This document discusses anesthesia considerations for fetal surgery. Fetal surgery presents unique challenges as two patients, the mother and fetus, must be anesthetized. Physiologically, pregnancy increases the mother's sensitivity to anesthetic agents and affects her respiratory, cardiovascular and gastrointestinal systems. The fetus depends on intact uteroplacental blood flow. Many anesthetic agents readily cross the placenta. Providing anesthesia requires integrating obstetric and pediatric practices while minimizing risk to both patients with little margin for error. Optimal anesthetic techniques for fetal surgery continue to be studied.
The Treatment of Recurrent Spontaneous Miscarriage-JCM (2)LIQIN ZHAO
This document discusses recurrent spontaneous miscarriage (RSM) and its treatment from both modern biomedical and traditional Chinese medicine (TCM) perspectives. RSM is defined as three or more consecutive miscarriages. From a biomedical view, the main causes are thought to be immunological factors (80% of cases), blood clotting disorders, thyroid disorders, and endocrine issues. TCM identifies six primary causes: deficiency of the kidney and spleen, kidney qi deficiency with blood stagnation, kidney yin deficiency with liver qi stagnation and blood heat, and spleen qi and blood deficiency. The document presents a TCM treatment program using acupuncture and herbal medicine to treat RSM by addressing the underlying imbalances.
This document discusses antenatal screening for fetal aneuploidy. It introduces cytogenetics and explains that chromosomal abnormalities occur in approximately 1-2% of live births. The most common types of aneuploidy are trisomy 21, trisomy 18, trisomy 13 and sex chromosome aneuploidies. Screening methods discussed include biochemical screening, ultrasound screening for soft markers and structural abnormalities, and non-invasive prenatal testing using cell-free DNA. Biochemical markers analyzed include PAPP-A, beta-hCG, AFP, uE3, and inhibin A. Soft markers seen on ultrasound include increased nuchal translucency, absent nasal bone, ech
Recurrent miscarriages need to be investigated actually. You had live births but now had four consecutive miscarriages. It is better to have a thrombophilia screen and products of conception needed to be send out for histopathology to check any chromosomal, congenital, structural anomaly.
Read More:https://www.icliniq.com/qa/miscarriage/why-am-i-having-frequent-miscarriages
Management of twin pregnancy with single fetal demise; Obstetrics - October 2019Kareem Alnakeeb
This document summarizes the current management of single fetal demise (sIUFD) in twin pregnancies. It discusses that sIUFD occurs in 3.7-6.8% of twin pregnancies and increases risks for the surviving twin. The management approach depends on chorionicity, gestational age, and whether the demise occurred in the first, second, or third trimester. For monochorionic twins after the first trimester, the surviving twin has increased risks of death, neurological issues, and preterm birth due to shared blood flow between twins. Conservative monitoring is recommended when possible to allow further fetal development, though delivery may be considered if the in utero environment is deemed hostile.
This document discusses multiple pregnancy (twins, triplets, etc.), including causes, complications, diagnosis and management. It notes that the incidence of multiple pregnancies has increased due to assisted reproductive technologies. Complications can include preterm birth, anemia, pregnancy-induced hypertension, and increased risk of stillbirth. Diagnosis involves ultrasound to determine chorionicity and number of fetuses. Management includes careful surveillance, diet supplementation, and deciding when to perform a cesarean delivery versus attempting a vaginal birth.
The document discusses two uncommon obstetrical procedures: the PUBS (Percutaneous Umbilical Blood Sampling) procedure and the EXIT (Ex Utero Intrapartum Treatment) procedure. The PUBS procedure involves using ultrasound to guide a needle into the umbilical vessels to sample or transfuse blood from the fetus. It is sometimes used therapeutically to treat fetal-maternal Rh incompatibility. The EXIT procedure involves partially delivering the fetus via caesarean section to perform an intervention such as establishing an airway before fully delivering the baby. Both procedures have specific anesthetic considerations including fetal anesthesia and uterine relaxation.
The Treatment of Recurrent Spontaneous Miscarriage-JCM (2)LIQIN ZHAO
This document discusses recurrent spontaneous miscarriage (RSM) and its treatment from both modern biomedical and traditional Chinese medicine (TCM) perspectives. RSM is defined as three or more consecutive miscarriages. From a biomedical view, the main causes are thought to be immunological factors (80% of cases), blood clotting disorders, thyroid disorders, and endocrine issues. TCM identifies six primary causes: deficiency of the kidney and spleen, kidney qi deficiency with blood stagnation, kidney yin deficiency with liver qi stagnation and blood heat, and spleen qi and blood deficiency. The document presents a TCM treatment program using acupuncture and herbal medicine to treat RSM by addressing the underlying imbalances.
This document discusses antenatal screening for fetal aneuploidy. It introduces cytogenetics and explains that chromosomal abnormalities occur in approximately 1-2% of live births. The most common types of aneuploidy are trisomy 21, trisomy 18, trisomy 13 and sex chromosome aneuploidies. Screening methods discussed include biochemical screening, ultrasound screening for soft markers and structural abnormalities, and non-invasive prenatal testing using cell-free DNA. Biochemical markers analyzed include PAPP-A, beta-hCG, AFP, uE3, and inhibin A. Soft markers seen on ultrasound include increased nuchal translucency, absent nasal bone, ech
Recurrent miscarriages need to be investigated actually. You had live births but now had four consecutive miscarriages. It is better to have a thrombophilia screen and products of conception needed to be send out for histopathology to check any chromosomal, congenital, structural anomaly.
Read More:https://www.icliniq.com/qa/miscarriage/why-am-i-having-frequent-miscarriages
Management of twin pregnancy with single fetal demise; Obstetrics - October 2019Kareem Alnakeeb
This document summarizes the current management of single fetal demise (sIUFD) in twin pregnancies. It discusses that sIUFD occurs in 3.7-6.8% of twin pregnancies and increases risks for the surviving twin. The management approach depends on chorionicity, gestational age, and whether the demise occurred in the first, second, or third trimester. For monochorionic twins after the first trimester, the surviving twin has increased risks of death, neurological issues, and preterm birth due to shared blood flow between twins. Conservative monitoring is recommended when possible to allow further fetal development, though delivery may be considered if the in utero environment is deemed hostile.
This document discusses multiple pregnancy (twins, triplets, etc.), including causes, complications, diagnosis and management. It notes that the incidence of multiple pregnancies has increased due to assisted reproductive technologies. Complications can include preterm birth, anemia, pregnancy-induced hypertension, and increased risk of stillbirth. Diagnosis involves ultrasound to determine chorionicity and number of fetuses. Management includes careful surveillance, diet supplementation, and deciding when to perform a cesarean delivery versus attempting a vaginal birth.
The document discusses two uncommon obstetrical procedures: the PUBS (Percutaneous Umbilical Blood Sampling) procedure and the EXIT (Ex Utero Intrapartum Treatment) procedure. The PUBS procedure involves using ultrasound to guide a needle into the umbilical vessels to sample or transfuse blood from the fetus. It is sometimes used therapeutically to treat fetal-maternal Rh incompatibility. The EXIT procedure involves partially delivering the fetus via caesarean section to perform an intervention such as establishing an airway before fully delivering the baby. Both procedures have specific anesthetic considerations including fetal anesthesia and uterine relaxation.
This document discusses various methods used to monitor fetal well-being during labor, including fetal heart rate monitoring, fetal blood sampling, fetal pulse oximetry, fetal electrocardiography, and ultrasound. It provides details on interpreting fetal heart rate patterns, the results of fetal blood sampling, and evidence regarding electronic fetal monitoring versus intermittent auscultation. While electronic fetal monitoring has increased cesarean rates compared to intermittent auscultation, studies have not found it reduces hypoxic ischemic encephalopathy or cerebral palsy rates.
The document provides information on two uncommon obstetrical procedures: the PUBS (Percutaneous Umbilical Blood Sampling) procedure and the EXIT (Ex Utero Intrapartum Treatment) procedure. The PUBS procedure involves using ultrasound guidance to insert a needle into the umbilical cord to sample fetal blood or perform a blood transfusion for Rh-incompatible pregnancies. The EXIT procedure involves performing a fetal intervention such as establishing an airway during a cesarean section while still maintaining placental circulation. Both procedures have unique anesthetic considerations including fetal paralysis, fetal anesthesia, and prolonged uterine relaxation.
Dr. John Snow popularized the use of pain relief during labor when he administered chloroform to Queen Victoria for the birth of her eighth child. The document discusses various methods of pain relief during labor, including non-pharmacological methods like Lamaze breathing techniques, and pharmacological methods like opioids administered parenterally or via neuraxial routes. It also addresses maternal and fetal risks, goals of labor analgesia, and the roles of obstetricians and anesthesiologists in managing labor pain.
