Anesthetic management for fetal surgery: lessons from a single-center experience (2019-2023)

Abstract

Background: Fetal surgery presents distinctive anesthetic challenges due to the need to balance maternal and fetal safety. This retrospective study evaluates the anesthetic management strategies used at a single center for various fetal interventions, including fetoscopic laser photocoagulation, fetal endoluminal tracheal occlusion, bipolar cord coagulation, and fetoscopic spina bifida repair.

Methods: We reviewed 195 fetal procedures performed between 2019 and 2023 at Rabin Medical Center. Data collected included maternal and fetal characteristics, anesthetic techniques (spinal, combined spinal-epidural, general), intraoperative hypotension, and perioperative complications. We examined the evolution of anesthetic practice, particularly focusing on hemodynamic management and postoperative pain control.

Results: Spinal anesthesia was increasingly preferred for shorter procedures such as fetoscopic laser photocoagulation and bipolar cord coagulation, while general anesthesia was used exclusively for spina bifida repair. Intraoperative hypotension was a significant issue, leading to the implementation of prophylactic phenylephrine infusions, which improved blood pressure control. A shift from volatile anesthesia to total intravenous anesthesia in spina bifida repair resulted in fewer complications, including reduced bleeding. Postoperative pain management was optimized with a multimodal approach, improving pain scores.

Conclusions: This study underscores the importance of tailoring anesthetic techniques to the specific fetal surgery. Key improvements in hypotension management, adopting total intravenous anesthesia for complex surgeries, and optimized postoperative pain control have contributed to better maternal and fetal outcomes. Ongoing reassessment and adaptation of anesthetic protocols remain critical as fetal surgery evolves.

Keywords: Bipolar cord coagulation; FETO; Fetal anesthesia; Fetal surgery; Fetoscopic laser photocoagulation; Materno-fetal anesthesia; Percutaneous fetoscopic spina bifida repair.