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164]

Review Article

Foetal surgery: Anaesthetic implications and

strategic management

Address for correspondence: Bhavani Shankar Kodali, Shobana Bharadwaj

Dr. Bhavani Shankar Kodali, University of Maryland Medical Center, University of Maryland, Baltimore, Maryland, USA
Department of Anesthesiology,
University of Maryland Medical
Center, 22 S Green Street, ABSTRACT
Baltimore, MD 21201, USA.
E‑mail: bkodali@som.
Intrauterine surgery is being performed with increasing frequency. Correction of foetal anomalies in
umaryland.edu
utero can result in normal growth of foetus and a healthier baby at delivery. Intrauterine surgery can
also improve the survival of babies who would have otherwise died at delivery, or in the neonatal
period. There are three commonly used approaches to correct foetal anomalies: open surgery,
where the foetus is exposed through hysterotomy; percutaneous approach, where needle or
foetoscope is inserted through the abdominal wall and the uterine wall; finally, ex utero intrapartum
treatment (EXIT) surgery, where the intervention is performed on the baby before terminating the
Access this article online maternal umbilical support to the baby. Anaesthetic management of the mother and the foetus
Website: www.ijaweb.org requires good understanding of maternal physiology, foetal physiology, and pharmacological and
surgical implications to the foetus. Uterine relaxation is a critical requisite for open foetal procedures
DOI: 10.4103/ija.IJA_551_18
and EXIT procedures. General anaesthesia and/or regional anaesthesia can be used successfully
Quick response code
depending on the nature of foetal intervention. Foetal surgery poses complications not only to
the foetus but also to the mother. Therefore, the decision for undertaking foetal surgery should
always consider the risk to the mother versus benefit to the foetus.

Key words: Anaesthesia for foetal surgery, EXIT procedure, foetal surgery, foetoscopy,
intrauterine surgery

INTRODUCTION of maternal and foetal implications of anaesthetics

is critical for optimum management of mother and
Intrauterine surgery is becoming popular for treating foetus during foetal intervention. It is also critical to
foetal congenital anomalies.[1] This has provided many understand the physiological changes in pregnancy that
foetuses with significant anomalies to survive to influence anaesthetic management [Table 1]. Tables 2a
full‑term pregnancy and beyond.[2] Many factors have and b summarise essential guidelines of anaesthetic
contributed to the success of this newly evolved field management of a pregnant woman undergoing surgery.
such as improvements in diagnostic and therapeutic
technology, advances in understanding foetal Approximately over 1000 such cases are performed
pathophysiology, and the natural history of many every year. This number is likely to increase in the
of these conditions. Foetal intervention procedures future with advances in technology, attainment of foetal
include open foetal surgery, minimally invasive intervention skills, and enthusiasm to perform foetal
foetal surgery, ex utero intrapartum treatment (EXIT) interventions based on positive results of published
procedures (intervention at caesarean delivery), foetal data.
endoscopic surgery, and laser ablation of umbilical
This is an open access journal, and articles are distributed under the terms of the
cords in twin pregnancies. An important consideration Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which
of intrauterine foetal intervention is that it should allows others to remix, tweak, and build upon the work non‑commercially, as long as
appropriate credit is given and the new creations are licensed under the identical terms.
not jeopardise the safety of the mother. In most cases,
For reprints contact: reprints@medknow.com
foetal intervention is performed during pregnancy and
pregnancy is continued to term. In some instances, How to cite this article: Kodali BS, Bharadwaj S. Foetal surgery:
EXIT surgery is performed on the foetus on placental Anaesthetic implications and strategic management. Indian J Anaesth
support, followed by delivery. An understanding 2018;62:717-23.

