Marc Van de Velde, MD, PhD
Professor of Anaesthesia, Catholic University Leuven (KUL)
Chair Department of Anaesthesiology, University Hospitals Leuven (UZL)
Leuven, Belgium
Anesthesia for fetal surgery: what to expect – what’s
expected.
Conflict of Interest
• Holder of the “Baxter UZ Leuven Anaesthesia Research Chair 2012 – 2014”
• Holder of the “Noble Gas research fund” supported by Air Liquide.
• Received financial support of the following companies for either research,
consulting or lectures:
– AstraZeneca.
– Glaxo Smith Kline.
– Air Liquide.
– BBraun.
– Baxter.
– Abbott.
– Smiths Medical.
– Nordic Pharma.
– Sintetica.
• Currently involved in multicenter trials initiated by the following pharmaceutical
companies:
– MSD; Air Liquide
Outline.
• Types of surgery: what to expect ?
• Anesthesia for fetal surgery: techniques and
what is expected from us ?
• Fetal pain perception !
• EXIT procedure.
Criteria for fetal surgery.
• Accurate diagnosis possible, no associated anomalies.
• Natural history documented and prognosis established.
• No effective postnatal therapy.
• In utero surgery effective in animals.
• Interventions performed in specialized multdisciplinary
centers, approval of local ethics committee and consent
of parents.
Open surgery Keyhole surgery
FETAL SURGERY
Most important complication:
PPROM and Preterm labour
Fetus or PlacentaFetus
Diemert et al. Dtschl Arzeblt Int 2012; 109, 603 - 608.
TTTS: laser ablation for twin to twin transfusion syndrome
Deprest et al. Sem Fetal Neonatal Med 2006; 11, 398 - 412.
Diemert et al. Dtschl Arzeblt Int 2012; 109, 603 - 608.
Senat et al. NEJM 2004; 351, 136 - 144.
GRADE I evidence
Diemert et al. Dtschl Arzeblt Int 2012; 109, 603 - 608.
Deprest, Nikolaides and Gratacos. Fetal Diagn Ther 2010; 29, 6 - 17.
Isolated congenital diaphragmatic hernia.
Isolated congenital diaphragmatic hernia.
Deprest, Nikolaides and Gratacos. Fetal Diagn Ther 2010; 29, 6 - 17.
Isolated congenital diaphragmatic hernia.
Deprest et al. Sem Fetal Neonatal Med 2006; 11, 398 - 412.
Deprest, Nikolaides and Gratacos. Fetal Diagn Ther 2010; 29, 6 - 17.
Isolated congenital diaphragmatic hernia.
Isolated congenital diaphragmatic hernia.
Deprest et al. Sem Fetal Neonatal Med 2006; 11, 398 - 412.
Deprest et al. Sem Fetal Neonatal Med 2006; 11, 398 - 412.
Diemert et al. Dtschl Arzeblt Int 2012; 109, 603 - 608.
Adzick J Ped Surg 2012; 47, 273 - 281.
Adzick et al. NEJM 2011; 364, 993 - 1004.
Adzick et al. NEJM 2011; 364, 993 - 1004.
Adzick et al. NEJM 2011; 364, 993 - 1004.
Lower birthweight
Adzick et al. NEJM 2011; 364, 993 - 1004.
Less
intracranial
pathology
postnatal
Adzick et al. NEJM 2011; 364, 993 - 1004.
Better
psychomotor
development
Iatrogenic rupture of membranes.
Deprest et al. Prenatal Diagnosis 2011; 31, 661 - 666.
Deprest et al. Prenatal Diagnosis 2011; 31, 661 - 666.
29 / 48
> 30 weeks
Outline.
• Types of surgery: what to expect ?
• Anesthesia for fetal surgery: techniques and
what is expected from us ?
• Fetal pain perception !
• EXIT procedure.
Maternal IV remifentanil.
• Easy to titrate.
• Short acting IV opioid.
• Successful immobilization of the
fetus.
• Excellent transplacental passage.