Retinopathy of prematurity (ROP) is a developmental vascular disorder of the retina that occurs in preterm infants. The retina is incompletely vascularized at birth for infants born before 30 weeks gestation. Premature birth interrupts normal retinal vascularization, exposing the retina to abnormal oxygen levels. This can cause vasoconstriction and arrest of blood vessel growth. Later, abnormal neovascularization may develop, potentially leading to retinal detachment and blindness if not treated. Screening guidelines recommend examinations starting at 4 weeks of age for infants born before 30 weeks, with treatment indicated for "threshold" or "pre-threshold" ROP. Laser photocoagulation is the primary treatment, which ablates the av
This document summarizes common neonatal morbidities that can result from complications during pregnancy and delivery. It discusses how conditions like diabetes, hypertension, infection, and nutritional imbalances in the mother can negatively impact the health of the newborn. The summary provides management considerations for treating infants born with various medical issues and outlines how close collaboration between obstetric and neonatal clinicians is important for counseling families and ensuring the best outcomes for both mother and baby.
The document discusses the evaluation and management of non-immune hydrops fetalis (NIHF). It begins by defining NIHF and listing common ultrasound findings. It then discusses evaluating the fetus for various potential causes of NIHF, including chromosomal abnormalities, anemia, twin-twin transfusion syndrome, cardiovascular defects, infections, and tumors. A thorough clinical evaluation of the mother and fetus is recommended to identify treatable conditions. Counseling should explain available options which may include termination of pregnancy for untreatable cases or antenatal management and treatment when possible. A step-wise investigation is outlined including detailed ultrasound, Doppler, fetal echocardiogram, and maternal/fetal testing to identify the underlying cause.
Preterm labor is a multifactorial problem that current treatment options address only symptomatically rather than causally. Preventative treatment with progesterone can lower preterm birth rates in high-risk groups by over 30%. Tocolysis using beta-adrenergic agonists like terbutaline and fenoterol can be used to prevent premature labor by relaxing the uterus. However, these drugs often cause side effects from activating the sympathetic nervous system.
- Stillbirth is defined as fetal death occurring after 20 weeks of gestation or a fetal weight of at least 500 grams. The worldwide stillbirth rate is over 3 million per year.
- The causes of stillbirth are often unknown, but may include maternal conditions like diabetes or hypertension, fetal conditions like growth restriction, and placental conditions like abruption. Advanced maternal age, obesity, and multiple gestations are also risk factors.
- Evaluation of stillbirth includes fetal autopsy, placental examination, and genetic testing. However, the optimal testing and management for subsequent pregnancies after an unexplained stillbirth remains uncertain due to lack of evidence.
Chromosome abnormalities are common in live births, stillbirths, and early fetal losses. Cytogenetic testing is indicated for recurrent miscarriages, familial chromosome abnormalities, clinical findings suggestive of abnormalities, and chromosome breakage syndromes. Analysis methods include karyotyping, FISH, aCGH to detect deletions/duplications. Trisomy 21 is the most common genetic cause of intellectual disability. It is usually due to an extra maternal chromosome 21 and causes characteristic physical and developmental features. Prenatal testing options include invasive and noninvasive methods to diagnose trisomy 21.
Miscarriage is pregnancy loss before 22 weeks’ gestation based on the LMP or if gestation age is unknown, it is the loss of an embryo or a fetus of less than 500g.
Fetal therapy involves both non-invasive and invasive procedures to diagnose and treat conditions affecting the unborn baby. Non-invasive procedures include administering medications to the mother that will benefit the fetus, such as steroids to promote lung maturity. Invasive procedures include intravascular transfusions to treat fetal anemia and correct blood counts, as well as fetoscopy to biopsy tissues and treat abnormalities. These invasive procedures require ultrasound guidance and careful monitoring to minimize risks to the mother and fetus. Fetal therapy is a multidisciplinary effort involving many specialists working together to diagnose and treat issues during pregnancy and improve outcomes for the unborn baby.
This document discusses key statistics and information about twin pregnancies. Some key points include:
- Twin pregnancies account for 1% of all pregnancies and have increased risks of mortality and morbidity compared to singletons.
- Zygosity, chorionicity, and amnionicity determine the type and risks associated with different twin pregnancies.
- Monitoring for conditions like twin-twin transfusion syndrome is important in managing high-risk aspects of multiple gestations.
- Factors like discordant growth, vascular connections between twins, and single fetal demise can impact the health of twins.
This document discusses pregnancy and surgery, specifically addressing whether they can safely mix. It notes that around 0.75-2% of pregnancies involve surgery. The most common surgeries are appendectomy, cholecystectomy, adnexal disease procedures, and trauma procedures. It reviews important physiologic changes in pregnancy and rates of complications from surgery. It discusses fetal hazards, principles of teratology, and implications for anesthetizing pregnant patients. It provides FDA categories and reviews effects of specific anesthetic agents. The document emphasizes using minimal effective doses of historically safe drugs and avoiding maternal hypotension, hypoxia, and hypercarbia.
Intrauterine Growth Restriction (IUGR) refers to fetuses that are small for their gestational age and display signs of chronic hypoxia or failure to thrive. It occurs in approximately 3-5% of pregnancies and can be caused by fetal, placental or maternal factors that restrict the fetus's growth. Diagnosis involves measuring fetal growth via ultrasound and Doppler to assess blood flow. Management focuses on identifying and treating the underlying cause, optimizing maternal nutrition, and monitoring the fetus for signs of worsening condition or need for delivery. The risks of IUGR include complications for both mother and baby during pregnancy, birth, and long term health issues.
This document discusses ectopic pregnancy, which occurs when a fertilized egg implants outside the uterus, most commonly in a fallopian tube. It presents a significant health risk and is a leading cause of maternal death in early pregnancy. While the incidence of ectopic pregnancy has increased in recent decades, improved diagnosis and treatment have reduced mortality rates by 80%. Key aspects of managing ectopic pregnancy discussed include using transvaginal ultrasound, beta-hCG levels, and laparoscopy to detect high-risk cases early. Treatment options presented are expectant management, medical management using methotrexate, and surgical management via laparoscopy or laparotomy.
This document discusses pain management options for labor and cesarean sections. It provides an overview of common medications and techniques used such as epidurals for labor analgesia and spinal anesthesia for c-sections. It also discusses managing common side effects like itching and risks of certain medications. Recent studies investigating links between labor pain management and risk of postpartum depression are summarized as well.
This document discusses complications and management of monochorionic twin pregnancies. It notes that monochorionic twins have higher risks of fetal loss and neurological issues than dichorionic twins. Complications can include twin-twin transfusion syndrome, selective intrauterine growth restriction, single fetal demise, and congenital anomalies. Management may involve planned delivery between 34-36 weeks depending on the complication. For uncomplicated monochorionic twins, an aim is vaginal delivery from 36 weeks with monitoring, though risks remain. Caesarean delivery is recommended for complications like monoamniotic twins or conjoined twins. Close monitoring in a fetal medicine center is important due to the risks.
Investigations for iufd & sb, how to select?Wafaa Benjamin
Standard investigations for IUFD include maternal blood tests, Kleihauer test, serology for TORCH and syphilis, random blood glucose, HbA1c, and thyroid tests. Foetal and placental investigations include microbiology, karyotype, and post-mortem examination. Selective investigations may also be considered depending on clinical assessment and history, such as maternal coagulation tests if DIC is suspected, bacteriology if infection is suspected, and thrombophilia screening if placental disease is suspected. The diagnostic yield is highest with post-mortem examination of the baby and placenta, though consent is required. The cause remains unknown in about half of IUFD cases even after investigation.
This document discusses anesthesia considerations for fetal surgery procedures. It describes how open fetal surgery requires general anesthesia but minimal invasive procedures can be done with local or regional anesthesia. Ex-utero intrapartum treatment procedures are open fetal surgeries but can be done with regional anesthesia if uterine relaxation can be achieved without volatile anesthetics using intravenous nitroglycerin. Both maternal and fetal factors must be considered during fetal anesthesia as the fetus is at risk from hypothermia, hypoperfusion and hypoxia during surgery due to its immature organ systems.
Efectos fetales de la anestesia espinal maternaAnestesia Dolor
1. Spinal anesthesia is commonly used for cesarean sections due to advantages for the mother such as remaining awake for the birth and facilitating post-op pain relief. However, hypotension is a common side effect that can pose risks to both mother and baby if severe or prolonged.
2. The review found that no single method completely prevents hypotension during spinal anesthesia for c-section but the risk can be reduced through IV fluids, vasopressors like ephedrine or phenylephrine, and leg compression. Even minor hypotension may cause issues for the baby like transient carbon dioxide retention.