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Kodali and Bharadwaj: Anaesthesia for foetal surgery

Procedures amenable to foetal intervention drugs on the foetus is minimal with regional
Table 3 lists indications of foetal interventions that are anaesthesia. During our experience of over two
currently being performed. With further proficiency, decades, we have transitioned from general anaesthesia
new indications are forthcoming.[3‑11] One of the most to regional anaesthesia for minimally invasive
common indications is aortic valvoplasty in the foetus. procedures [aortic valvoplasty, Table 4 and Figure 1].[12]
This improves the growth and performance of the General anaesthesia was a preferred technique during
left ventricle at birth. Generally, each center of foetal the earlier phase of our practice. This was based on the
intervention offers one or two procedures which may perception that uterine relaxation and foetal analgesia
be considered their field of expertise. were essential requirements of foetal intervention.[12,13]
Foetuses undergoing procedures at mid to late gestation
Anaesthesia for minimally invasive procedures may have the requisite neural development for pain
The choice of anaesthesia depends on invasive and stress response.[14] Hormonal and haemodynamic
procedure. Regional anaesthesia is the preferred stress responses do suggest that foetuses respond to
technique where feasible. The impact of anaesthetic noxious stimuli.[15,16] Therefore, foetal analgesia is a
prime concern to be addressed during anaesthesia for
Table 1: Anatomical and Physiological Changes of foetal surgery. Although it was our belief two decades
Pregnancy ago that uterine relaxation was necessary for minimally
System Changes invasive surgery, such as aortic valvoplasty, experience
Cardiovascular Cardiac output increases 30%‑50%, systemic over a decade suggests that uterine relaxation for
system vascular resistance decreases 30%, blood
volume increases by about 50% minimally invasive procedures was not essential.
Respiratory Minute ventilation increases 40%‑50%, oxygen
system consumption increases 20%‑40%, function
residual capacity is reduced 20%, normal PaCO2
is 28‑32 mmHg
Gastrointestinal Upward rotation of stomach, increased incidence
system of reflux due to progesterone
Haematologic Plasma volume increases more than red blood
system cell volume increases, most clotting factors
increase
Renal system Renal blood flow and glomerular filtration rate
increases decreasing creatinine
Nervous Minimum alveolar concentration decreases by
system 30%‑40%
More extensive block after neuraxial anaesthesia
Anatomic Weight gain and increased vascularity of mucus
membrane

Table 2a: General anaesthesia in a pregnant patient

Figure 1: Ultrasound-guided needle placement into foetal left ventricle.
Position Left or right uterine displacement
A balloon catheter placed through the needle across the aortic valve
Premedication Oral sodium citrate 30 mL to facilitate aortic valvuloplasty
Metoclopramide 10 mg intravenous
Induction Rapid sequence propofol and
succinylcholine Table 3: Intrapartum foetal interventions
Ventilatory adjustments Keep PETCO2 32‑34 mmHg Minimally invasive foetal surgery procedures
Maintenance Desflurane, sevoflurane, or isoflurane, Twin‑twin transfusion syndrome: laser ablation of blood vessels[9,10]
fentanyl, oxygen in air, and muscle Obstructive uropathy: shunt insertion and valve ablation[3]
relaxants (vecuronium, rocuronium) Aortic or pulmonary stenosis: valvuloplasty[11]
Haemodynamics Blood pressure within 20% baseline Cyanotic heart disease: atrial septostomy[8]
through boluses of ephedrine or Congenital diaphragmatic hernia: tracheal balloon occlusion[4]
phenylephrine; noninvasive cardiac output
Spina bifida: fetoscopic closure of the malformation[5]
is an additional adjuvant in monitoring
Twin reversed arterial perfusion: radiofrequency ablation[6]
Open foetal surgery
Table 2b: Regional anaesthesia in a pregnant patient Myelomeningocele repair
Epidural anaesthesia Sacrococcygeal teratoma excision
Combined spinal epidural anaesthesia Resection of intrathoracic masses
Maintain blood pressures and cardiac output as close to baseline Congenital diaphragmatic ‑ temporary tracheal occlusion
during the procedure Congenital cystic adenoid malformation ‑ excision

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Kodali and Bharadwaj: Anaesthesia for foetal surgery