Van de Velde et al. Anesth Analg 2005; 101, 251 - 258.
Van de Velde et al. Anesth Analg 2005; 101, 251 - 258.
General Anaesthesia.
• General anaesthesia:
– Rapid sequence induction.
– Maintenance with inhalational
anaesthetics.
– Once baby delivered: propofol and
opioids + epidural anaesthesia.
• Epidural catheter for postoperative
analgesia.
Maternal monitoring / installation.
• Epidural catheter.
• Arterial and CVP lines.
• Good IV access.
• Blood and IV fluid heating.
• Standard monitoring: ECG, etCO2
and saturation.
Open surgery – EXIT: issues.
• Maintain normal uteroplacental
perfusion.
• Monitoring of fetus.
• Blood loss.
• Uterine relaxation.
Outline.
• Types of surgery: what to expect ?
• Anesthesia for fetal surgery: techniques and
what is expected from us ?
• Fetal pain perception !
• EXIT procedure.
The New York Times Magazine 2008
Does the fetus feel pain ?
Indications and strategies to treat
fetal pain.
Does the fetus experience pain ?
Anatomy Neurophysiology
Behavior Stress response
Anatomical pathways 1. Peripheral receptors:
7-20 weeks.
2. Afferent fibers: C-fibers
8-30 weeks.
3. Spino-thalamic fibers:
16-20 weeks.
4. Thalamo-cortical fibers:
17-24 weeks.
5. Efferent-inhibitory
fibers after birth.
Fitzgerald M. Pain Res Clin Management 1993; 3, 19 - 36.
Lowery et al. Sem Perinatol 2007; 31, 275.
Anatomical pathways
Lowery et al. Sem Perinatol 2007; 31, 275.
Neuro-physiological data
• Primitive EEG: 19 weeks.
• Sustained EEG: 22 weeks.
• Somato-sensory evoked
potentials: 24 weeks.
• Structured EEG: 26 weeks
• EEG with sleep-awake
patterns: 28 – 30 weeks.
• => nociceptive systems
functional from 24 weeks.
Glover and Fisk. Brit J Obstet Gynecol 1999; 106, 881-886.
Klimach and Cooke. Develop Med Chil Neurol 1988; 30, 208 – 214.
Behavior
• Movement to external stimuli: 8
weeks.
• Reaction to sound: 20 weeks.
• Behavioral response to painful
stimuli: 22 weeks (premature
infants).
• Differentiation of sound: 28 weeks.
Prechtl. Early Hum Dev 1985; 12, 91 - 98.
De Vries. Early Hum Dev 1985; 12, 301 – 322.
Fetal Stress Response
• Measurement of
stress hormones:
– Cortisol.
– β – endorphin.
– Noradrenaline.
• Regional fetal blood
flow.
Giannakoulopoulos et al. The Lancet 1994; 344, 77-81.
β-endorphin and cortisol.
Giannakoulopoulos et al. The Lancet 1994; 344, 77-81.
Pain perception from 24 weeks
Pain perception possible from
14 - 16 weeks
Long term implications: Hyperalgesia
Taddio et al. The Lancet 1997; 349, 599 - 603.
Nerve sprouting
Reynolds et al. J Comp Neur 1995; 358, 487 - 498.
– Does the fetus feel pain ?
– Indications and strategies to treat fetal
pain.
Indications to treat fetal pain.• Direct surgical trauma of the fetus.
• Late termination of pregnancy (> 20 weeks ???): analgesia +
fetocide.
• Endoscopic, intrauterine surgery on placenta, cord and
membranes.
– To avoid fetal movements:
• To improve surgical exposure.
• To avoid fetal pain.
• Painful, non-lethal conditions ???
• Vaginal delivery – instrumental vaginal delivery ????
Outline.
• Types of surgery: what to expect ?
• Anesthesia for fetal surgery: techniques and
what is expected from us ?
• Fetal pain perception !
• EXIT procedure.
CONCLUSIONS
• Fetal surgery is a clinical reality and no longer an
experimental procedure.
• Many challenges to the anaesthetist.