes the EXIT: the baby is partially
delivered through the opening but remains
attached by its umbilical cord to
the placenta, while a pediatric
otolaryngologist-head & neck surgeon
establishes an airway so the fetus can
breathe. Once the EXIT is complete, the
umbilical cord is clamped then cut and the
infant is fully delivered. Then the
remainder of the C-section proceeds.

7. INDICATIONS-
Cervical masses- cystic hygroma, goiter,
hemangioma, lymphangioma,
neuroblastoma, teratoma.
Lung mass- congenital cystic adenomatoid
malformation.
Mediastinal mass- lymphangioma, teratoma.
Congenital high airway obstruction
syndrome- laryngeal atresia/stenosis,
tracheal atresia /stenosis.

8. MANAGEMENT OF EXIT PROCEDURE
Primary
goals
Maintain a prolonged state of
uterine relaxation
To sustain placental-
foetal perfusion
To delay placental
separation

9. CHALLENGES FACED:
Good co-ordination
between
obstetricians &
Maternal- foetal
surgeons operating
on the baby
To preserve
enough blood flow
through the
umbilical cord
Protect he
placenta{
maternal heart-
lung machine}
Avoid uterine
contractions and
manipulation of
the umbilical cord
Minimal time to
secure the airway
of the foetus

10. 2] MINIMALLY INVASIVE MID-GESTSTIONAL
PROCEDURES
Minimally invasive fetal procedures include
 Percutaneous interventions guided by
ultrasound, also known as fetal image–
guided surgery for intervention or therapy
(FIGS-IT)
 Fetal endoscopic surgery using small
endoscopic instruments dually guided by
direct fetoscopic camera view and
simultaneous real-time ultrasound imaging.
 Fetal endoscopic surgery is typically
accomplished percutaneously, but
sometimes requires a small maternal
minilaparotomy.

11. INDICATIONS-
 Fetal anaemia or thrombocytopenia for intrauterine
transfusion.
 Aortic stenosis, intact atrial septum or pulmonary atresia by
percutaneous fetal valvuloplasty or septoplasty.
 Lower urinary tract obstruction- percutaneous vesico-amniotic
shunting or fetoscopic posterior valve laser ablation.
 Twin reverse arterial perfusion[TRAP]- umbilical
radiofrequency ablation or fetoscopic coagulation .
 Twin to twin transfusion syndrome[TTTS]- fetoscopic laser
photocoagulation of placental vessels.
 Amniotic band syndrome- fetoscopic band ligation.

12. FIGS-IT-
 It involves manipulation of the fetus with either an
incision in the uterus or by endoscopic view inside
the uterus. The manipulaton is under the real time
cross- sectional view provided by the sonogram.
 It can be done under maternal regional anaesthesia-
spinal or epidural or local anaesthesia.
 It is the least invasive of all the procedures and thus
it is of the least problem to the mother in terms of
hospitalization and discomfort.

13. ANAEMIA AND INTRAUTERINE TRANSFUSION:
CAUSES
• Secondary to rhesus D (RhD) sensitization
• other red blood cell (RBC) antigens
• parvovirus B19 infection
• maternal-foetal haemorrhage
• homozygous thalassemia
DIAGNO
SIS
• An increased peak MCA blood flow velocity more than 1.5 multiples
of the median
• Foetal blood sampling from the umbilical vein is the gold standard
TREAT
MENT
• IUT > 18 to 20 weeks gestational age
• Intraperitoneal transfusions < 18-20 weeks GA
6 cases
in 1000
live
births

14. ANAESTHESIA
• LA with minimal maternal sedation and
analgesia
• Anaesthesiologist should be prepared for an
emergent CS ( if foetus is at viable
gestational age)
• Fentanyl is administered to the foetus before
use of an intrahepatic approach
• Muscle relaxant can be administered to the
foetus to decrease foetal movement
COMPLICATIONS
• Perinatal foetal loss
• transient foetal bradycardia
• emergency caesarean delivery
• Intrauterine infection
• rupture of membranes
• Neurodevelopmental impairment including cerebral palsy,
severe developmental delay ,bilateral deafness