Table 4: Data from reference 12, 1999–2005

Cases by Year and Diagnosis
Year Total cases Cardiac EXIT Tracheal clip Bladder shunt TTTS
1999 2 0 1 1 0 0
2000 3 1 2 0 0 0
2001 9 2 6 0 0 1
2002 12 10 2 0 0 0
2003 20 14 2 0 2 2
2004 19 18 0 0 0 1
2005 24 21 1 0 0 2
Total 89 66 14 1 2 6
Anesthetic technique
Foetal anomaly n Intervention GA RA GA + RA
Bladder obstruction 2 Shunt 0 2 0
Twin Transfusion 4 Cord ligation 2 2 0
Diaphragmatic hernia 12 EXIT 8 0 4
Restrictive Ventricle septum 8 Septostomy 6 0 2
Pulmonary stenosis 5 Balloon 3 0 2
Aortic stenosis 46 Balloon 28 0 18
EXIT – Ex utero intrapartum treatment; TTTS – Twin-twin transfusion syndrome; GA – General anaesthesia; RA – Regional anaesthesia

Moreover, administration of minimum alveolar general anaesthesia for providing postoperative

concentration (MAC) over 1.5 can have depressant pain relief. As an alternative, administration of
effect on the foetal myocardium. Administration of a preoperative intrathecal opioid can be used.
foetal intramuscular fentanyl (ultrasound‑guided) can Both methods are equally efficacious in providing
resolve the foetal pain concern. Foetal intramuscular postsurgical pain relief. General anaesthesia by a
injection of fentanyl along with a neuromuscular rapid sequence induction, followed by maintenance
blocking agent ensures foetal immobility and foetal of anaesthesia using inhalational anaesthetic
analgesia. Combined spinal epidural anaesthesia agents, is a preferable technique as inhalational
provides optimum conditions for minimally invasive agents provide dose‑dependent uterine relaxation
procedures such as aortic valvoplasty. One milliliter necessary for optimum foetal surgical exposure.[18,19]
of hyperbaric bupivacaine 0.75% with dextrose, with Isoflurane, sevoflurane, and desflurane have been
or without fentanyl 10 µg, provides an adequate level used successfully, although the latter two are more
for foetal intervention. Left uterine displacement and potent than isoflurane.[20] To prevent hypotension
monitoring of blood pressure are essential to maintain and foetal bradycardia, supplemental IV medications
blood pressures within close limits of baseline. can be used in the initial stages of anaesthesia and
Recently, we have been using a noninvasive cardiac inhalational agents are used when foetal exposure
output device to continuously monitor cardiac output.
is required.[21] A two to three MAC concentration of
The cardiac output data and blood pressure data provide
inhalational agents is required for desired uterine
valuable information while choosing the appropriate
relaxation and exposure. An arterial line will be
vasopressors [maternal intravenous (IV) phenylephrine
helpful to monitor maternal blood pressure accurately.
and/or ephedrine]. Maintenance of maternal
Central venous pressure monitoring is rarely required.
haemodynamics near normal values assures a steady
Additional nitroglycerine boluses (50–100 µg IV) or
cardiovascular state at the time of foetal intervention.
infusion (0.5–1 µg/kg/min) can be used to supplement
Medications that may be used for foetal anaesthesia and
uterine relaxation, when inhalational agents are
immobility are fentanyl 10–50 µg/kg and vecuronium
not sufficient. If neuraxial anaesthesia is being used
0.1–0.3 mg/kg. Resuscitation medications for the foetus
include epinephrine 1 μg/kg, and atropine 0.02 mg/kg. for foetal surgery, IV nitroglycerine offers a good
If foetal packed red blood cell transfusion becomes method to achieve uterine relaxation. However,
necessary, cytomegalovirus‑free, leukocyte‑depleted this may be associated with maternal tachycardia,
O‑negative blood can be considered.[1,17] tachyphylaxis, methaemoglobinemia, headache,
and pulmonary oedema.[22,23] Before uterine incision,
Open foetal surgery placental position is ascertained. Uterine incision
Surgery on the foetus is facilitated by a hysterotomy. is made with a stapling device to prevent excessive
An epidural can be placed before induction of uterine bleeding. The amniotic sac membranes are
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Kodali and Bharadwaj: Anaesthesia for foetal surgery

sealed to the endometrium. Amniotic infusion with

warm lactated Ringer’s solution is used to maintain
foetal temperature, maintain uterine volume, and
avoid compression of umbilical cord.[23] Vasopressors
are required to maintain blood pressure during
the procedure because of vasodilatory effects of
inhalational agents and/or nitroglycerine. Additional
monitoring of cardiac output through arterial line is a
good adjuvant in maintaining cardiovascular stability.
Guarded administration of IV fluids is recommended
to prevent maternal pulmonary oedema following
foetal surgery. Foetal monitoring during the procedure
can be achieved with pulse oximetry, continuous or
intermittent echocardiography, foetal scalp electrodes, Figure 2: A foetus with a neck tumor. Airway being secured before
and umbilical blood sampling.[18] disrupting uteroplacental–umbilical cord blood flow (EXIT)