3. Fetal oxygenation is dependent on several factors like placental function, uterine and umbilical blood
This document discusses various methods used to monitor fetal well-being during labor, including fetal heart rate monitoring, fetal blood sampling, fetal pulse oximetry, fetal electrocardiography, and ultrasound. It provides details on interpreting fetal heart rate patterns, the results of fetal blood sampling, and evidence regarding electronic fetal monitoring versus intermittent auscultation. While electronic fetal monitoring has increased cesarean rates compared to intermittent auscultation, studies have not found it reduces hypoxic ischemic encephalopathy or cerebral palsy rates.
The document provides information on two uncommon obstetrical procedures: the PUBS (Percutaneous Umbilical Blood Sampling) procedure and the EXIT (Ex Utero Intrapartum Treatment) procedure. The PUBS procedure involves using ultrasound guidance to insert a needle into the umbilical cord to sample fetal blood or perform a blood transfusion for Rh-incompatible pregnancies. The EXIT procedure involves performing a fetal intervention such as establishing an airway during a cesarean section while still maintaining placental circulation. Both procedures have unique anesthetic considerations including fetal paralysis, fetal anesthesia, and prolonged uterine relaxation.
Dr. John Snow popularized the use of pain relief during labor when he administered chloroform to Queen Victoria for the birth of her eighth child. The document discusses various methods of pain relief during labor, including non-pharmacological methods like Lamaze breathing techniques, and pharmacological methods like opioids administered parenterally or via neuraxial routes. It also addresses maternal and fetal risks, goals of labor analgesia, and the roles of obstetricians and anesthesiologists in managing labor pain.
Retinopathy of prematurity (ROP) is a developmental vascular disorder of the retina that occurs in preterm infants. The retina is incompletely vascularized at birth for infants born before 30 weeks gestation. Premature birth interrupts normal retinal vascularization, exposing the retina to abnormal oxygen levels. This can cause vasoconstriction and arrest of blood vessel growth. Later, abnormal neovascularization may develop, potentially leading to retinal detachment and blindness if not treated. Screening guidelines recommend examinations starting at 4 weeks of age for infants born before 30 weeks, with treatment indicated for "threshold" or "pre-threshold" ROP. Laser photocoagulation is the primary treatment, which ablates the av
This document summarizes common neonatal morbidities that can result from complications during pregnancy and delivery. It discusses how conditions like diabetes, hypertension, infection, and nutritional imbalances in the mother can negatively impact the health of the newborn. The summary provides management considerations for treating infants born with various medical issues and outlines how close collaboration between obstetric and neonatal clinicians is important for counseling families and ensuring the best outcomes for both mother and baby.
The document discusses the evaluation and management of non-immune hydrops fetalis (NIHF). It begins by defining NIHF and listing common ultrasound findings. It then discusses evaluating the fetus for various potential causes of NIHF, including chromosomal abnormalities, anemia, twin-twin transfusion syndrome, cardiovascular defects, infections, and tumors. A thorough clinical evaluation of the mother and fetus is recommended to identify treatable conditions. Counseling should explain available options which may include termination of pregnancy for untreatable cases or antenatal management and treatment when possible. A step-wise investigation is outlined including detailed ultrasound, Doppler, fetal echocardiogram, and maternal/fetal testing to identify the underlying cause.
Preterm labor is a multifactorial problem that current treatment options address only symptomatically rather than causally. Preventative treatment with progesterone can lower preterm birth rates in high-risk groups by over 30%. Tocolysis using beta-adrenergic agonists like terbutaline and fenoterol can be used to prevent premature labor by relaxing the uterus. However, these drugs often cause side effects from activating the sympathetic nervous system.
- Stillbirth is defined as fetal death occurring after 20 weeks of gestation or a fetal weight of at least 500 grams. The worldwide stillbirth rate is over 3 million per year.
- The causes of stillbirth are often unknown, but may include maternal conditions like diabetes or hypertension, fetal conditions like growth restriction, and placental conditions like abruption. Advanced maternal age, obesity, and multiple gestations are also risk factors.
- Evaluation of stillbirth includes fetal autopsy, placental examination, and genetic testing. However, the optimal testing and management for subsequent pregnancies after an unexplained stillbirth remains uncertain due to lack of evidence.
Chromosome abnormalities are common in live births, stillbirths, and early fetal losses. Cytogenetic testing is indicated for recurrent miscarriages, familial chromosome abnormalities, clinical findings suggestive of abnormalities, and chromosome breakage syndromes. Analysis methods include karyotyping, FISH, aCGH to detect deletions/duplications. Trisomy 21 is the most common genetic cause of intellectual disability. It is usually due to an extra maternal chromosome 21 and causes characteristic physical and developmental features. Prenatal testing options include invasive and noninvasive methods to diagnose trisomy 21.
Miscarriage is pregnancy loss before 22 weeks’ gestation based on the LMP or if gestation age is unknown, it is the loss of an embryo or a fetus of less than 500g.
Fetal therapy involves both non-invasive and invasive procedures to diagnose and treat conditions affecting the unborn baby. Non-invasive procedures include administering medications to the mother that will benefit the fetus, such as steroids to promote lung maturity. Invasive procedures include intravascular transfusions to treat fetal anemia and correct blood counts, as well as fetoscopy to biopsy tissues and treat abnormalities. These invasive procedures require ultrasound guidance and careful monitoring to minimize risks to the mother and fetus. Fetal therapy is a multidisciplinary effort involving many specialists working together to diagnose and treat issues during pregnancy and improve outcomes for the unborn baby.
This document discusses key statistics and information about twin pregnancies. Some key points include:
- Twin pregnancies account for 1% of all pregnancies and have increased risks of mortality and morbidity compared to singletons.
- Zygosity, chorionicity, and amnionicity determine the type and risks associated with different twin pregnancies.
- Monitoring for conditions like twin-twin transfusion syndrome is important in managing high-risk aspects of multiple gestations.
- Factors like discordant growth, vascular connections between twins, and single fetal demise can impact the health of twins.
This document discusses pregnancy and surgery, specifically addressing whether they can safely mix. It notes that around 0.75-2% of pregnancies involve surgery. The most common surgeries are appendectomy, cholecystectomy, adnexal disease procedures, and trauma procedures. It reviews important physiologic changes in pregnancy and rates of complications from surgery. It discusses fetal hazards, principles of teratology, and implications for anesthetizing pregnant patients. It provides FDA categories and reviews effects of specific anesthetic agents. The document emphasizes using minimal effective doses of historically safe drugs and avoiding maternal hypotension, hypoxia, and hypercarbia.
Intrauterine Growth Restriction (IUGR) refers to fetuses that are small for their gestational age and display signs of chronic hypoxia or failure to thrive. It occurs in approximately 3-5% of pregnancies and can be caused by fetal, placental or maternal factors that restrict the fetus's growth. Diagnosis involves measuring fetal growth via ultrasound and Doppler to assess blood flow. Management focuses on identifying and treating the underlying cause, optimizing maternal nutrition, and monitoring the fetus for signs of worsening condition or need for delivery. The risks of IUGR include complications for both mother and baby during pregnancy, birth, and long term health issues.
This document discusses ectopic pregnancy, which occurs when a fertilized egg implants outside the uterus, most commonly in a fallopian tube. It presents a significant health risk and is a leading cause of maternal death in early pregnancy. While the incidence of ectopic pregnancy has increased in recent decades, improved diagnosis and treatment have reduced mortality rates by 80%. Key aspects of managing ectopic pregnancy discussed include using transvaginal ultrasound, beta-hCG levels, and laparoscopy to detect high-risk cases early. Treatment options presented are expectant management, medical management using methotrexate, and surgical management via laparoscopy or laparotomy.
This document discusses pain management options for labor and cesarean sections. It provides an overview of common medications and techniques used such as epidurals for labor analgesia and spinal anesthesia for c-sections. It also discusses managing common side effects like itching and risks of certain medications. Recent studies investigating links between labor pain management and risk of postpartum depression are summarized as well.
This document discusses complications and management of monochorionic twin pregnancies. It notes that monochorionic twins have higher risks of fetal loss and neurological issues than dichorionic twins. Complications can include twin-twin transfusion syndrome, selective intrauterine growth restriction, single fetal demise, and congenital anomalies. Management may involve planned delivery between 34-36 weeks depending on the complication. For uncomplicated monochorionic twins, an aim is vaginal delivery from 36 weeks with monitoring, though risks remain. Caesarean delivery is recommended for complications like monoamniotic twins or conjoined twins. Close monitoring in a fetal medicine center is important due to the risks.
Investigations for iufd & sb, how to select?Wafaa Benjamin
Standard investigations for IUFD include maternal blood tests, Kleihauer test, serology for TORCH and syphilis, random blood glucose, HbA1c, and thyroid tests. Foetal and placental investigations include microbiology, karyotype, and post-mortem examination. Selective investigations may also be considered depending on clinical assessment and history, such as maternal coagulation tests if DIC is suspected, bacteriology if infection is suspected, and thrombophilia screening if placental disease is suspected. The diagnostic yield is highest with post-mortem examination of the baby and placenta, though consent is required. The cause remains unknown in about half of IUFD cases even after investigation.
