Pediatric Anesthesia ISSN 1155-5645

EDUCATIONAL REVIEW

Anesthesia for fetal surgery

Monica A. Hoagland & Debnath Chatterjee
Department of Anesthesiology, Children’s Hospital Colorado, Colorado Fetal Care Center, University of Colorado School of Medicine, Aurora,
CO, USA

Keywords
fetal therapy; fetal monitoring; fetal heart
rate; hydrops fetalis; ex-utero intrapartum
treatment; fetal resuscitation
Correspondence
Dr. Debnath Chatterjee, Associate
Professor of Anesthesiology, Children’s
Hospital Colorado and Director of Fetal
Anesthesia, Colorado Fetal Care Center,
University of Colorado School of Medicine,
13123 East 16th avenue, B 090, Aurora, CO
80045, USA
Email:
debnath.chatterjee@childrenscolorado.org
Summary
Fetal therapy is an exciting and growing field of medicine. Advances in prena-
tal imaging and continued innovations in surgical and anesthetic techniques
have resulted in a wide range of fetal interventions including minimally inva-
sive, open mid-gestation, and ex-utero intrapartum treatment procedures. The
potential for maternal morbidity is significant and must be carefully weighed
against claimed benefits to the fetus. Appropriate patient selection is critical,
and a multidisciplinary team-based approach is strongly recommended. The
anesthetic management should focus on maintaining uteroplacental circula-
tion, achieving profound uterine relaxation, optimizing surgical conditions,
monitoring fetal hemodynamics, and minimizing maternal and fetal risk.

Section Editor: Mark Thomas

Accepted 26 December 2016

doi:10.1111/pan.13109

re-examined the basic tenets of fetal therapy, taking into

Introduction
Over the last three decades, much progress has been
made in the field of fetal surgery. Technological
advances, particularly in prenatal diagnostic imaging,
have allowed a better understanding of the natural his-
tory and pathophysiology of fetal anomalies. Experi-
mental animal models of several potentially correctable
lesions have been developed to demonstrate the feasibil-
ity of complex fetal surgery (1). Furthermore, continued
refinements in surgical and anesthetic techniques have
resulted in a wide range of fetal interventions being per-
formed at different stages of pregnancy, not only to save
the life of the fetus but also to prevent permanent organ
damage (1,2). However, all fetal therapies are invasive
and carry a substantial risk to both the mother and
fetus. As the mother gains no direct benefit from
surgical intervention, maternal safety is paramount and
the inherent risk of maternal complications must be
weighed against the potential benefits to the fetus (2). A
recent presentation at the International Fetal Medicine
and Surgical Society meeting and discussions at the
North American Fetal Therapy Network (NAFTNet)
account advances in the field of fetal therapy (T. M.
Crombleholme, Personal communication) (Table 1).
Anesthetic management of these cases must provide ade-
quate operating conditions while minimizing maternal
and fetal risk.
Types of fetal interventions
There are three broad categories of fetal interventions:
minimally invasive interventions, open mid-gestation
fetal surgeries, and ex-utero intrapartum treatment
(EXIT) procedures. Minimally invasive interventions
are the most commonly performed fetal interventions
and include both needle-based ultrasound-guided proce-
dures (e.g., percutaneous umbilical blood sampling,
radiofrequency ablation, balloon valvuloplasty, shunt
placement) and fetoscopic interventions with ultrasound
guidance (laser photocoagulation for twin–twin transfu-
sion, umbilical cord coagulation, tracheal occlusion,
amniotic band release, ablation of posterior urethral
valves) (Table 2). Fetoscopes and endoscopes as small
as 1.0–3.8 mm in diameter are inserted percutaneously

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M.A. Hoagland and D. Chatterjee Anesthesia for fetal surgery

Table 1 Criteria for fetal therapy (T.M. Crombleholme, Personal communication)