Despite the transfer of inhalational agents from maternal procedures also facilitate transition to extracorporeal
to foetal circulation, which may be unpredictable, membrane oxygenation for oxygenation of the baby
fentanyl for analgesia and muscle relaxant for foetal and maintaining on the system until cardiorespiratory
immobility can be administered intramuscularly to anomaly is corrected and the baby can oxygenate
the foetus. Volatile anaesthetics can be discontinued well on its own. Once the oxygenation of the baby
or decreased soon after uterine closure. Anaesthesia is assured without the need of maternal support,
can be maintained by propofol infusion. Maternal the baby is delivered from the uterus and umbilical
postoperative pain should be controlled with IV circulation is terminated. Procedures involving longer
opioids. An intrathecal narcotic, if given prior to than 2 h have been successfully performed using EXIT
general anaesthesia, can adequately supplement procedures.[26]
analgesia to decrease postoperative pain. If an epidural
is placed prior to general anaesthesia, epidural The majority of EXIT procedures are performed
postoperative analgesia can be provided. Extubation under general anaesthesia using high concentrations
should be performed with minimal coughing to of volatile anaesthetics at the time of hysterotomy to
avoid uterine dehiscence. Adequate postoperative facilitate uterine relaxation.[23] Uterine relaxation is
pain control is associated with lower oxytocin essential for facilitating the controlled delivery of the
concentrations in the blood, thereby decreasing foetal head and maintaining the placental circulation
premature uterine contractions.[24] Preoperative rectal by preventing placental separation from the uterus.
indomethacin (50 mg) and postprocedure magnesium Vasoactive medications will be necessary to maintain
sulphate (4–6 g IV loading dose followed by 1–2 g/h IV blood pressure. Arterial blood pressure monitoring
infusion) are administered for tocolysis.[25] Terbutaline is preferable for titration of vasoactive medications.
and nifedipine are used as supplements if above are Cardiac output monitoring can provide additional
ineffective. data for choosing vasoactive medications. Maintaining
maternal blood pressures and cardiac output closer to
EXIT (ex utero intrapartum treatment procedures) baseline ensures adequate placental blood flow.
This is also known as operation on placental circulation.
The intervention can be performed with vaginal or The usual precautions of general anaesthesia for
caesarean delivery. The latter is preferable as it offers caesarean delivery apply to EXIT procedures.
greater control and longer duration of placental support. After the baby is delivered, uterotonics should be
Usually, these procedures are reserved for foetuses who administered and inhalational agents are terminated.
are unable to oxygenate upon delivery due to airway As the concentration of induction agents decrease, IV
abnormalities. An example of this is securing the propofol can be administered for maintaining general
baby’s airway at the time of delivery, where the airway anaesthesia. A Bispectral Index Monitor can assure
is compressed by a tumor (cystic hygroma), and while adequate depth of anaesthesia for this transition
the baby is supported by the maternal circulation and maintain optimal depth of general anaesthesia.
through umbilical cord [Figures 2 and 3]. EXIT Postoperative analgesia can be achieved through an

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Kodali and Bharadwaj: Anaesthesia for foetal surgery

cord in twin reversed arterial perfusion, division of

amniotic bands in amniotic band syndrome, and
laser ablation of posterior urethral valves through
foetal cystoscopy are other procedures undertaken
using foetoscopy. A combined epidural spinal
anaesthesia as described below with sedation is
suitable for these procedures.