16. CONGENITAL HEART DEFECTS
8-10/ 1000 live births
Foetal cardiac interventions :-
(1) aortic balloon valvuloplasty for treatment of critical aortic stenosis and evolving hypoplastic left heart
syndrome (HLHS)
(2) atrial septostomy for highly restrictive or intact atrial septum seen in HLHS
(3) pulmonic valvuloplasty for pulmonary atresia or intact ventricular septum and hypoplastic right ventricles
Anaesthesia:-
Maternal local anaesthesia infiltration or neuraxial block
General anaesthesia may be preferred for uterine relaxation to facilitate an external version to change
foetal positioning and improve cannula trajectory in some cases
Before cannula insertion, intramuscular fentanyl and a paralytic agent are administered to the foetus
foetal resuscitation drugs must be readily available
Complications:-
Foetal bradycardia
Pericardial effusion
Ventricular thrombosis
Foetal death
Aortic regurgitation & minimal subsequent left ventricular growth

17. A- Depiction of ideal foetal
position and insertion needle
orientation. The foetal left
chest is anterior, and the
pathway from maternal
abdomen entry point to the
apex of the left ventricle is
unobstructed.
B- This linear cannula course
continues from left ventricle
apex to the aortic valve

18. OBSTRUCTIVE UROPATHY
1 in 1000 pregnancies
Causes:-
Posterior urethral valves, Urethral obstruction, ectopic ureter, ureterocoele, mega
cystis, megaureter, multicystic kidney
Investigations:-
Ultrasound investigations of oligohydramnios
Fetal MRI to determine the presence of associated foetal anomalies
Interventions:-
Vesico-amniotic catheter shunt placement inserted percutaneously with USG guidance &
LA
Fetal cystoscopy with ablation of the urethral obstruction
Fetal complications:-
trauma, iatrogenic abdominal wall injury, gastroschisis, and amnioperitoneal leaking
Maternal complications
PPROM, preterm labour and delivery & infection

19. DEVELOPMENTAL CONSEQUENCES OF FOETAL URETHRAL
OBSTRUCTION
 Oligohydramnios
 Potter’s facies (prominent infra-orbital folds)
 Hypoplastic lungs
 Flexion contracture
 Hydronephrosis
 Type 4 cystic dysplasia
 Renal failure
 Hydroureter and megacystis
 Abdominal muscle deficiency
 Prune belly

21. 3] MIDGESTATIONAL OPEN SURGERIES
 It involves a maternal laparotomy, a hysterotomy
and the need for intraoperative uterine
relaxation.
 The fetus is exteriorized for surgery and after the
surgery is complete the fetus is placed back into
the uterus which is closed.
 The fetus continues to grow through the rest of
gestation with the reversal of the disease process
that prompted the fetal intervention.
 There is increased risk to the mother and the
fetus as compared to the minimally invasive
procedures.

22. INDICATIONS-
 Meningomyelocoele- closure of the
defect through hysterotomy .
 Sacrococcygeal teratoma- open fetal
tumour debulking.
 Congenital diaphragmatic hernia-
tracheal occlusion.
 Congenital cystic adenoid
malformation- open surgical resection.

23. CONGENITAL DIAPHRAGMATIC HERNIA:
1 in 2500 newborn infants
Increased survival at higher centres due to
Surfactant administration, specialized ventilation techniques to minimize lung trauma, surgical closure of the defect,
and availability of ECMO therapy
minimally invasive foetal endoscopic surgical techniques
percutaneous endoscopic endotracheal intubation is used to place a small detachable occlusive balloon in the foetal
trachea ,it is deflated and removed before term with a second foetal endoscopic surgical techniques procedure.
The balloon removal may improve type II pneumocyte function, increase surfactant production, and allow a vaginal
delivery when appropriate
Definitive tracheal occlusion restricts the normal outflow of foetal lung fluid [100ml/kg/day] and provides an increase
in pulmonary hydrostatic pressure. This increased pressure pushes the viscera out of the thorax, promotes expansion
of the hypoplastic lung, and thereby improves lung growth and development surgical repair planned postnatally
Use of ultrasound imaging to determine the ratio of foetal lung area to head circumference (LHR) and the presence of
thoracic liver herniation (“liver up” versus “liver down”) are the most reliable prognostic indicators of foetal CDH
outcome. LHR < 0.7= no survival, LHR>1.4= 72.7% or greater survival rate
foetal MRI measurement of lung volume

26. ADVANTAGES OF FETAL SURGERY
 Early intervention before
irreversible damage is the
paramount benefit.
 Surgical manipulations and post
operative period are simplified.
 The birth of an apparently normal
child and absence of a scar.
 The salvage of compromised
anatomical structure.
 The cost affectiveness of a post
operative period in utero.