Topic Historical viewpoint Current considerations

Fetal anomaly
Patient selection
Patient selection
Maternal safety
Reporting requirement
Oversight requirement
Center infrastructure
Significant fetal anomaly that interferes with organ
development, whose alleviation might allow for fetal
development to proceed normally.
Fetus should be singleton without concomitant
anomalies.
Selection for treatment must be based on careful
clinical evaluation and sound knowledge of natural
history of fetal disease. Intervention can be ethically
justified only if there is reasonable probability of
benefit.
Implied but not stated: Maternal risks should be minor
and acceptable to mother and family.
All case material should be reported, regardless of
outcome, to a fetal-treatment registry and/or medical
literature.
A multi-disciplinary team of specialists should concur
on the plan for innovative treatment and obtain
approval of an institutional review board.
There should be access to a level III high-risk-obstetric
unit, and bioethical and psychological counseling.
Indications for fetal therapy have expanded and goals
have evolved from simple survival to reducing
morbidity and improving long-term outcomes.
Effective therapies for multiple gestation, with or
without an innocent bystander cotwin, may be
considered if the fetal therapy will prolong and/or
improve outcome of the pregnancy as a whole.
Advances in prenatal diagnosis have allowed a better
understanding of the natural history and
pathophysiology of several fetal anomalies. Prognostic
indicators are being developed to consider risk/benefit
profile to the fetus and mother.
Maternal expectations and autonomy have increased.
Pregnant women are increasingly seeking fetal
therapies and some are willing to incur greater risks
upon themselves. Realistic expectations of prognosis
and postnatal course must be discussed.
Despite presence of fetal therapy registries and clinical
trials, geographic and regulatory barriers exist.
Mandatory reporting is not in effect.
In addition to a multi-disciplinary team-based approach,
ethics oversight, transparent counseling and
participation in registries are strongly encouraged.
Expectations for minimum resources, expertise,
experience, credentialing and infrastructure for the
organization and medical personnel have been set.

into the uterine cavity under ultrasound guidance to
visualize and perform the planned procedures (T.M.
Crombleholme, Personal communication) (Figure 1).
Minimally invasive interventions are typically per-
formed in early or mid-gestation with local or neuraxial
anesthesia with or without intravenous sedation.
Open mid-gestation fetal surgeries have evolved over
the years. Currently, the most common indication is pre-
natal repair of myelomeningocele (MMC) defect. Less
common indications include resection of large fetal lung
masses, debulking of sacrococcygeal teratomas and vesi-
costomy for lower urinary tract obstruction (Table 2).
Open fetal surgeries are performed under general anes-
thesia with neuraxial anesthesia for postoperative pain
control. Prior to hysterotomy, profound uterine relax-
ation is achieved using high doses of volatile anesthetic
agents with or without additional tocolytic agents. Typi-
cally, the fetus is positioned within the uterus in a man-
ner to allow direct access to the surgical site on the fetus.
Upon completion of the fetal surgical procedure, the
hysterotomy is closed in multiple layers and aggressive
tocolysis is maintained postoperatively to prevent
preterm labor.
Ex-utero intrapartum treatment procedures are per-
formed close to term gestation. During an EXIT proce-
dure, fetal interventions are performed on placental
bypass prior to delivery of the newborn. The EXIT pro-
cedure was originally developed to secure the airway for
fetuses with severe congenital diaphragmatic hernia that
had previously undergone open in utero tracheal clip
occlusion (4). The most common indication for an EXIT
procedure is to secure the airway for fetuses with large
oropharyngeal or neck masses, congenital high airway
obstruction syndrome, and severe micrognathia. This
transforms a potentially fatal neonatal airway emer-
gency into a controlled clinical scenario, allowing suc-
cessful transition to extra-uterine life. The indications
for EXIT procedures continue to evolve and have
expanded to include resection of fetal lung masses com-
pressing the intrathoracic airway and controlled extra
corporeal membrane oxygenation (ECMO) cannulation
(5–7) (Table 3). For EXIT procedures unrelated to the
airway, the fetal airway is always secured prior to fetal
intervention, so that a patent airway is present in the
event of emergent fetal delivery prior to completing the
fetal intervention. Unlike a standard cesarean section,
profound uterine relaxation must be achieved before
hysterotomy. In addition, uteroplacental blood flow,
uterine volume, and maternal hemodynamics must be
maintained, while fetal cardiac dysfunction must be
minimized (6). Upon completion of the fetal interven-
tion and before clamping of the umbilical cord, volatile

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Table 2 Fetal malformations treated with minimally invasive and open fetal surgery