This document discusses anesthesia considerations for fetal surgery procedures. It describes how open fetal surgery requires general anesthesia but minimal invasive procedures can be done with local or regional anesthesia. Ex-utero intrapartum treatment procedures are open fetal surgeries but can be done with regional anesthesia if uterine relaxation can be achieved without volatile anesthetics using intravenous nitroglycerin. Both maternal and fetal factors must be considered during fetal anesthesia as the fetus is at risk from hypothermia, hypoperfusion and hypoxia during surgery due to its immature organ systems.
Efectos fetales de la anestesia espinal maternaAnestesia Dolor
1. Spinal anesthesia is commonly used for cesarean sections due to advantages for the mother such as remaining awake for the birth and facilitating post-op pain relief. However, hypotension is a common side effect that can pose risks to both mother and baby if severe or prolonged.
2. The review found that no single method completely prevents hypotension during spinal anesthesia for c-section but the risk can be reduced through IV fluids, vasopressors like ephedrine or phenylephrine, and leg compression. Even minor hypotension may cause issues for the baby like transient carbon dioxide retention.
3. Fetal oxygenation is dependent on several factors like placental function, uterine and umbilical blood
Anesthetic Effects On The Fetus And NewbornAhmed Shalabi
Anesthetics are generally not teratogenic, though some animal studies found increased abnormalities with nitrous oxide exposure. Epidemiological studies in humans found no association between anesthetic exposure and birth defects. While anesthetics are not structural teratogens, some may cause behavioral changes in developing brains by interfering with receptor development. Epidural analgesia is associated with increased maternal fever during labor, which epidemiological evidence links to higher risks of cerebral palsy and other neurological injuries in infants. However, the mechanisms linking epidurals, fever, and injury remain unclear.
This document discusses various methods of assessing fetal well-being during pregnancy, known as antepartum fetal monitoring. It describes tests such as fetal movement counting, non-stress tests, biophysical profiles, and Doppler velocimetry that evaluate factors like fetal heart rate, movement, tone and amniotic fluid to detect any complications. The goal is to allow intervention before fetal death or damage from hypoxia while avoiding unnecessary early delivery. Each test has benefits and limitations in accurately detecting issues with the placenta or fetus.
This document discusses the anesthetic management of non-obstetric surgery in pregnant patients. It covers objectives of maternal safety and fetal consideration. It provides data on the timing of surgeries during pregnancy and their indications. It also discusses the altered maternal physiology during pregnancy and the implications for anesthesia management, including changes to the respiratory, cardiovascular and coagulation systems. Potential risks to the fetus from surgery and anesthesia are outlined. Finally, it reviews various anesthetic agents and the current evidence regarding their teratogenicity in humans.
This document summarizes key information about immunological diseases that can affect pregnancy, including antiphospholipid syndrome (APS), systemic lupus erythematosus (SLE), and idiopathic thrombocytopenic purpura (ITP). It discusses the pathogenesis, diagnosis, and management of these conditions. For APS, it describes how antiphospholipid antibodies can cause pregnancy complications like miscarriage and preeclampsia. Treatment involves low molecular weight heparin and aspirin. For ITP, it explains how antibodies destroy platelets, increasing bleeding risk, and treatment may involve corticosteroids and IVIG when platelet counts are low.
1. Recurrent miscarriage, defined as three or more consecutive pregnancy losses, affects 1% of couples trying to conceive. Risk factors include advancing maternal and paternal age, previous miscarriages, antiphospholipid syndrome, genetic factors, anatomical abnormalities, endocrine disorders, immune factors, and certain infections.
2. Antiphospholipid syndrome, caused by antiphospholipid antibodies that inhibit trophoblast function and cause inflammation and thrombosis, is the most important treatable cause, present in 15% of recurrent miscarriage cases.
3. Other factors discussed include parental chromosomal rearrangements in 2-5% of cases, embryonic chromosomal abnormalities accounting for 30-57% of further miscarri
IVIG may prolong pregnancies complicated by Rh alloimmunization before 18-20 weeks by delaying the onset of severe fetal anemia requiring intrauterine transfusion compared to previous untreated pregnancies. However, the evidence is conflicting and more research is still needed.
A 21-year-old woman experienced anaphylaxis after receiving buccal misoprostol for labor induction at 41 weeks of gestation. She developed pruritus, flushing, urticaria, and laryngeal edema. Epinephrine and cesarean delivery were performed, allowing for safe delivery of the neonate with minimal maternal morbidity. This case report describes a rare occurrence of anaphylaxis induced by misoprostol during labor, highlighting the importance of prompt recognition and treatment of anaphylaxis when inducing labor to prevent maternal and neonatal complications.
This document discusses anesthesia for fetal surgeries and intrauterine procedures. It begins with an introduction to fetal surgeries and guidelines for performing them. It then categorizes fetal surgical interventions and discusses specific fetal conditions treated and interventions used. Some risks and benefits of fetal surgery are outlined. The document then focuses on anesthetic management for various procedures, including effects of anesthesia on the fetus and fetal monitoring. It provides details on anesthesia for minimally invasive procedures, open fetal surgery, and fetal response and analgesia. In summary, it is a comprehensive overview of fetal surgeries, conditions treated, and considerations for anesthetic management.
This document provides an overview of hypertension in pregnancy. It begins with classifications of hypertensive disorders in pregnancy and risk factors. The pathophysiology involves placental insufficiency causing endothelial dysfunction and an imbalance of vasoactive substances. Clinical manifestations involve multiple organ systems due to failure of autoregulation from high blood pressure. Management involves monitoring, prevention of complications, and delivery when indicated to resolve the condition.
This document discusses teratogenesis and environmental exposures that can increase risks during pregnancy. It defines a teratogen as an agent that can interfere with normal embryo or fetal development. While major birth defects are usually considered, teratogens can also increase risks of other adverse outcomes. About 10% of major birth defects are due to environmental exposures. The document reviews historical cases of recognized teratogens like thalidomide and discusses principles of teratology, mechanisms of pathogenesis, adverse case reports, and pregnancy registries for monitoring drug safety.
Optimization of ovarian stimulation to improve success rate in ‘ART’Apollo Hospitals
ART is defined as the technique used where there is a need for in-vitro preparation or manipulation of gametes. The commonest ARTs are intrauterine insemination (IUI) and in-vitro fertilization (IVF). Ovarian stimulation is required with these procedures to increase the pregnancy rate as ART with natural cycle has a very low pregnancy rate. Optimizing pregnancy rates per cycle is the real basis for ovarian stimulation protocols in ART.
Pharmacodynamics and kinetics during pregnancyReem Alyahya
This presentation discuss the following objectives:
-Drug therapy during pregnancy, childbirth, and lactation.
-Physiological changes of drugs in pregnant women.
-Drug toxicity
-Cross-placental transfer of drugs
-Exertion of drugs in breast milk
-Drug safety + ABCDX
This document discusses the physiological changes that occur during pregnancy and how they impact anesthesia. It covers hematological, cardiovascular, respiratory, gastrointestinal and other organ system changes. Key points include a 40% increase in maternal blood volume, decreased uterine blood flow in the supine position, decreased FRC making mothers more susceptible to hypoxemia, and increased risk of gastric aspiration due to decreased LES tone. Regional anesthesia is preferred for c-sections to allow mother/baby bonding while avoiding neonatal drug exposure from general anesthesia. Precautions must be taken to prevent hypotension from regional blocks.
This document summarizes research on decreased fetal movements (FMs) as perceived by pregnant women. It discusses how a reduction in FMs can indicate fetal distress but is difficult to define. Methods for monitoring FMs like cardiotocography (CTG), Doppler ultrasound, biophysical profiles, and vibroacoustic stimulation are reviewed. While these tests are used to assess fetuses with reduced movements, evidence of their clinical benefits is limited. Current guidelines for managing decreased FMs are based on inconsistent evidence. More research is needed to establish standardized definitions and evidence-based management protocols.
Non Obstetric Surgery in Pregnant Patients discusses considerations for anesthesia when performing non-obstetric surgery on pregnant patients. Anesthesiologists must provide safe anesthesia for both the mother and fetus by considering the physiological changes of pregnancy and avoiding fetal asphyxia, teratogenic drugs, and preterm labor. Regional anesthesia techniques like spinal or epidural blocks are preferred when possible due to advantages like limited drug exposure to the fetus. Surgery should generally be performed in the second trimester to balance maternal and fetal risks. Fetal monitoring is recommended during procedures to assess fetal well-being.
This document summarizes the physiological changes that occur during pregnancy and discusses their implications for anesthesia. Key points include:
- Blood volume, plasma volume, and cardiac output increase significantly during pregnancy to meet demands of the uterus, placenta, and fetus. Regional anesthesia can cause hypotension due to further decreases in peripheral resistance.
