FETAL SURGERY: TECHNIQUES - Perioperative Management and Preterm Labor
Posted by Surgery on Sep 26, 2008
The fetal surgery operative team is also a multidisciplinary effort and includes two pediatric surgeons, a maternal fetal medicine specialist with particular skill in obstetrical ultrasonography, an obstetric anesthesiologist, and possibly a neonatology resuscitation team at the ready, depending on the gestational timing of surgery and its indications. The operative steps of the entire procedure are performed by the lead pediatric surgeon with assistance from the others as necessary. (=:Cardizem=)The mother is positioned with left uterine displacement to avoid inferior vena cava compression by the gravid uterus, and she and her baby are anesthetized with a halogenated agent. Maternal monitoring is accomplished with routine noninvasive monitoring. There are two surgical approaches to the fetus; one involves opening the uterus (open hysterotomy) and delivering the fetal part to be repaired, the other employs minimal access techniques.
Perioperative Management and Preterm Labor
Postoperatively, preterm labor occurs in 100% of patients, but to a varying degree (19,20:Cardizem). Indomethacin, magnesium sulfate, and terbutaline are the mainstays of postoperative tocolysis. Before discharge to home, maintenance tocolysis is instituted in the form of oral Nifedipine or a terbutaline pump.
Fetal surgery thus far has established a very safe maternal track record. With the everpresent threat of preterm labor, all patients experience postoperative uterine contractions. The mean time to delivery following fetal surgery has been reported to be 10 weeks at a mean gestational age of 34 weeks (15:Cardizem). Despite the effect of uterine manipulation on the likely release of vasoactive mediators, there have been few other predictable maternal morbidities (21:Cardizem).
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