27. RISKS
MATERNAL RISKS-
 Chorioamniotic membrane separation
 Preterm premature rupture of
membranes[PPROM]
 Preterm labour
 Chorioamnionitis
 Haemorrhage
 Pulmonary oedema

28.  Oligohydramniosis
 Spontaneous membrane rupture
 Spontaneous labour
 Hysterotomy site thin, partial or
completely dehisced at delivery
 Maternal mirror syndrome in case of
fetal hydrops [ triple edema – foetal,
placental hydrops with pre-eclampsia]
 Amniotic fluid leak and wound infection

29. FETAL RISKS-
 Teratogenicity from anaesthetic drugs
 Prematurity
 Intrauterine infection
 Intrauterine fetal demise
 Fetal vascular embolic events
 Intestinal atresia
 Renal agenesis

30. Premature closure of ductus
arteriosus
CNS injuries due to maternal
hypoxia or fetal circulatory
disturbances
Fetal bradycardia during repair
Respiratory distress syndrome
Hypoxia and hypercarbia

31. MATERNAL PHYSIOLOGIC CHANGES AND ANAESTHETIC
RISKS
PHYSIOLOGIC CHANGES
 GASTRIC
 Acidity
 Emptying
 Reflux
 PULMONARY
 FRC
 O2 consumption
 Capillary permeability
RISKS
 Aspiration
pneumonitis
 Hypoxemia

32. CONTD..
 CARDIOVASCULAR
 Preload
 Contractility
 Arrythmias
 CENTRAL NERVOUS
SYSTEM
 MAC
 Neuromuscular
blockade sensitivity
 Hypotension
 Sedation and
weakness

33. PHYSIOLOGICAL PARAMETERS IN A FOETUS:
foetal cardiac output depends on
heart rate
The foetal cardiac output (sum of
RV & LV output) ≈ 425 to 550
mL/min/kg throughout gestation
Changes in preload has minimal
effect on cardiac output as
-foetal myocardium is less
compliant than adult myocardium
-Constraining forces of the fluid-
filled lungs limit ventricular
filling. normal
foetal blood volume increases
during gestation & approximately
two thirds of the foetal placental
blood volume resides within the
placenta.
During the second trimester, foetal
blood volume ≈ 120 to 160 mL/kg
of foetal body weight
After mid-gestation, Estimated
foetal blood volume (mL) = 11.2 ×
GA − 209.4
In normal pregnancy, the mean
foetal Hb increases linearly
from
11 g/dL at 17 weeks gestation
to
15 g/dL at 40 weeks gestation
with a SD of ±1 g/dL

34. DOES THE FETUS EXPERIENCES
PAIN??
 Pressure, temperature and
vibration sensory nerve terminals
develop in human skin- 6-10
weeks.
 Skin nerve terminals required for
peripheral sensory nociception-
10-17 weeks.
 Reflex withdrawal from a noxious
stimuli without input from
cerebral cortex-19 weeks.

35.  Thalamic pain fibres reach the
somatosensory cortex-24-26 weeks and the
auditory cortical plate -26-28 weeks.
 The fetus exhibits pituitary-adrenal,
sympathoadrenal and circulatory stress
response to noxious stimuli as early as 18
weeks of gestation.
 Fetuses are unlikely to experience pain
before 24 weeks of gestation because the
cortex requires additional growth and
development to establish the extensive
neural network of pathways to other CNS
structures.