- Respiratory function changes include elevated diaphragm and decreased functional residual capacity, making pregnant women more susceptible to hypoxemia. Rapid sequence induction requires pre-oxygenation.
- Gastrointestinal changes like decreased lower esophageal sphincter tone increase risk of regurgitation and aspiration under general anesthesia. Regional techniques are preferred for labor and delivery.
Similar to Anesthesia for fetal surgery techniques (20)
This bill seeks to ensure that women seeking abortions after 20 weeks of fertilization are informed about evidence that unborn children at this stage of development can experience pain during certain abortion procedures. The bill cites several findings regarding the capacity for unborn children to feel pain after 20 weeks of development, as well as existing laws and regulations that aim to protect animals and fetuses from unnecessary pain and discomfort. If passed, it would add a new title to the Public Health Service Act requiring abortion providers to inform women of the pain the unborn child could experience during the procedure.
The document discusses evidence related to whether a fetus can experience pain. It summarizes the development of anatomical structures and pathways involved in pain perception in a fetus from 8 weeks gestation onwards. It also discusses physiological evidence from preterm infants that suggests nociceptive pathways are functional from 24-26 weeks gestation. The document considers arguments that a fetus may experience pain in a primitive way without requiring consciousness, self-consciousness, or previous experience. It notes evidence that early painful experiences can have long-term effects on stress responses and sensitivity to pain.
An unborn child has the capacity to feel pain by 20 weeks gestation according to scientific evidence. By this point in development, the neural pathways, nerve tracts, thalamus, and cortex necessary to feel pain are all present. Studies show the unborn child responds to touch as early as 6 weeks and releases stress hormones when injected with a needle at 18 weeks, similar to the stress response in adults feeling pain. While abortion methods do not provide anesthesia to the unborn child, commercial livestock must be rendered insensible to pain before slaughter according to federal law.
This document discusses two approaches to understanding associative learning: the propositional approach and the dual-system approach. The propositional approach argues that associative learning results from controlled reasoning processes, while the dual-system approach argues it results from both controlled reasoning and the automatic formation of links between mental representations. The authors review evidence from past research and conclude that there is little support for the automatic link-formation mechanism proposed by the dual-system approach. Instead, they argue learning is better understood as resulting from propositional reasoning processes.
This document discusses the concept of fetal pain and whether a fetus is capable of perceiving pain. It explores definitions of pain, the anatomical and neurophysiological development of the fetal nervous system, and behavioral responses to stimuli. While connections from the spinal cord to the thalamus develop by 20 weeks, and thalamocortical connections are present from around 26 weeks, the document notes debate around whether these are necessary for pain perception. It concludes that while the very young fetus is likely incapable of feeling pain, the capacity for pain perception likely develops before full term birth.
The document reviews the development of the fetal pain system and debates whether a fetus can feel pain. It finds that:
1) While reflex reactions to noxious stimuli can occur very early in development, cortical processing required for the emotional experience of pain likely only emerges after 26 weeks of gestation with the development of thalamo-cortical connections.
2) Before the cortex is involved, noxious stimuli can still trigger stress responses that affect development.
3) Rather than speculate on fetal pain, the clinically relevant aim is to avoid noxious stimuli to prevent their potential adverse effects on development.
This document summarizes a research article about the mental capacities of newborn infants. It argues that while newborns appear helpless, research shows they have an integrated consciousness and can engage in synchronized interactions with caregivers. This suggests newborns have intersubjective minds, emotions, and motives for social engagement. The study of infant cognition required moving beyond theories of the mind as developing through experience and language alone, to recognize innate capacities for shared intentionality and cultural learning from birth.
1) The article proposes that the primary function of consciousness is to integrate competing demands from specialized systems in the nervous system that influence skeletal muscle plans.
2) These "supramodular systems" operate in parallel to control actions like breathing, pain response, elimination, but can only collectively influence action through consciousness.
3) During a "supramodular conflict", when different systems demand opposing skeletal muscle actions, consciousness is necessary to integrate the systems and determine the appropriate response.
This commentary agrees with Shanahan's view that language acquisition has an emotional basis. It provides a supplementary neuroscience perspective, arguing that:
1) Primary-process emotional systems in subcortical brain regions like the central amygdala generate affective intensity, not just secondary cognitive processes.
2) Social-emotional systems like separation distress, nurturance, play, and lust motivated the development of inter-subjective communication between mothers and infants, which may have promoted linguistic prosody.
3) Early affective communication through melodic "motherese" engages infants more than cognitive thought, and music is tightly linked to language in brain and development. Language may have evolved from our emotional nature through
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The study recorded EEG signals simultaneously from the scalp and thalamus of 7 patients undergoing deep brain stimulation for essential tremor. The patients performed a go/no-go task where they had to either execute or withhold a cued finger movement based on subsequent go or no-go cues. Event-related potentials differentiated between go and no-go conditions earlier at thalamic recording sites compared to scalp sites, suggesting the thalamus is involved in early classification of go and no-go instructions. Correlations between thalamic and frontal scalp responses were stronger for no-go activities, indicating the thalamus provides information to frontal areas involved in inhibiting prepared actions. The findings support a role for the thalamus
The document discusses whether a fetus can feel pain and at what gestational age. It examines the anatomical, physiological, and behavioral evidence. While the fetus's experience of pain cannot be directly measured, the neural pathways for pain are developed by 20 weeks gestation. The fetus shows stress responses to invasive procedures from 16 weeks onward. Therefore, it is possible the fetus can feel pain from 20 weeks of gestation. More research is needed to fully understand fetal pain and how to provide appropriate analgesia during invasive prenatal procedures.
This document summarizes recent research on the development of nociceptive (pain-sensing) circuits in infants. It discusses how:
1) Nociceptive neurons are specified early in development through molecular pathways involving tyrosine kinase receptors and neurotrophic factors.
2) Functional synapses and neural circuits in the dorsal horn develop over the first postnatal weeks through changes in excitatory and inhibitory synaptic transmission.
3) Sensory activity, both non-nociceptive and excessive nociceptive inputs, can influence the development of pain processing circuits in early life.
More from South Dakota Pain Capable Unborn Child Protection Act (20)
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These slides walk through the story of 1 Samuel. Samuel is the last judge of Israel. The people reject God and want a king. Saul is anointed as the first king, but he is not a good king. David, the shepherd boy is anointed and Saul is envious of him. David shows honor while Saul continues to self destruct.
Chapter wise All Notes of First year Basic Civil Engineering.pptxDenish Jangid
Chapter wise All Notes of First year Basic Civil Engineering
Syllabus
Chapter-1
Introduction to objective, scope and outcome the subject
Chapter 2
Introduction: Scope and Specialization of Civil Engineering, Role of civil Engineer in Society, Impact of infrastructural development on economy of country.
Chapter 3
Surveying: Object Principles & Types of Surveying; Site Plans, Plans & Maps; Scales & Unit of different Measurements.
Linear Measurements: Instruments used. Linear Measurement by Tape, Ranging out Survey Lines and overcoming Obstructions; Measurements on sloping ground; Tape corrections, conventional symbols. Angular Measurements: Instruments used; Introduction to Compass Surveying, Bearings and Longitude & Latitude of a Line, Introduction to total station.
Levelling: Instrument used Object of levelling, Methods of levelling in brief, and Contour maps.
Chapter 4
Buildings: Selection of site for Buildings, Layout of Building Plan, Types of buildings, Plinth area, carpet area, floor space index, Introduction to building byelaws, concept of sun light & ventilation. Components of Buildings & their functions, Basic concept of R.C.C., Introduction to types of foundation
Chapter 5
Transportation: Introduction to Transportation Engineering; Traffic and Road Safety: Types and Characteristics of Various Modes of Transportation; Various Road Traffic Signs, Causes of Accidents and Road Safety Measures.
Chapter 6
Environmental Engineering: Environmental Pollution, Environmental Acts and Regulations, Functional Concepts of Ecology, Basics of Species, Biodiversity, Ecosystem, Hydrological Cycle; Chemical Cycles: Carbon, Nitrogen & Phosphorus; Energy Flow in Ecosystems.
