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Anesth Analg 2000;91:500
© 2000 International Anesthesia Research Society

LETTERS TO THE EDITOR

Anesthesia for Fetal Intervention

Miriam J. P. Harnett, MB, FFARCSI, and Ronald Hurley, MD

Department of Anesthesiology, Perioperative and Pain Management Brigham and Women’s Hospital Harvard Medical School Boston, MA 02115

The anesthetic management for the fetal operation on placental support procedure has been previously described (1–3). However, the advantages of combining general with regional anesthesia/analgesia for this procedure has not been described.

A 21-yr-old, gravida 2, para 1 parturient was referred to our hospital for cesarean delivery and the operation on placental support procedure. Early in her pregnancy, she had been diagnosed as having polyhydramnios. Subsequent investigation by using ultrasound and magnetic resonance imaging revealed that the fetus had an extremely large cervical teratoma–extending from the base of the tongue to the sternal notch–which completely occluded the trachea.

An epidural catheter was sited at the L2-3 interspace. After the induction of anesthesia, profound uterine relaxation was maintained with sevoflurane (end tidal 2.8%–2.9%) in 100% oxygen during cesarean delivery while a surgical airway was established in the fetus. With the baby delivered but with placental circulation still intact, direct laryngoscopy, followed by rigid bronchoscopy, revealed that intubation was not possible. Therefore, a surgical airway was established via a tracheostomy. The umbilical cord was then clamped, and 5 units of oxytocin was given IV, followed by an oxytocin infusion. Sevoflurane was discontinued immediately to facilitate uterine contraction. Analgesia was provided with 10 mL of bupivacine 0.25% and 100 µg of fentanyl via the epidural catheter in divided doses over the following 10 minutes, and midazolam 2 mg and fentanyl 100 µg were administered IV to supplement anesthesia. Surgery was completed in 45 minutes. The patient was comfortable on awakening. Total blood loss was 1000 mL. Postoperative analgesia was provided with a continuous infusion of 0.125% bupivacine with fentanyl 2 µg/mL. Three milligrams of preservative-free morphine was administered before the removal of the epidural catheter the following morning.

Apart from providing intraoperative and postoperative analgesia, the presence of an epidural catheter allows complete discontinuation of the volatile agent after cord clamping. This should promote immediate and sustained uterine contraction and, therefore, reduce the likelihood of uterine atony and subsequent massive obstetric hemorrhage.

References

  1. Tanaka M, Sato S, Naito H, Nakayama H. Anaesthetic management of a neonate with prenatally diagnosed cervical tumor and upper airway obstruction. Can J Anaesth 1994;41:236–40.[Abstract/Free Full Text]
  2. Gaiser RR, Cheek TG, Kurth CD. Anesthetic management of cesarean delivery complicated by ex utero intrapartm treatment of the fetus. Anesth Analg 1997;84:1150–3.[ISI][Medline]
  3. Shih GH, Boyd GL, Vincent RD, et al. The EXIT Procedure facilitates delivery of an infant with a pretacheal teratoma. Anesthesiology 1998;89:1573–5.[ISI][Medline]




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press