Fetal malformation Pathophysiology Fetal intervention

Twin-to-twin transfusion
syndrome (TTTS)
Twin reversed arterial perfusion
(TRAP) sequence
Selective growth restriction in
monochorionic twins
Lower urinary tract obstruction/
Posterior urethral valves (PUV)
Congenital pulmonary airway
malformation
Fetal hydrothorax
Congenital diaphragmatic
hernia (CDH)
Amniotic band syndrome
Critical aortic stenosis with
evolving hypoplastic left heart
syndrome (HLHS)
HLHS with highly restrictive or
intact atrial septum
Myelomeningocele
Sacrococcygealteratoma
Monochorionic twin pregnancy with abnormal blood
flow between the twins. Donor twin develops
oligohydramnios and growth restriction. Recipient
twin develops polyhydramnios, cardiomyopathy and
hydrops. Potential for fetal demise.
Monochorionic twin pregnancy with one acardiac
twin. Normal (pump) twin provides retrograde
perfusion to the acardiac twin. Pump twin develops
congestive heart failure.
Intrauterine death of one twin leads to significant
neurologic morbidity in surviving co-twin
Renal dysplasia due to obstruction and pulmonary
hypoplasia due to oligohydramnios. Neonatal renal
and respiratory failure.
Cystic lesions or pleural effusion cause pulmonary
hypoplasia, mediastinal shift and polyhydramnios.
Eventual fetal hydrops.
Herniated abdominal viscera and lung compression
results in pulmonary hypoplasia and pulmonary
hypertension.
Strands of amniotic membrane entangle the fetus,
leading to limb amputation, syndactyly, craniofacial
or body wall defects.
Progressive left ventricular dysfunction and arrested
growth.
Left atrial hypertension and pulmonary vein stenosis
Damage to exposed spinal cord and Chiari II
malformation leads to paraplegia and obstructive
hydrocephalus.
Arteriovenous shunting with high-output cardiac
failure and fetal hydrops. Distorted pelvic anatomy.
Serial amnioreduction
Selective fetoscopic laser photocoagulation
(SFLP)
Selective fetal reduction by radiofrequency
ablation or fetoscopic cord coagulation
Selective fetal reduction by radiofrequency
ablation or fetoscopic cord coagulation
Selective fetal reduction by radiofrequency
ablation
Vesicoamniotic shunt placement
Fetoscopic ablation of PUV
Open fetal vesicostomy
Serial thoracocentesis
Fetoscopicthoracoamniotic shunt placement
Open fetal lobectomy
Fetal endoscopic tracheal occlusion (FETO)
Laser release of amniotic bands
Aortic balloon valvuloplasty
Atrial septostomy with balloon or stent
Open fetal repair
Open tumor debulking

anesthetic agents are discontinued to allow return of
uterine tone to minimize uterine bleeding. After clamp-
ing of the umbilical cord and delivery of the newborn,
uterotonic drugs are administered and uterine massage
is initiated. The newborn is then transferred to an
adjoining operating room for further resuscitation and
stabilization. The anesthetic management for open mid-
gestation and EXIT procedures is similar, with the
exception of return of uterine tone at the end of the
EXIT procedure.
Anesthetic considerations
The optimal anesthetic technique for fetal surgery
depends on the planned surgical approach, extent of
expected fetal surgical stimulation, maternal medical
history, and patient and surgeon preference. The anes-
thesiologist is responsible for providing care to two (or
more) patients who may have conflicting anesthetic and
hemodynamic requirements. Important considerations
include relevant maternal and fetal physiology, available
methods for fetal assessment, drug delivery, and resusci-
tation and risk to both the mother and fetus.
Maternal–fetal physiology
A complete review of the physiologic changes of preg-
nancy is beyond the scope of this paper, but pertinent
changes in cardiac and pulmonary physiology will be
briefly reviewed. Heart rate, stroke volume, and cardiac
output increase in early gestation and continue to rise
throughout pregnancy. Cardiac output increases to 50%
above prepregnancy levels at term gestation and
increases further in the immediate postpartum period
due to autotransfusion from the placental circulation.
Systemic vascular resistance and blood pressure initially
decrease, reaching a nadir in the second trimester. Blood
pressure returns to prepregnancy values at term