Water Pollution: Water Quality standards, Introduction to Treatment & Disposal of Waste Water. Reuse and Saving of Water, Rain Water Harvesting. Solid Waste Management: Classification of Solid Waste, Collection, Transportation and Disposal of Solid. Recycling of Solid Waste: Energy Recovery, Sanitary Landfill, On-Site Sanitation. Air & Noise Pollution: Primary and Secondary air pollutants, Harmful effects of Air Pollution, Control of Air Pollution. . Noise Pollution Harmful Effects of noise pollution, control of noise pollution, Global warming & Climate Change, Ozone depletion, Greenhouse effect
Text Books:
1. Palancharmy, Basic Civil Engineering, McGraw Hill publishers.
2. Satheesh Gopi, Basic Civil Engineering, Pearson Publishers.
3. Ketki Rangwala Dalal, Essentials of Civil Engineering, Charotar Publishing House.
4. BCP, Surveying volume 1
Chapter wise All Notes of First year Basic Civil Engineering.pptx
Anesthesia for fetal surgery techniques
1. Seminars in Fetal & Neonatal Medicine 15 (2010) 40–45
Contents lists available at ScienceDirect
Seminars in Fetal & Neonatal Medicine
journal homepage: www.elsevier.com/locate/siny
Anesthesia for fetal surgery
Kha M. Tran*
Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia, and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
s u m m a r y
Keywords: Fetal surgery pushes the limits of knowledge and therapy beyond conventional paradigms by treating the
Fetal anesthesia developing fetus as a patient. Providing anesthesia for fetal surgery is challenging for many reasons. It
Fetal surgery requires integration of both obstetric and pediatric anesthesia practice. Two patients must be anes-
Fetal therapy
thetized for the benefit of one, and there is little margin for error. Many disciplines are involved, and
Placental circulation
communication must be effective. Conducting anesthetic research with vulnerable populations, such as
pregnant women and their fetuses, is difficult, and many questions remain unanswered. Work must be
done in the study of possible neurotoxicity caused by exposure of developing brain to anesthetic agents.
The effects of stress on the developing fetus must also be further examined. Optimal anesthetic regimens
remain to be determined.
Ó 2009 Elsevier Ltd. All rights reserved.
1. Introduction increased nerve sensitivity, hormonal changes in pregnancy,
reduced protein levels, and pH changes in the cerebrospinal fluid.
Fetal surgery is a rapidly evolving discipline. The idea of treating Pregnancy also increases sensitivity to non-depolarizing muscle
the fetus as a patient is not intuitive and has its roots in the 1960s relaxants.
when intraperitoneal blood transfusions were performed for the Management of the airway of a pregnant woman is potentially
treatment of erythroblastosis fetalis. Invasive surgical therapies in more difficult. Engorgement of the airway mucosa has multiple
humans began in the 1980s after rigorous study in animal models. implications. Smaller endotracheal tubes must be used and nasal
These cases involved maternal laparotomy and hysterotomy to intubation may cause epistaxis. The potential for difficult intuba-
access and treat fetuses. The anesthetic techniques developed to tion is increased and airway complications are a significant factor in
facilitate these invasive procedures are based on the physiology of anesthesia-related morbidity and mortality.2–5 Oxygen consump-
the pregnant woman and fetus and also are derived from an tion increases and functional residual capacity (FRC) decreases,
understanding of the procedure to be performed. increasing the risk for hypoxia.
Pregnancy is a high cardiac output state. At term, cardiac output
is increased by about 50% from non-pregnant values.1 Systemic
2. Physiology vascular resistance is decreased by about 20% secondary to vaso-
dilation and the addition of the placenta, a low-resistance circuit.
2.1. Maternal Supine hypotension may result from aortocaval compression.
During pregnancy, plasma volume increases relatively more than
The physiologic changes of pregnancy impact anesthetic red blood cell volume increases, and hemoglobin concentrations
management. Many organ systems are affected, the most relevant fall.
being the neurologic, respiratory, cardiovascular, gastrointestinal, The pregnant patient is at risk for aspiration of gastric contents.
and hematologic systems. Generally, maternal sensitivity to anes- Displacement of the stomach and decreased lower esophageal
thetic agents is increased.1 Minimum alveolar concentration (MAC) sphincter tone may allow reflux of gastric contents. Intragastric
for isoflurane and halothane is lower in pregnancy. Increased pressure is highest in the third trimester. Gastric emptying of solids
dermatomal spread of epidural anesthetics is likely due to and liquids is slowed during labor.1
The coagulation system is in a state of accelerated, compensated
intravascular coagulation. This hypercoagulable state is suggested
* Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, 9th
Floor, Main Hospital, Philadelphia, PA 19104, USA. Tel.: þ1 215 590 1858;
by an increase in the majority of coagulation factors, a decrease in
fax: þ1 215 590 1415. prothrombin and partial thromboplastin times, and a decrease in
E-mail address: trank@email.chop.edu antithrombin III. Increased fibrinolysis is suggested by an increase
1744-165X/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.siny.2009.05.004
2. K.M. Tran / Seminars in Fetal & Neonatal Medicine 15 (2010) 40–45 41
of fibrin degradation products. Attention must be paid to whereas phenylephrine could be used if the maternal heart rate
thromboprophylaxis. were high.
Neuraxial and general anesthetics have variable effects on
2.2. Fetal uterine blood flow. As long as maternal systemic pressure is
maintained, epidural anesthesia does not alter uterine blood flow
Fetal physiology is complex. Neurologic pathways for cortical in elective cesarean sections.22 Pain and stress will decrease uterine
transmission of noxious stimuli in humans are still developing into blood flow.23 Relief of pain with an epidural may attenuate this
the third trimester.6 With both isoflurane and halothane, the reduction. Barring resultant hemodynamic changes, intravenous
anesthetic requirement of fetal lambs is lower than that of a preg- induction agents (thiopental, propofol, etomidate, and ketamine)
nant ewe.7,8 Perception and processing of pain is controversial, but do not affect uterine blood flow greatly. Volatile anesthetics
noxious stimuli will elicit a physiologic response in the human decrease uterine tone and increase risk of bleeding.24 Light and
fetus, as evidenced by increases in cortisol, b-endorphin, and moderate levels of volatile anesthesia will slightly depress blood
decreases in the pulsatility index of the fetal middle cerebral pressure, but uterine vasodilation maintains blood flow. In a sheep
artery.9 model of fetal surgery, with deeper levels of volatile anesthesia,
The placenta acts as the organ of respiration, and a major role of uterine vasodilation cannot compensate for the reductions in blood
the lung in utero is production of fetal lung fluid. Restriction of pressure and cardiac output, and fetal acidosis occurs.25 However, it
egress of this fluid results in pulmonary hyperplasia, whereas is important to note that no medications were given to the preg-
continuous drainage results in hypoplasia.10 nant ewes to support their blood pressure while undergoing
The fetal circulation is notable for being a parallel system prior general anesthesia with high doses of volatile agent. Maternal
to transitioning to a serial circulation at birth. The fetal myocar- hypocapnea or hyperventilation with positive pressure will likely
dium has a higher proportion of non-contractile elements, and is decrease uterine blood flow and fetal oxygen tension. Hypercapnea
also stiffer than adult myocardium.11 Increases in preload will may increase fetal oxygen tension.26
provide minimal, if any, incremental increases of stroke volume Simple mechanical factors are important in the maintenance of
and cardiac output.12 Variation in heart rate provides a relatively uteroplacental perfusion and fetal oxygen delivery. Occlusion of the
greater contribution to variation in cardiac output. This lack of umbilical cord, either from loss of amniotic fluid or from surgical
response to preload has been attributed to poor compliance of the manipulation, will cause rapid deterioration in the condition of the
myocardium, but may also be due to extrinsic compression of the fetus. Likewise, integrity of the uteroplacental interface must also
fetal heart that is relieved with aeration of the lungs and clear- be maintained. Intraoperative separation of the placenta from the
ance of lung fluid.13 uterus is catastrophic.
The blood volume of a fetus varies during gestation. At 16–22
weeks, blood volume of the fetoplacental unit has been estimated 2.4. Placental transport
at 120–162 mL/kg of fetal weight.14,15 It is important to note that
about two-thirds of the blood volume is contained on the placental Factors controlling placental drug transfer include size, lipid
portion of the fetoplacental unit.16 solubility, protein-binding pKa, pH of fetal blood, and blood flow.