36. FETAL PHYSIOLOGY AND ANAESTHETIC RISKS
PHYSIOLOGIC CHANGES RISKS
 Hypotension
 Bradycardia
 Hypotension
 hypotension
 CARDIOVASCULAR
 Starling s curve
 Vagal tone
 Baro-reflex
 Blood volume

37. CONTD..
 CNS
 MAC
 CUTANEOUS
 Evaporation
 Heat loss
 Bruising
 Sedation
 Hypotension
 Hypothermia
 Anaemia

38. COAGULATION
 Bleeding  Hypotension
 Anaemia

39. PRE-OPERATIVE ASSESMENT AND COUNSELLING FOR ALL
PROCEDURES:
 Maternal safety is the primary focus when
determing a plan that will optimize fetal
outcome.
 A multidisciplinary approach with thorough open
communication is essential to the success of each
fetal intervention.
 Optimum functioning of a fetal treatment
programme requires effective communication
among the members of a multidisciplinary team,

40.  including surgeons, ultrasonographers,
maternal fetal medicine physicians,
anaesthesiologists, nurses, genetic
counselors and social workers.
 An understanding of the physiologic
changes of pregnancy and their effects
on anaesthetic management is necessary
for appropriate perioperative planning
and risk assessment.

41.  A thorough maternal and fetal evaluation
and frank discussion of risks and benefits by
all team members with the mother is
required to determine an appropriate care
plan.
 In addition to anaesthetic considerations
associated with nonobstetric surgery during
pregnancy, fetal surgery requires planning
for fetal anaesthesia and analgesia , fetal
monitoring ,uterine relaxation and post
operative fetal monitoring and tocolysis.

42. FETAL MONITORING
 Pre-operative:
 Fetal heart rate[FHR]
 Umbilical artery flow velocity- both
absent and reversed umbilical artery
diastolic flow are associated with
increased perinatal morbidity and
mortality.
 Intra-operative:
 Fetal Echocardiography
 Fetal Pulse Oximetry- normal SPO2-40-
70%, <30%- hypoxia and imminent
bradycardia and collapse can occur.
 PO2 from cord blood
 Fetal Hb from cord blood

43. CONTD…
Intra-operative:
 FHR monitoring with external Doppler or
fetal scalp electrode.
 USG- allows imaging of FHR, cardiac
contractility, cardiac filling as well as
Doppler assessment of umbilical cord flow.
 Temperature monitoring via maternal core
and amniotic fluid temperature.

44. FETAL ANAESTHESIA AND ANALGESIA
 Anaesthetic goals include prevention of
fetal movement, inhibition of circulatory
stress response, adequate pain relief and
potentially even fetal amnesia.
 Opioid analgesics can be transferred to
the fetus by maternal administration or
direct intramuscular or intravenous
umbilical cord administration using
ultrasound guidance.

45.  For most invasive procedures that can cause
noxious fetal stimulation , fetal intramuscular
administration of fentanyl 10-20 ug/kg is used
to provide analgesia immediately before the
intervention.
 This can be achieved percutaneously using USG
guidance or under direct vision when a
hysterotomy is performed.
 Prophylactic intramuscular atropine 20 ug/kg
with opioids is administered to minimize the
risk of fetal bradycardia.

46.  Fetal movements can be prevented by
intramuscular or umbilical vessel administration
of muscle relaxant using USG guidance.
 Drugs used commonly- Pancuronium OR
Vecuronium in doses- 0.3mg/kg IM or 0.1-
0.25mg/kg IV.
 Onset of paralysis occurs in 2-5 minutes with an
approximate duration of 1-2 hrs.
 Maternal administration and placental transfer
of I.V. remi-fentanyl [0.1ug/kg/min] provides
adequate fetal immobility during fetoscopic
interventions that involve umbilical cord or
placenta.

47.  For open fetal procedures, placental
transfer of maternally administered
general anesthesia with the volatile
anaesthetics provides fetal anaesthesia.
 These anaesthetics transfer across the
placenta with fetal concentration and
fetal to maternal ratio [F/M] depending
on both the maternal inspired
concentration and the duration of
maternal anaesthetic administration.