Mirror syndrome
Mirror syndrome is the development of maternal
a pulmonary oedema in the setting of severe
foetal hydrops. These patients can present with
preeclampsia‑like symptoms which can make
distinguishing between this condition and preeclampsia
difficult.[7] The most common maternal symptoms
are weight gain and maternal oedema (89.3%),
followed by elevated blood pressure (60.7%), mild
anaemia and haemodilution (46.4%), albuminuria
and proteinuria (42.9%), elevated uric acid and
creatinine (25%), mild elevated liver enzymes (19.6%),
oliguria (16.1%), and headache and visual
b disturbances (14.3%). Severe maternal complications
Figure 3: (a) Airway secured at EXIT procedure. (b) Surgical exicision including pulmonary oedema occur in 21.4% of
of cystic hygroma cases.[28] The average rate of intrauterine death and
stillbirth is 35.7%, and the average time until maternal
epidural route if there is a preexisting catheter. If symptoms disappear is about 8.9 days.[28] The etiology
not, systemic analgesics can be used. A transverse remains unclear, but the maternal symptoms are
abdominal plane block can offer additional analgesia. reversible by successful foetal intrauterine therapy
Overall risk of haemorrhage is increased due to atonic or, in certain cases with poor foetal prognosis, by
uterus. Crossed match blood should be available for foetal termination.[29] Foetal intervention includes
these procedures. placement of a peritoneal‑amniotic shunt. This
resolves the foetal hydrops and maternal mirror
Foetoscopy procedures syndrome in some cases.[30] For foetoscopy procedures,
Foetal endoscopic surgery (‘Fetendo’) obviates the anaesthesia is induced and maintained by combined
need for a large uterine incision and may reduce the spinal–epidural technique, with subarachnoid
overall risks of foetal surgery by causing less uterine injection of administrations of 2.5 mg of bupivacaine
trauma and ultimately less preterm labor. In 1973, and 25 mcg of fentanyl. Additional anaesthesia is
Schrimgeour introduced the term foetoscopy after provided through epidural catheter by administering
exposing the uterus at laparotomy and inserting a 6–9 mL of 1%–2% lidocaine with epinephrine (1 in
2.2‑mm needle scope to view the amniotic cavity 200,000) or 0.25% bupivacaine, as required. This
and foetus.[27] Foetoscopy surgery can be performed cautious approach prevents hypotension which may
by two methods. In the first method, trocars are require fluid boluses, thus predisposing parturient to
introduced into the uterine cavity through a the risk for developing mirror syndrome (Ballantyne
laparotomy. In the second, less invasive method, a syndrome). Hence, it is prudent to avoid fluid overload
trocar is introduced percutaneously. Foetoscopy has in these patients undergoing foetal therapy.
since then adapted to many foetal interventions.
Temporary tracheal occlusion is a promising strategy Postoperative precautions
to enlarge the lungs in foetuses with congenital The foetal heart is closely monitored in the immediate
diaphragmatic hernia. Aberrant vessels leading postoperative period. The duration of monitoring
to twin–twin transfusion syndrome can be ligated depends on the nature of intervention and may extend to
to prevent foetal death. Similarly, radiofrequency 24–48 h following open foetal intervention. Premature
ablation or coagulation of nonviable twin’s umbilical labour should be avoided with uses of tocolytics. Left

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Kodali and Bharadwaj: Anaesthesia for foetal surgery