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Pediatric Anesthesia 27 (2017) 346–357
M.A. Hoagland and D. Chatterjee
Figure 1 Selective fetoscopic laser photocoagulation for twin-to-
twin transfusion syndrome (Reprinted with permission from Chidsey
Medical Media).
gestation. Hypotension is exacerbated in the supine
position due to aortocaval compression starting as early
as the second trimester. Hemodilution causes a 15%
decrease in hematocrit by the second trimester. Oxygen
consumption increases in pregnancy and peaks at 60%
above prepregnancy values in the immediate postpartum
period. This is mediated by an increased minute ventila-
tion and tidal volume with minimal change in respira-
tory rate. The increased minute ventilation causes a
decrease in PaCO2 to 30 mmHg and a compensatory
decrease in bicarbonate to maintain normal acid–base
status. Functional residual capacity decreases by 20% at
term gestation, predisposing parturients to rapid hypox-
emia during periods of apnea. Rapid hypoxemia,
changes in upper airway anatomy and an increased risk
of gastric reflux increase the risk for aspiration and diffi-
cult or failed intubation in this population (8).
Fetal hemodynamics and oxygenation are important
considerations that must be addressed during fetal
Table 3 Indications for EXIT procedures
Type Rationale
EXIT-to-airway Extrinsic compression
Intrinsic obstruction
Iatrogenic
Miscellaneous
EXIT-to-resection Intrathoracic airway or persistent
mediastinal compression
EXIT-to-ECMO Severe cardiopulmonary compromise
EXIT-to-separation Bridge to separation
CDH, congenital diaphragmatic hernia; EXIT, ex-utero intrapartum treatment; FETO, fetal endoscopic tracheal occlusion.
© 2017 John Wiley & Sons Ltd
Pediatric Anesthesia 27 (2017) 346–357
Anesthesia for fetal surgery
surgery. The fetal circulation is a parallel circuit with a
normal total intravascular blood volume of 100–
110 ml
kg 1. The fetal myocardium has a greater pro-
portion of noncontractile elements compared to mature
myocardium and it functions close to the upper limit of
the Frank–Starling curve. Fetal heart rate (FHR) is the
most important determinant of cardiac output and fetal
bradycardia (heart rate <100 bpm) is a strong indicator
of fetal distress (9). Common physiologic stressors
include hypoxia, noxious stimuli, and hypothermia. The
umbilical vein contains the highest oxygen levels in the
fetal circulation, with a normal PO2 of 30 mmHg.
Despite low oxygen tension, adequate oxygen delivery is
maintained by an increased hemoglobin concentration
(18 g
dl 1) and an increased hemoglobin oxygen affinity
compared to maternal circulation (9,10). The gestational
age at which a fetus is aware of pain is strongly debated.
The thalamocortical connections necessary for pain per-
ception do not develop until 23–30 weeks of gestational
age. However, noxious stimuli can elicit neuroendocrine
and hemodynamic responses by 18–20 weeks of gesta-
tional age. Elevations in catecholamine and cortisol
secretion cause increased placental vascular resistance
and decreased blood flow to the fetus. This results in
fetal bradycardia and compensatory redistribution of
blood flow from peripheral tissues to the brain, heart,
and placenta (known as the central sparing effect) (11).
In addition, the fetal stress response increases uterine
irritability and the onset of premature labor (9,10).
Although a mid-gestation fetus may not perceive nox-
ious stimuli, analgesia is required to prevent these neu-
roendocrine and hemodynamic alterations. Procedures
on noninnervated fetal tissues, such as the placenta and
umbilical vessels, do not require fetal analgesia.
Maintenance of adequate uteroplacental blood flow
and management of uterine tone are key factors in the
anesthetic management of fetal interventions. Acute
alterations in uteroplacental blood flow can cause rapid
fetal hypoxia and bradycardia. Common causes include
Fetal malformations
Cervical teratoma, lymphatic malformation epignathus, epulis, hemangioma
Congenital high airway obstruction syndrome, laryngeal atresia/stenosis,
laryngeal web/cyst
Prior FETO for CDH
Severe micrognathia
Congenital pulmonary airway malformation, bronchogenic cyst,
thoracic or mediastinal tumors
CDH with poor prognostic indicators, hypoplastic left heart syndrome with
intact/restrictive atrial septum
Conjoined twins
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Anesthesia for fetal surgery
decreased oxygen delivery to the uteroplacental circula-
tion (maternal hypoxemia, hypotension, hypovolemia,
or aortocaval compression), decreased umbilical cord
perfusion (uterine contractions, increased placental vas-
cular resistance, or cord compression), and decreased
oxygen delivery to fetal tissues (fetal anemia or cardiac
dysfunction). In the event of fetal bradycardia, these
conditions should be immediately addressed by increas-
ing maternal oxygenation, raising maternal blood pres-
sure, administering tocolytic agents, and repositioning
the fetus to relieve cord compression (9).
Uterine relaxation is required for most fetal interven-
tions and is continued postoperatively for open mid-
gestation procedures to prevent preterm labor. Patients
commonly receive perioperative indomethacin and cal-
cium channel blockers for tocolysis. For open mid-
gestation and EXIT procedures, additional intraopera-
tive uterine relaxation is achieved with high-dose volatile
agents with or without magnesium sulfate infusion.
Nitroglycerin and beta-agonist agents can be used if
needed. Pertinent maternal side effects include muscle
weakness and pulmonary edema from magnesium sul-
fate, hypotension from calcium channel blockers, and
tachycardia and electrolyte abnormalities from beta-
agonists (Table 4). For patients receiving magnesium
sulfate, intravenous fluid administration is restricted to
prevent pulmonary edema and neuromuscular blocking
agents must be used cautiously. Fetal side effects include
tachycardia, constriction of the ductus arteriosus, car-
diac depression, and renal dysfunction (12,13) (Table 4).
Loss of uterine volume is a strong stimulus for uterine
contraction. Uterine volume is maintained intraopera-
tively by only partial fetal delivery and continuous
amnioinfusion with warmed saline. Patients undergoing
an EXIT procedure must have return of uterine tone
immediately after delivery of the fetus to prevent exces-
sive maternal hemorrhage. Volatile agents must be dis-
continued prior to fetal delivery and oxytocin is
routinely administered after delivery. Additional utero-
tonic agents may be required (Table 4).
Fetal monitoring and drug administration
Methods available for fetal monitoring, drug adminis-
tration, and resuscitation are determined by the type of
fetal procedure being performed. Preoperative fetal
evaluation with ultrasound, echocardiography, and/or
MRI is used to document the baseline cardiac function
as well as physiologic and anatomic effects of the fetal
anomaly. During most minimally invasive procedures,
fetal assessment is limited to intermittent measurement
of the FHR by Doppler ultrasound. This is generally
performed immediately after induction and at the end
350
M.A. Hoagland and D. Chatterjee
of the procedure. During open mid-gestation and EXIT
procedures, fetal echocardiography is performed as fre-
quently as every 3–5 min from the time of hysterotomy
until uterine closure to provide a continuous assessment
of FHR, ventricular function and volume, atrioventric-
ular valve competence, and ductal patency (14,15). The
FHR can also be assessed by palpation of the umbilical
cord. Fetal pulse oximetry is used during EXIT proce-
dures. The normal range for fetal saturation (FSpO2) is
30–70%; however, the values vary significantly based
on site of measurement due to mixing of well-saturated
and desaturated blood in the fetal circulation. Adult
pulse oximeters are not calibrated to provide accurate
measurements in the normal range of FSpO2 (16). In
addition, normal fetal oxygenation occurs in the middle
range of the oxygen–hemoglobin dissociation curve,
where small changes in PO2 result in large changes in
FSpO2. Therefore, these measurements are not always
reliable. Accuracy is further limited by light interference
and conditions such as vasoconstriction and strong
uterine contractions that decrease fetal pulse pressure
(9). Fetal blood is not routinely sampled for analysis, as
this carries a risk for fetal vasospasm or hemorrhage.
Drugs can be administered to the fetus by transpla-
cental passage of maternal medications or direct intra-
venous or intramuscular injection to the fetus. The
transplacental passage of drugs requires maternal drug
exposure via intravenous sedation or general anesthesia,
often at a higher concentration than is clinically indi-
cated for her own anesthetic needs. Drug passage
depends on lipid solubility, pH of maternal and fetal
blood, drug ionization and protein binding, maternal
drug concentration, and uteroplacental perfusion. The
majority of intravenous anesthetic agents easily cross
the placenta, although dexmedetomidine crosses only in
limited amounts and neuromuscular blocking drugs do
not cross at all (17). The uptake of volatile agents in the
fetus is delayed compared to the mother, but a good
clinical effect is achieved due to the lower MAC require-
ments of the fetus compared to the mother (9).
Direct fetal drug administration allows more precise
dosing and eliminates the need for maternal drug expo-
sure. Common sites for intravascular access include the
umbilical vein, hepatic vein, large peripheral veins, and
intracardiac drug administration. The shoulders and
buttocks are used as sites for intramuscular injection.
Both intravascular and intramuscular administration
carry a risk of fetal injury and the noxious stimulation
can trigger a hemodynamically significant stress
response in a nonanesthetized fetus. If the stress
response is triggered, blood will be shunted away from
the sites of intramuscular injection resulting in delayed
and unpredictable drug absorption. The umbilical vein
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Pediatric Anesthesia 27 (2017) 346–357
M.A. Hoagland and D. Chatterjee Anesthesia for fetal surgery