48.  During caeserian section, isoflurane and
desflurane both have an F/M ratio of
approximately 0.7 within 10 min of duration
while nitrous oxide has a ratio of 0.83
within 3 minutes of administration.
 Side-effects- High levels of volatile
anaesthetics can depress fetal myocardium
and can lead to fetal acidosis.
 Volatile anaesthetic concentrations often
employed for uterine relaxation[>2MAC]
demonstrate significant reduction in
maternal COP and associated decrease in
uterine perfusion by 30%.

49. MANAGEMENT OF MINIMALLY INVASIVE
PROCEDURES
 Monitored anaesthesia care[MAC] with the
infiltration of a local anaesthetic agent into
the abdominal wall provides an adequate level
of maternal comfort.
 Opioids and benzodiazepines or other IV
anaesthetic agents can be used for maternal
analgesia and anxiolysis ,titrated to avoid
deep sedation and the associated risk for
pulmonary aspiration of gastric contents or
respiratory compromise during pregnancy.

50. CONTD…
 Additional use of supplemental
anaesthetic drugs decreases likelihood
for fetal movements via placental
transfer.
 For fetoscopic procedures which involve
use of endoscope trocars that are only 1-
5 mm in diameter , local infiltration
anaesthesia can be used.
 Although maternally administered
opioids or benzodiazepins can reduce
fetal motion they do not guarantee
immobility for procedures directly
involving the fetus.

51. Neuraxial techniques- Spinal or
Epidural can be beneficial in the
following:
 Multiple insertion sites are required.
 Need for maternal immobility and
comfort.
 When mini-laprotomy is indicated
 Appropriate patient co-operation during
the procedure.

52.  General anaesthesia is rarely necessary
for percutaneous procedures unless the
placental location and fetal orientation
present potential technical difficulty or
uterine exteriorization is needed.
 Fetal immobility can be achieved by IV /
IM administration of opioid and a muscle
relaxant in the fetus.
 Weight-based unit doses of atropine
20ug/kg

53. CONTD..
 And epinephrine 10ug/kg should be
immediately available in individually labelled
syringes for direct administration to the fetus
by the surgeon in emergent situations of fetal
compromise.
 If the gestational age is compatible with
extrauterine life, the anaesthesiologist should
be prepared to emergently provide general
maternal anaesthesia and the obstetrician
should be prepared to perform an emergency
caeserian delivery if fetal bradycardia persists
despite efforts to resuscitate in utero.

54. MANAGEMENT OF OPEN PROCEDURES
 PRE-OPERATIVE-
 Complete maternal history and physical examination.
 Complete fetal work-up to exclude other anomalies.
 Imaging studies with USG and fetal MRI to determine
the fetal lesion and placental location.
 Maternal counselling by multidisciplinary team and
presurgical team meeting.

55. CONTD..
 PRE-OPERATIVE-
 Lumbar epidural catheter placement for post –
operative analgesia.
 Prophylactic medications- antacids [ranitidine-
0.25-1mg/kg] , anti-emetics[metoclopromide-
0.15mg/kg] for aspiration prophylaxis and
tocolytics like Mg sulphate IM and rectal
indomethacin in some cases.
 Obtain estimate of fetal weight via antenatal
USG to aid in weight based fetal dosing.

56. PRE-OPERATIVE-
 Blood products typed and cross-matched
for potential maternal and fetal
transfusion , fetal blood should be type O –
negative , leucocyte depleted , irradiated,
cytomegalovirus negative and cross-
matched against mother.
 Written informed consent with the risks
and outcomes explained .

57. INTRA-OPERATIVE-
 Secure a wide – bore IV access.
 Attach monitors- NIBP, ECG and Pulse
oximeter.
 Left uterine displacement by keeping a wedge
below the right hip or left lateral tilt to
about 15 degree to prevent supine-
hypotension syndrome.
 Pre-oxygenation for 3 minutes before
induction

58. CONTD..
 INTRA-OPERATIVE-
 Rapid sequence induction and intubation
 Maintain maternal FiO2 greater than 50% and
end-tidal CO2 28-30 mmhg.
 USG to determine fetal and placental
positioning.
 Urinary catheter placed, additional large-bore
IV access device placed with or without
arterial line.