lateral tilt of the patients in the postoperative period in Fetal Surgery; 17 October, 2012. Avaialble from: https://
www.mdedge.com/acssurgerynews/article/56082/obstetrics/
and haemodynamics and oxygenation monitoring myelomeningocele‑repair‑drives‑changes‑fetal‑surgery/
should be adopted. Venous thromboprophylaxis page/0/4. [Last accessed on 2018 Aug 23].
should be considered. 3. Casella DP, Tomaszewski JJ, Ost MC. Posterior urethral
valves: Renal failure and prenatal treatment. Int J Nephrol
2012;2012:351067.
Complications 4. Deprest J, Nicolaides K, Done’ E, Lewi P, Barki G, Largen E, et al.
Apart from the complications related to anaesthesia Technical aspects of fetal endoscopic tracheal occlusion for
congenital diaphragmatic hernia. J Pediatr Surg 2011;46:22‑32.
for caesarean delivery, or interim nonobstetric
5. Kohl T, Tchatcheva K, Merz W, Wartenberg HC, Heep A,
surgery, there is susceptibility towards postoperative Müller A, et al. Percutaneous fetoscopic patch closure of human
pulmonary oedema due to tocolytic use or foetal spina bifida aperta: Advances in fetal surgical techniques may
obviate the need for early postnatal neurosurgical intervention.
anomaly (hydrops foetalis). In addition, foetal surgery Surg Endosc 2009;23:890‑5.
can predispose the mother to other potential maternal 6. Lee H, Wagner AJ, Sy E, Ball R, Feldstein VA, Goldstein RB, et al.
risks such as haemorrhage, premature rupture of Efficacy of radiofrequency ablation for twin‑reversed arterial
perfusion sequence. Am J Obstet Gynecol 2007;196:459.e1‑4.
membranes, chorio‑amnion membrane separation, 7. Llurba E, Marsal G, Sanchez O, Dominguez C, Alijotas‑Reig J,
preterm labour, preterm delivery, foetal demise, Carreras E, et al. Angiogenic and antiangiogenic factors before
and after resolution of maternal mirror syndrome. Ultrasound
chorioamnionitis, placental abruption, and increased
Obstet Gynecol 2012;40:367‑9.
need for maternal transfusion at the time of delivery. 8. Marshall AC, van der Velde ME, Tworetzky W, Gomez CA,
Wilkins‑Haug L, Benson CB, et al. Creation of an atrial septal
SUMMARY defect in utero for fetuses with hypoplastic left heart syndrome
and intact or highly restrictive atrial septum. Circulation
2004;110:253‑8.
Foetal surgery requires a coordinated multidisciplinary 9. Roberts D, Gates S, Kilby M, Neilson JP. Interventions
approach. The benefit to the baby should be weighed for twin‑twin transfusion syndrome: A cochrane review.
Ultrasound Obstet Gynecol 2008;31:701‑11.
against the risk to the mother. With advancements 10. Roberts D, Neilson JP, Kilby M, Gates S. Interventions for
in technology and skill of interventional clinicians, the treatment of twin‑twin transfusion syndrome. Cochrane
Database Syst Rev 2008;23:CD002073.
many more foetal anomalies will be diagnosed 11. Tworetzky W, Wilkins‑Haug L, Jennings RW, van der Velde ME,
in utero with proposed novel interventions. The Marshall AC, Marx GR, et al. Balloon dilation of severe aortic
temptation to undertake novel approaches will require stenosis in the fetus: Potential for prevention of hypoplastic left
heart syndrome: Candidate selection, technique, and results of
careful evaluation of maternal risk. The anaesthetic successful intervention. Circulation 2004;110:2125‑31.
approach must consider a technique that ensures 12. Silva V, Tsen LC, Wilkins‑Haug L, Kodali BS. A Womb with
maternal and foetal cardiovascular stability, sustained a view: Anesthetic, obstetric, and neonatal care issues for
in‑utero fetal surgery. Anesthesiology 2006;104 Suppl:A12.
placental blood flow, minimal depression of foetal 13. Glover V, Fisk NM. Fetal pain: Implications for research and
organ functions, foetal analgesia, foetal immobility, practice. Br J Obstet Gynaecol 1999;106:881‑6.
14. Jevtovic‑Todorovic V, Hartman RE, Izumi Y, Benshoff ND,
adequate blocking of the foetal stress response, and Dikranian K, Zorumski CF, et al. Early exposure to common
uterine relaxation during surgical procedure. For anesthetic agents causes widespread neurodegeneration in
EXIT procedures, return of uterine tone is critical the developing rat brain and persistent learning deficits.
J Neurosci 2003;23:876‑82.
after delivery of the baby. International consensus 15. Giannakoulopoulos X, Sepulveda W, Kourtis P, Glover V,
from academic societies is guiding future strategies Fisk NM. Fetal plasma cortisol and beta‑endorphin response to
of management. For example, an international MOMs intrauterine needling. Lancet 1994;344:77‑81.
16. Lee SJ, Ralston HJ, Drey EA, Partridge JC, Rosen MA. Fetal
trial supports foetal repair of meningomyelocele for pain: A systematic multidisciplinary review of the evidence.
normal growth and function of neuraxial system in the JAMA 2005;294:947‑54.
17. Saxena KN. Anaesthesia for fetal surgeries. Indian J Anaesth
foetus and beyond after delivery.[31] 2009;53:554‑9.
18. De Buck F, Deprest J, Van de Velde M. Anesthesia for fetal
Financial support and sponsorship surgery. Curr Opin Anaesthesiol 2008;21:293‑7.
Nil. 19. Van de Velde M, De Buck F. Fetal and maternal analgesia/
anesthesia for fetal procedures. Fetal Diagn Ther 2012;31:201‑9.
20. Yoo KY, Lee JC, Yoon MH, Shin MH, Kim SJ, Kim YH, et al.
Conflicts of interest The effects of volatile anesthetics on spontaneous contractility
There are no conflicts of interest. of isolated human pregnant uterine muscle: A comparison
among sevoflurane, desflurane, isoflurane, and halothane.
Anesth Analg 2006;103:443‑7.
REFERENCES 21. Boat A, Mahmoud M, Michelfelder EC, Lin E,
Ngamprasertwong P, Schnell B, et al. Supplementing
1. Sviggum HP, Kodali BS. Maternal anesthesia for fetal surgery. desflurane with intravenous anesthesia reduces fetal cardiac
Clin Perinatol 2013;40:413‑27. dysfunction during open fetal surgery. Paediatr Anaesth
2. ACS Surgery News. Myelomeningocele Repair Drives Changes 2010;20:748‑56.