Table 4 Commonly used tocolytic and uterotonic agents (12,13)

Tocolytic agents Dose Side effects

Calcium channel Nifedipine 10–20 mg PO every 6–8 h Maternal vasodilation with flushing and hypotension.
blockers
NSAIDs Indomethacin 50–100 mg PR or PO Maternal platelet dysfunction and GI upset. Fetal premature closure of
(max daily dose 200 mg) the ductusarteriosus, renal dysfunction with oliguria, intraventricular
hemorrhage and necrotizing enterocolitis.
Volatile anesthetics 2–3 MAC Requires endotracheal intubation and hemodynamic monitoring.
1
Magnesium sulfate 4–6 g load over 20 min, 2 g
h infusion Maternal lethargy, muscle weakness, headache, nausea/vomiting,
pulmonary edema, respiratory and cardiac arrest. Fetal lethargy and
hypotonia. Toxic serum levels: decreased reflexes at 12 mg
dl 1,
respiratory depression at 14–18 mg
dl 1, cardiac arrest at 18 mg
dl 1.
Reverse effects with 1 g of calcium gluconate. Caution with muscle
relaxants.
Nitroglycerin 50–100 mcg IV; 15–20 mcg
kg 1
min 1
Maternal hypotension
Beta-adrenergic Terbutaline 250 mcg IM or IV; Maternal tachycardia, arrhythmias, hypotension, myocardial ischemia,
agonists 5–10 mcg
min 1 IV pulmonary edema, hyperglycemia and hypokalemia. Fetal tachycardia
and metabolic derangements.