The coagulation system evolves throughout the fetal and High lipid solubility allows rapid transfer, but may result in trap-
neonatal period. The fetus produces coagulation factors indepen- ping of drug in the placenta. Local anesthetics and opioids have
dently of the mother, and these factors do not cross the placenta.17 higher acid dissociation constants and may be trapped in ionized
The plasma concentrations of these proteins increase with form in the fetal circulation if the fetal pH is lower than the drug’s
increasing gestational age. pKa. Protein binding has a variable effect depending on the
While in utero, fetal temperature is linked to maternal particular drug and protein interaction.
temperature. A fetus exposed through a hysterotomy during open Although newer volatile anesthetics such as desflurane and
surgery needs to increase heat production, but it cannot. Mainte- sevoflurane have not been studied as thoroughly as halothane and
nance of fetal normothermia during open surgery can be chal- isoflurane, the low molecular weight and lipid insolubility of these
lenging due to the lack of shivering and non-shivering medications should allow rapid transfer with relatively high fetal/
thermogenesis, the immature skin barrier, and increased evapora- maternal (F/M) ratios. Halothane and isoflurane have an F/M ratio
tive losses. of 0.7–0.9 and 0.7 respectively.27,28 The F/M ratio of nitrous oxide is
0.83.29
2.3. Uteroplacental blood flow Thiopental crosses rapidly into the fetal circulation, but F/M
ratios range widely, between 0.4 and 1.1.30 Propofol has been
The fetus depends on intact uteroplacental blood flow and studied at both term and mid-gestation and F/M ratios range
patent umbilical vessels for respiration and nutrition. Uterine blood between 0.5 and 0.85.30 Propofol infusions may be used for
flow, while a surrogate for fetal oxygen delivery, does correlate with maternal sedation in early pregnancy for minimally invasive
fetal umbilical venous PO2.18 Uterine blood flow is directly related cases. Diazepam is a commonly used drug for maternal and fetal
to uterine perfusion pressure (the difference between uterine sedation. Within minutes of injection the F/M ratio reaches unity
arterial and venous pressure), and inversely related to uterine and ratios approach 2.0 after an hour.30 Midazolam has an F/M
vascular resistance. For fetal surgical procedures, maternal hypo- ratio of 0.76 at term30 and is gaining popularity in minimally
tension, aortocaval compression, and uterine contractions decrease invasive cases. Morphine is also commonly used for maternal and
uterine blood flow. The effect of vasopressors, vasodilators, and fetal analgesia and sedation. The F/M ratio of fentanyl varied from
anesthetic agents on uterine blood flow is variable because these 0.16 to 1.2 in one small study of maternal intravenous adminis-
agents affect uterine arterial pressure and uterine vascular resis- tration.30 Remifentanil is a short-acting potent opioid that is
tance at the same time. Studies comparing ephedrine and phenyl- finding some use in both obstetric anesthesia and anesthesia for
ephrine for maintenance of blood pressure have shown no great fetal surgery.31
clinical differences in neonatal outcome and lend slightly more Succinylcholine in large (300 mg) or repeated doses crosses
support to phenylephrine to support maternal blood pressure.19–21 the placenta and affects the fetus. Non-depolarizing muscle
Ephedrine is a logical choice if the maternal heart rate is low, relaxants and anticholinesterase agents are large, ionized
3. 42 K.M. Tran / Seminars in Fetal & Neonatal Medicine 15 (2010) 40–45
molecules that do not easily cross the placenta. Vecuronium F/M minimally invasive procedures, a multidisciplinary team meeting is
ratios are 0.06–0.11. Atropine readily crosses the placenta as held with the family to introduce the team, discuss the details, and
opposed to glycopyrrolate which has a mean F/M ratio of 0.22. A address concerns from any of the parties.
case of fetal bradycardia has been attributed to placental passage
of neostigmine. Ephedrine crosses the placenta readily with an F/ 4.2. Preoperative preparation
M ratio of 0.7.30
Preparation begins with the standard anesthetic history and
3. Surgical issues physical examination. Specific questions for the mother should
evaluate respiratory or circulatory compromise by the gravid
3.1. Minimally invasive interventions uterus, as evidenced by symptoms of shortness of breath or
light-headedness. More severe symptoms of aortocaval
These are the most frequently performed fetal surgical proce- compression would call for meticulous left uterine displacement
dures. The uterine cavity is accessed percutaneously with needles and would raise the level of suspicion in a mother with persis-
and small sheaths. Visualization of structures is provided non- tent hypotension after induction of anesthesia. Severity of
invasively by ultrasound and by fetoscopes inserted through the gastroesophageal reflux may change the anesthetic plan in
sheaths. Minimally invasive techniques allow for a wide range of minimally invasive cases where maternal sedation is considered.
therapeutic options via a variety of operative techniques. Maternal imaging and blood work will be guided by the history
The access may be as minor as one small gauge radiofrequency and physical examination. A type and screen is reasonable for
probe or may be as involved as multiple trocars for a robot-assisted most minimally invasive fetoscopic cases; open cases should not
myelomeningocele (MMC) repair in the fetal sheep model. Endo- proceed without cross-matched blood for the mother and type
scopes range from 1.0 to 3.8 mm external diameter.32 The timing of O-negative blood for the fetus immediately available. Maternal
these procedures is typically in early or mid-gestation. antibodies to blood antigens can cross the placenta, and the
O-negative blood for the fetus can be cross-matched with the
3.2. Open mid-gestation surgery maternal sample.
Specific fetal information is also needed. Location of the
After induction of anesthesia, a maternal laparotomy is per- placenta affects patient positioning. The estimated fetal weight is
formed. The location of this incision is usually transverse, but more used to determine dosage of fetal drugs. The actual disease process
cephalad than that performed for a low-segment transverse and pathophysiology, and the extent of anatomic or physiologic
cesarean section. The fetus is exposed, but only the necessary derangement, will give the providers an idea of the physiologic
anatomy is delivered via the hysterotomy. For example, in an MMC reserve of the fetus. Fetal studies to elucidate the lesion and extent
closure, the lesion is exposed, while the rest of the fetus remains of physiologic derangements include ultrasound, echocardiog-
bathed in amniotic fluid in the uterus. If a fetal thoracotomy is raphy, and fetal magnetic resonance imaging. Serial studies track
planned, an arm is delivered, and the shoulder and chest are the changes. Lung lesions may grow or shrink, airway compression
exposed while the rest of the fetus remains in the uterus. After may worsen or resolve, combined cardiac outputs may change,
surgery and wound closure, the fetus is replaced in the uterus, and hydrops fetalis may ensue, and polyhydramnios may develop at any
warmed Ringer’s lactate is infused to restore amniotic volume. time.
Antibiotics are also instilled into the amniotic fluid. The uterus is Aspiration prophylaxis in the obstetric population includes oral
closed and a flap of omentum is sewn over the uterine closure to sodium citrate, histamine receptor blockers or proton pump
help seal it and prevent amniotic fluid leakage. inhibitors, and prokinetic agents such as metoclopramide.
3.3. Ex-utero intrapartum therapy (EXIT) procedure 4.3. Minimally invasive
Whereas both cases start in a similar fashion, the EXIT proce- These cases are the most variable in the need for maternal
dure has several key differences when compared with open mid- analgesia and anesthesia, and in the need for fetal analgesia or
gestation cases. Since the fetus will be delivered at the end of the immobility. Communication with the surgical team is vital. An
case, these procedures are performed at or near term to optimize anesthetic plan can range from local anesthetic infiltration to
lung maturity. Before the umbilical cord is clamped, surgical sedation to neuraxial to general anesthesia. Medications can be
intervention is performed that will allow successful transition to given directly to the mother by the anesthesia team and, thus,
extrauterine life.33 This intervention may involve laryngoscopy, indirectly to the fetus by placental transfer. Medications can also
rigid bronchoscopy, intubation, tracheostomy, or it may involve be given directly to the fetus by the surgical team. Route of direct
resection of large lung lesions while on placental bypass.34 After administration can be variable; intramuscular, intravenous, and
completion of the procedure, the newborn is managed by team intracardiac routes have been described.9,35,36 Maternal analgesia
headed by a neonatologist for further resuscitation and manage- can often be accomplished with local anesthetic infiltration,
ment in an intensive care unit. whereas in other cases, a neuraxial technique or general anes-
thesia may be necessary. Fetal monitoring is typically limited
4. Anesthetic plan to measurement of the fetal heart rate by the obstetricians
with an ultrasound. Echocardiography may be used in cardiac
4.1. Teamwork/communication interventions.
Instrumentation for treatment of twin-to-twin transfusion
Fetal surgical cases require teamwork. The disciplines that syndrome has shrunk in size and invasiveness has decreased.
interact may include pediatric general surgery, obstetrics, pediatric Previously, at the author’s institution, these procedures were
anesthesia, obstetric anesthesia, cardiology, radiology, neonatology, performed with general anesthesia or neuraxial techniques. These
neonatal nursing, and operating room nursing. At our institution, procedures are now done with sedation. The current practice at
weekly meetings keep team members apprised of new patients and our institution includes maternal fasting, one intravenous (IV)
new developments with existing patients. Before open or catheter, aspiration prophylaxis, and tocolysis with preoperative
4. K.M. Tran / Seminars in Fetal & Neonatal Medicine 15 (2010) 40–45 43
indomethacin. Light sedation is administered to the mother to Intravenous crystalloid administration is kept to a minimum
provide maternal comfort and decreased fetal movement. Multiple because of the risk of maternal pulmonary edema after fetal
regimens have been used successfully, including combinations of surgery.40 Administration of 500 mL of crystalloid for a case is
opioids and other sedatives such as benzodiazepines or propofol. typical. Swings in blood pressure are likely to be exacerbated by
In a randomized double-blind trial comparing diazepam and restrictive administration of fluids and frequent use of vasopres-
remifentanil for fetal immobilization in minimally invasive sors. Clinically, the maternal blood pressure improves with exte-
surgery, the remifentanil group (0.1 mg/kg/min) had significantly riorization of the uterus and with surgical manipulation.