59.  INTRA-OPERATIVE-
 Activation of upper, lower or both forced air
warmers to maintain maternal normothermia.
 Prophylactic antibiotics are administered.
 Fetal resuscitation drugs [ atropine 20ug/kg,
epinephrine 10 ug/kg] should be prepared pre-
operatively for emergent treatment of intra-
operative fetal hemodynamic compromise and
should be given to the scrub nurse in sterile
fashion.

60. INTRA-OPERATIVE-
 After the skin incision, high concentrations
of volatile anaesthetic [2-3 minimum
alveolar concentration] started for uterine
relaxation.
 IV Nitroglycerine as an infusion or in small
boluses [50-200 ug] is useful to decrease
the uterine tone.
 IV propofol and remi-fentanyl with
desflurane at 1.5 MAC has provided
adequate uterine relaxation in one
retrospective study.

61. CONTD..
 INTRA-OPERATIVE-
 For rare patients with contraindications to
either volatile anaesthetics of general
anaesthesia , a neuraxial technique in
conjunction with IV administration of
nitroglycerine in doses upto 20 ug/kg/min have
been used successfully.
 Blood pressure is maintained with IV
phenylephrine [0.5-1ug/kg] , ephedrine 2.5-10
mg IV or glycopyrrolate [10ug/kg], typical goal
is to maintain the mean arterial pressure[MAP]
within 10% of preindution baseline with
appropriate heart rate.

62. INTRA-OPERATIVE-
 Placement of fetal monitors if
needed[eg: fetal pulse oximeter,
intrauterine temperature probe].
 IM fetal administration of opioid and
neuromuscular blocking agent after
hysterotomy along with an
anticholinergic agent.
 Placement of fetal IV access if significant
fetal blood loss is anticipated.

63.  External irrigation of fetus with warmed saline
to prevent hypothermia.
 Blood and fluids to be given to the fetus should
be warmed.
 IV Crystalloid restriction to less than 2 L to
reduce the risk for pulmonary oedema.
 IV loading dose of Magnesium sulphate 4-6 g
over 20 min once the uterine closure begins.
 Discontinue volatile agents and / or NTG once
Mg Sulphate load is complete.

64.  Administer propofol, opioids and nitrous
oxide as needed.
 Provide post –operative analgesia via the
epidural catheter.
 Monitor neuromuscular blockade
carefully because of Mg sulphate.
 Extubate after the patient is fully
awake.

65. POST-OPERATIVE –
 Continue tocolytic therapy with IV NTG 1-
10 ug/kg/min or IV Mg sulphate 1-2 g/hr for
approximately 24 hrs or more for
prolonged post- operative uterine
relaxation.
 Invasive monitoring with a maternal intra-
arterial catheter is recommended when
prolonged use of NTG is planned and
patient should be monitored for onset of
pulmonary oedema.

66. CONTD..
 POST-OPERATIVE-
 Additional tocolytic agents like indomethacin,
terbutaline and nifedipine are often used.
 Administration of indomethacin requires
periodic monitoring by fetal echocardiography
because premature closure of ductus arteriosus
is a known complication of therapy.
 Continuous FHR monitoring is done to manage
fetal distress if detected.

67.  POST-OPERATIVE-
 Patient controlled epidural analgesia .
 Monitor uterine activity and variability in FHR.
 Ongoing fetal evaluation.
 If maternal pulmonary oedema is suspected,
CXR-PA view should be obtained and if
significant compromise is seen then patient
should be admitted in ICU for ventilatory
support and diuretic therapy.

68. FUTURE CONSIDERATIONS
 Fetal surgery is a relatively new and
rapidly evolving area of clinical
medicine.
 In utero treatment raises complex and
difficult ethical, social and legal issues
that go far beyond that of most adult
and pediatric surgical interventions and
include questions regarding maternal
rights, access to care and the option for
pregnancy termination.

69. Future rigorous research is
needed:
 Optimal anaesthetic techniques should be
determined to ensure maternal and fetal
cardiovascular stability.
 To evaluate the best gestational age of
anaesthetic exposure.
 Assess the impact of anaesthetic
management strategies on myometrial tone
and uteroplacental perfusion.
 Determine the adequacy of fetal
anaesthesia and analgesia.