Uterotonic agents Dose Side effects

Oxytocin 10–40 U IV infusion Hypotension, tachycardia, myocardial ischemia

Prostaglandins PGF2a- Carboprost 0.25 mg IM Bronchoconstriction (contraindicated in patients with reactive airway
disease)
PGE1-Misoprostol 600–1000 mcg PR, No contraindications
sublingual or buccal
Ergot alkaloids Methylergonovine 0.2 mg IM Vasoconstriction (contraindicated in patients with hypertension and
preeclampsia)

is not innervated and cannulation will not trigger the
stress response, however, this comes with a significant
risk of vasospasm and subsequent fetal hypoxia. Intrac-
ardiac drug administration is usually reserved for fetal
cardiac procedures due to the risk for arrhythmia and
tamponade. Drug volumes should be limited to 0.2–
0.5 ml due to the potential for fetal injury during intra-
muscular injections and the small cardiac chamber size
for intracardiac injections (9). Intramuscular injections
are commonly used for minimally invasive and open
mid-gestation procedures, while intravascular access is
reserved for EXIT procedures.
Fetal resuscitation is indicated for fetal bradycardia
(FHR < 100), hypoxemia (FpSO2 less than 30–40%),
impaired ventricular function, and decreased cardiac fill-
ing. Initial resuscitation should focus on improving
uteroplacental blood flow, as discussed above. The anes-
thesiologist should increase maternal inspired oxygen,
administer intravenous fluids and vasoactive agents to
improve maternal blood pressure, administer tocolytic
agents or high-dose volatile agents to decrease uterine
tone, and ensure that the patient is appropriately posi-
tioned to relieve aortocaval compression. The surgeons
should reposition the fetus and increase uterine volume
to relieve cord compression. If the initial measures are
unsuccessful, resuscitation is continued with
epinephrine, atropine, and volume administration and,
if needed, chest compressions performed by the surgeon
at 100–150 b
min 1. If hemodynamic instability persists
and the fetus is viable, the next step is emergent fetal
delivery with neonatal resuscitation. If the fetus has
reached the limits of viability, this possibility should be
discussed preoperatively and a second anesthesia team
or neonatology team must be available to care for the
newborn while the primary anesthesiologist continues to
care for the mother.
Risks of fetal intervention
Fetal surgical interventions require profound alter-
ations in normal maternal–fetal physiology and carry
risk of significant maternal and fetal morbidity and
mortality. These procedures do not provide any medical
benefit to the mother and, therefore, maternal risk
should be minimized. Maternal comorbidities that
increase anesthetic risk are contraindications to fetal
surgery. The most common problems after fetal inter-
vention are preterm labor and premature rupture of
membranes (10), which may require prolonged mater-
nal hospitalization and tocolysis with significant mor-
bidity (Table 4) and which may result in the delivery of
an extremely preterm neonate. Patients undergoing