less fetal movement and surgeons reported better operating Phenylephrine and ephedrine should be prepared. Vasopressor
conditions.37 Initially tocolysis involved preoperative indometh- infusions allow for smoother blood pressure control. Central
acin, postoperative magnesium infusions, and post-discharge oral venous pressure measurement has guided fluid therapy in the
nifedipine or subcutaneous terbutaline. Post-discharge tocolysis is past, but has not been used recently.
now rare. Severe intravenous fluid restriction is no longer routine. After exposure of the fetus, an intramuscular injection of
Pulmonary edema has been reported after fetoscopic surgery, but fentanyl (20 mg/kg), atropine (20 mg/kg), and vecuronium (0.2 mg/
this case was more likely due to absorption of irrigation fluids kg) is given by the surgical team. Amniotic fluid is lost through
through venous channels in the myometrium than a capillary leak the hysterotomy, but is replaced with a continuous infusion of
phenomenon.38 Since surgical techniques vary, intravenous fluid warmed Ringer’s lactate using a Level 1 infusion device. If fetal IV
restriction may be necessary, as well as a close accounting of access is necessary it is obtained, and IV tubing is handed over the
irrigation used during these cases. drapes to the anesthesia team. Monitoring of the fetus in these
By contrast with the anesthetic for complicated twin gesta- cases may include direct observation, heart rate by ultrasound,
tions, providing anesthesia for balloon dilation of fetal aortic fetal echocardiography, and pulse oximetry.41,42 If a pulse oxi-
stenosis involves maternal general endotracheal anesthesia and meter is placed by the surgical team, the hand is covered with
intramuscular administration of fentanyl, vecuronium, and atro- sterile foil to prevent artifact from the operating room lights, and
pine to the fetus.39 The potential risks of administration of a sterile cable is passed to the anesthesia team. Fetal oxygen
general anesthesia in a pregnant woman are outweighed by the saturation ranges from 40% to 70%.43,44 Fetal echocardiographic
need for a completely immobile mother and fetus, along with the monitoring is continuous. Cardiac filling, contractility, and rate,
potential need for fetal analgesia as the catheters and needles are along with patency of the ductus arteriosus, are helpful in anes-
advanced through the fetal chest wall and heart. These two thetic management of the fetus. Umbilical blood gas measure-
different techniques, both for minimally invasive surgery, illus- ment may be used in selected cases.
trate the need for collaboration between the teams to prioritize The anesthesia team must watch closely for fetal bradycardia,
needs and balance risks and benefits to arrive at an optimal maternal or fetal bleeding, and maternal blood pressure changes.
anesthetic plan. Careful observation and understanding of the events occurring in
Strategies must be in place for failed procedures or fetal distress. the surgical field is important. A decrease in fetal oxygen saturation
These plans will depend on the gestational age of the fetuses, their is an indicator of fetal distress.41 In the absence of a decrease in fetal
projected viability and preoperative discussion with the family. oxygen saturation, a common sign of fetal distress is bradycardia.
Plans may range from supportive or palliative therapy to emergent Blood products should be readily available. Prior to resection of
cesarean delivery. large chest lesions, a transfusion of warm packed red blood cells
may improve fetal hemodynamic stability. With closure of the
4.4. Open mid-gestation uterus, tocolysis is begun with a bolus of IV magnesium sulfate, the
epidural block is initiated, and the volatile anesthetic is reduced.
Open mid-gestation surgery requires significant uterine relax- The maternal abdomen is closed, and the mother is extubated
ation. General endotracheal anesthesia with high-dose volatile awake.
(two times the minimum alveolar concentration) is most often used
to achieve uterine relaxation for open surgery. Desflurane is the 4.5. EXIT
agent chosen at our institution because its low solubility allows for
rapid emergence from deep anesthesia. Intravenous nitroglycerin Several key differences for the EXIT procedure are due to the fact
can also be used to augment uterine relaxation. Relaxation allows that the fetus is to be delivered at the conclusion of the case.
for easier fetal manipulation and decreases the likelihood of initi- Uterine relaxation is only needed intraoperatively, not post-
ation of labor from uterine surgical manipulation. Relaxation may operatively. Magnesium sulfate is not given. Another difference is
allow increased uterine blood flow as long as maternal blood the need for two operating rooms and a resuscitation area for the
pressure is maintained, and results in fetal exposure to some neonatal team. General endotracheal anesthesia is used at our
volatile anesthetic agents. The mother is at risk for hypotension institution to provide high dose volatile anesthetics, but adequate
both from the anesthetic agents and from aortocaval compression. uterine relaxation with neuraxial anesthetic and nitroglycerin
The desired systemic blood pressure should be close to baseline. infusion has been reported.45,46 After the patient has been
After fasting, placement of a peripheral IV line, oral tocolysis adequately anesthetized, the surgical team passes sterile items off
and aspiration prophylaxis, a high lumbar epidural is placed for the field for the anesthesia team. These may include tubing for IV
postoperative analgesia. A test dose of local anesthesia is given, fluids, pulse oximeter cables, and oxygen tubing for a sterile
but if volatile anesthesia is used, no other local anesthetic is given Mapleson D circuit. Distinguishing fetal fluids and medication from
until the end of the case. Under standard monitoring, left uterine maternal fluids and drugs is important to avoid confusion espe-
displacement, preoxygenation, rapid sequence induction and cially in emergent or urgent parts of the procedure. Fetal well-being
intubation take place. An orogastric tube, Foley catheter, and leg is monitored with pulse oximetry, heart rate, and possibly echo-
compression devices are placed. Ventilation should maintain cardiography. Following maternal laparotomy, placental mapping
normocapnia. Because of the risk for rapid bleeding, a second and hysterotomy, the fetus is externalized as little as possible to
large-bore peripheral IV line is placed. An arterial catheter is permit surgical approach to the lesion while continuing umbilical
placed because small changes in maternal blood pressure may blood flow. An intramuscular injection of narcotic and muscle
have dramatic effects on fetal perfusion, heart rate and function. relaxant is given. Once the airway is secured or lesion resected,
5. 44 K.M. Tran / Seminars in Fetal & Neonatal Medicine 15 (2010) 40–45
surfactant is given to the fetus if premature and the lungs are
ventilated. It is important that no ventilation take place until the Practice points
umbilical cord is ready to be divided. Increases in oxygen satura-
tion, the presence of end-tidal CO2, and good chest movement are First do no harm: remember maternal safety.
indicators of successful intubation. Fiberoptic bronchoscopy can be The anesthetic plan should be based on understanding
also be used as confirmation. The baby is delivered for care by the of maternal and fetal physiology and the needs of the
case.
neonatal surgical team.
Communication is vital.
Once the umbilical cord is divided, uterine relaxation must be
Minimally invasive cases present the widest range of
promptly reversed. Administration of oxytocin and rapidly anesthetic possibilities.
decreasing the inspired concentration of volatile anesthetic is Open mid-gestation cases require intense intraoperative
adequate in most cases, but methylergonovine and prostaglandin uterine relaxation and postoperative tocolysis.
F2a should be readily available. After uterine tone is established, the EXIT procedures require intense intraoperative uterine
hysterotomy is closed. After maternal hemodynamic stability is relaxation and planning for the post-EXIT care of the
ensured, the epidural catheter is dosed to provide postoperative neonate in the form of neonatology and secondary
analgesia. The mother is extubated awake. operating room teams.
Additional considerations for EXIT procedure include the pres-
ence of both a neonatologist and a second operating room team.
The neonatal team receives the newborn if the EXIT is technically
successful, and the operating room team is prepared to take the
newborn and complete the surgery when the EXIT procedure is not Research directions
successful.
Quantification of human fetal exposure to anesthetic
agents.
4.6. Intraoperative fetal resuscitation Examination of the effects of anesthetics on the devel-
oping brain.
Fetal distress may occur during any surgical procedure and may Examination of the effects of surgical stress on the fetus.
result from cord compression or kinking, placental separation, high Fetal outcome studies with various anesthetic
techniques.
uterine tone, maternal hypotension, hypoxia, or anemia. Fetal
hypothermia, hypovolemia and anemia are also potential causes of
fetal distress. Cardiac dysfunction may result from prolonged
exposure to high doses of volatile anesthetic agents. As with any
change in vital signs, the cause of the derangement must be sought Conflict of interest statement
while therapy begins.
Good condition of the mother must be ensured. The umbilical None declared.
cord must be patent, aortocaval compression should be avoided,
and the integrity of the uteroplacental unit must also be
Funding sources
confirmed. Fetal distress and new-onset maternal hypotension
may result from occult placental abruption. Ultrasound can be
None.
used to confirm this diagnosis. Direct observation of the fetus can
assist with these diagnoses. The surgical team will be able to
confirm adequate uterine relaxation, and fetal echocardiography References
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