722 Indian Journal of Anaesthesia | Volume 62 | Issue 9 | September 2018

Page no. 82
[Downloaded free from http://www.ijaweb.org on Thursday, October 3, 2019, IP: 42.107.205.164]

Kodali and Bharadwaj: Anaesthesia for foetal surgery

22. Garcia PJ, Olutoye OO, Ivey RT, Olutoye OA. Case scenario: Olejek A. Intrauterine fetal surgery. World Sci News
Anesthesia for maternal‑fetal surgery: The ex utero 2017;76:5‑15.
intrapartum therapy (EXIT) procedure. Anesthesiology 28. Braun T, Brauer M, Fuchs I, Czernik C, Dudenhausen JW,
2011;114:1446‑52. Henrich W, et al. Mirror syndrome: A systematic review of fetal
23. Olutoye OO, Olutoye OA. EXIT procedure for fetal neck associated conditions, maternal presentation and perinatal
masses. Curr Opin Pediatr 2012;24:386‑93. outcome. Fetal Diagn Ther 2010;27:191‑203.
24. Santolaya‑Forgas J, Romero R, Mehendale R. The effect of
29. Chimenea A, García‑Díaz L, Calderón AM, Heras MML,
continuous morphine administration on maternal plasma
Antiñolo G. Resolution of maternal mirror syndrome after
oxytocin concentration and uterine contractions after open
succesful fetal intrauterine therapy: A case series. BMC
fetal surgery. J Matern Fetal Neonatal Med 2006;19:231‑8.
25. Adzick NS. Open fetal surgery for life‑threatening fetal Pregnancy Childbirth 2018;18:85.
anomalies. Semin Fetal Neonatal Med 2010;15:1‑8. 30. Heyborne KD, Chism DM. Reversal of ballantyne syndrome
26. Hirose S, Farmer DL, Lee H, Nobuhara KK, Harrison MR. The by selective second‑trimester fetal termination. A case report.
ex utero intrapartum treatment procedure: Looking back at the J Reprod Med 2000;45:360‑2.
EXIT. J Pediatr Surg 2004;39:375‑80. 31. Kitagawa H, Pringle KC. Fetal surgery: A critical review. Pediatr
27. Barbachowska AB, Krzanik K, Zamlynski M, Bodzek P, Surg Int 2017;33:421‑33.

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3) Images:
Submit good quality color images. Each image should be less than 4096 kb (4 MB) in size. The size of the image can be reduced by decreas-
ing the actual height and width of the images (keep up to about 6 inches and up to about 1800 x 1200 pixels). JPEG is the most suitable
file format. The image quality should be good enough to judge the scientific value of the image. For the purpose of printing, always retain a
good quality, high resolution image. This high resolution image should be sent to the editorial office at the time of sending a revised article.
4) Legends:
Legends for the figures/images should be included at the end of the article file.

Indian Journal of Anaesthesia | Volume 62 | Issue 9 | September 2018 723

Page no. 83