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Pediatric Anesthesia 27 (2017) 346–357
Anesthesia for fetal surgery
open procedures are at risk for hemorrhage due to the
profound uterine relaxation that is required intraopera-
tively. They must also have cesarean sections for all
future deliveries, as the hysterotomy increases risk for
uterine rupture in labor. The fetus is exposed to painful
stimuli and anesthetic medications, both of which may
have long-term effects on the developing nervous sys-
tem or cause perioperative cardiac dysfunction.
Anesthetic management
Preoperative evaluation
A multidisciplinary team of specialists including fetal
surgeons, maternal–fetal medicine specialists, anesthesi-
ologists, neonatologists, radiologists, nurses, and social
workers must be actively involved in the counseling,
planning, and preparation for fetal interventions (18). A
multidisciplinary team meeting with the mother and her
family is held a few days before surgery to explain the
planned fetal intervention, discuss surgical and anes-
thetic risks, address any concerns, and obtain informed
consent. If the fetus is viable (>24 weeks gestational
age), a preoperative discussion regarding code status for
the fetus must occur. If the mother desires full resuscita-
tion, then plans must be in place for emergent delivery
and neonatal resuscitation in the event of fetal distress
not responsive to intrauterine resuscitation.
The preoperative anesthetic evaluation should include
a detailed history of maternal comorbidities, previous
anesthetics, and obstetric complications. Any significant
cardiopulmonary disease or increased anesthetic risk is a
contraindication to fetal intervention. A focused physi-
cal examination of the airway, heart, lungs, and spine
must be performed. Preoperative laboratory testing
should include a complete blood cell count and may
include other tests as dictated by the history and physi-
cal examination. While a type and screen will suffice for
minimally invasive procedures, a type and cross-match
should be ordered for open mid-gestation fetal surgeries
and EXIT procedures. For the fetus, leukocyte reduced,
irradiated, O-negative blood, cross-matched to mother
should be readily available.
Fetal evaluation should include assessments of anat-
omy and physiology, as well as discussions of planned
surgical intervention and anticipated postnatal course.
Fetal imaging studies including ultrasonography, fetal
MRI, and fetal echocardiography must be reviewed.
Pertinent information for the anesthesiologist includes
baseline FHR and cardiac function, estimated fetal
weight for drug dosing, and location of the placenta and
fetus, which determines patient positioning and the
potential need to exteriorize the uterus.
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M.A. Hoagland and D. Chatterjee
Minimally invasive procedures
Minimally invasive procedures are commonly per-
formed under maternal local or neuraxial anesthesia,
with or without intravenous sedation (Table 5). Impor-
tant factors to consider when choosing the anesthetic
technique include the number, position, and size of port
sites, anticipated patient position, and surgeon and
patient preference. These techniques will not provide
uterine relaxation and intravenous sedation will provide
only limited fetal analgesia via transplacental transfer.
For fetal surgery on noninnervated tissues (the placenta
and umbilical cord) (9), no additional analgesia is
required. For other interventions, fetal analgesia is pro-
vided by intramuscular injection of a fetal cocktail,
commonly comprised of fentanyl (10–20 lg
kg 1),
vecuronium (0.2 mg
kg 1) or rocuronium (2 mg
kg 1),
and atropine (20 lg
kg 1). The mother is monitored
with standard ASA monitors and the FHR will be
assessed after induction and at the end of the procedure.
During percutaneous fetal cardiac interventions, contin-
uous fetal echocardiography is also performed to moni-
tor the fetus. Intravenous fluids should be restricted to
<750 ml to prevent postoperative pulmonary edema
that is associated with perioperative tocolysis and intra-
operative amnioinfusion. Vasopressors will likely be
required to maintain normal hemodynamics.
Open mid-gestation procedures
Open procedures are typically performed under general
endotracheal anesthesia (Table 5). Preoperatively, a
high lumbar epidural catheter is inserted for postopera-
tive pain control. However, due to anticipated intraop-
erative hemodynamic instability, the epidural catheter is
not bolused until the end of the surgery. While position-
ing the patient supine on the operating table, a wedge is
used to maintain at least 15 degrees of uterine displace-
ment. After adequate preoxygenation, a rapid sequence
induction is performed to facilitate endotracheal intuba-
tion. During controlled mechanical ventilation, care
must be taken to maintain normocarbia (PETCO2 30–
35 mmHg), as hypocarbia causes uterine vasoconstric-
tion with decreased fetal perfusion (10). In addition to
standard ASA monitors, a second large bore intra-
venous access is obtained and an arterial line is placed
for close hemodynamic monitoring.
During the maintenance of general anesthesia, care
must be taken to maintain normal maternal hemody-
namics and uterine perfusion, while also providing pro-
found uterine relaxation during the hysterotomy. This
has typically been accomplished with volatile anesthetic
agents, particularly desflurane, which can be titrated
© 2017 John Wiley & Sons Ltd
Pediatric Anesthesia 27 (2017) 346–357
M.A. Hoagland and D. Chatterjee Anesthesia for fetal surgery

rapidly. Desflurane is administered at normal anesthetic
concentrations before and after hysterotomy, but is
increased to 2–3 MAC during uterine manipulation to
achieve relaxation. However, this technique is associated
with significant fetal cardiac dysfunction, including a
60% rate of ventricular dysfunction, 11% rate of brady-
cardia, and 19–35% rate of atrioventricular valve regur-
gitation. Seven percent of patients had severe
cardiovascular events and 4% required intraoperative
fetal resuscitation with chest compressions (14). These
effects can be attributed to maternal hypotension with
placental hypoperfusion as well as direct fetal myocar-
dial depression.
An alternative technique relies on intravenous anes-
thesia (commonly propofol and remifentanil infusions)
prior to and after uterine manipulation with the addi-
tion of desflurane (1–1.5 MAC) during hysterotomy to
achieve uterine relaxation. This supplemental intra-
venous anesthesia (or ‘SIVA’) technique results in a
shorter duration and peak concentration of volatile
exposure to the fetus. In an animal model, the SIVA
technique is associated with more stable maternal hemo-
dynamics, improved uterine blood flow, and better fetal
acid–base status than exposure to high-dose desflurane
(19). In a nonrandomized review of human subjects,
patients maintained with the SIVA technique had a
decreased incidence of fetal ventricular dysfunction and
fetal resuscitative interventions (26% for SIVA vs 61%
for high-dose desflurane) than those maintained with
desflurane alone (20).
After maternal laparotomy, the uterus is exposed and
the placental edges are mapped using a sterile ultra-
sound probe. Profound uterine relaxation is achieved
prior to hysterotomy with either high-dose volatile agent
or SIVA technique, magnesium sulfate infusion and pos-
sibly additional tocolytics. These interventions are likely
to result in significant hypotension. Vasopressors will be
required, as intravenous fluids are restricted to prevent
pulmonary edema. Subsequently, a hemostatic hystero-
tomy is performed using a specialized absorbable uterine
stapler (Medtronic, Minneapolis, MN, USA). Uterine
volume is maintained by a continuous infusion of
warmed saline through a silicone catheter inserted into
the uterine cavity. The fetus is either partially delivered
or positioned within the uterus in a manner to allow
direct access to the surgical site. Fetal exposure is mini-
mized to prevent hypothermia and maintain intrauterine
volume. Transplacental passage of maternally adminis-
tered anesthetic agents will provide some fetal analgesia.
However, an intramuscular fetal cocktail of fentanyl,
vecuronium or rocuronium, and atropine is also admin-
istered to ensure complete blockade of the fetal stress
response as well as to immobilize the fetus. Fetal heart
rate, cardiac function, and ventricular filling are contin-
uously monitored by echocardiography during the time
of uterine manipulation and fetal intervention. Esti-
mated fetal weight-based resuscitation doses of epi-
nephrine and atropine must be prepared in a sterile
fashion and be immediately available on the surgical
field for intramuscular delivery. If the fetus has reached
the limits of viability, personnel should be available for
emergent delivery and neonatal resuscitation.
Upon completion of the fetal surgical procedure, the
hysterotomy is closed in multiple layers. Subsequently,
the volatile agent is discontinued and intravenous anes-
thetic agents are used for the remainder of the case.

Table 5 Anesthetic management for fetal interventions

Mid-gestation open
Minimally invasive procedures procedures EXIT procedures

Maternal anesthesia Local or neuraxial anesthesia
+/ intravenous sedation
Fetal anesthesia +/ IM medications
Maternal hemodynamics Vasopressors
Fluid restriction
Fetal hemodynamics and resuscitation Pre/postoperative echo
Uterine tone Pre/postoperative tocolytics
General anesthesia with
postoperative epidural
analgesia
Transplacental and IM
Vasopressors
Fluid restriction
Arterial Line
Intraoperative echo
IM resuscitation meds
Emergent fetal delivery
Pre/postoperative tocolytics
High-dose volatile agent
Magnesium infusion
General anesthesia with
postoperative epidural analgesia
Transplacental and IM/IV
Vasopressors
Fluid administration
Arterial Line
Intraoperative echo, pulse ox
IM/IV resuscitation meds
Cardiac compressions
Emergent fetal delivery
Preoperative tocolytics
High-dose volatile agent
Postdelivery uterotonics

EXIT, ex-utero intrapartum treatment.

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Pediatric Anesthesia 27 (2017) 346–357
Anesthesia for fetal surgery
Neuromuscular blocking drugs should be used cau-
tiously and fully reversed due to the significant muscle
weakness caused by magnesium sulfate. The mother is
extubated when fully awake and following commands.
Postoperative analgesia is achieved using a continuous
epidural infusion with patient controlled rescue doses,
epidural morphine, and additional intravenous anal-
gesics (acetaminophen and ketorolac) as needed. Ade-
quate analgesia is essential to attenuate the maternal
stress response, which can trigger preterm labor (9,10).
Due to the extensive uterine manipulation required
for these procedures, perioperative tocolysis to prevent
preterm labor is critical. Patients will likely be main-
tained perioperatively with indomethacin and magne-
sium sulfate for 48 h (21). Indomethacin may be held
if there is evidence of constriction of the ductus
arteriosus on fetal echocardiography (15). Calcium
channel blockers are often continued for the duration
of pregnancy (21).
EXIT procedures
The initial management of patients undergoing EXIT
procedures is similar to that of open mid-gestation pro-
cedures (Table 5). Patients undergo general endotracheal
anesthesia with rapid sequence induction and neuraxial
blockade for postoperative pain control. Due to the
potential for excessive maternal hemorrhage and hemo-
dynamic instability, two peripheral IVs and an arterial
line should be placed. Patients will not be started on a
magnesium sulfate infusion or maintained on postopera-
tive tocolytics. Due to the decreased risk of pulmonary
edema, intravenous fluids can be administered for
hypotension. However, patients are still likely to require
vasopressors due to the high doses of volatile agents used
during the procedure. During the preparation of the sur-
gical field, the surgical team will pass sterile oxygen tub-
ing, a pulse oximeter cable, and intravenous tubing from
the surgical field to the anesthesiologist which will be
used for fetal ventilation, monitoring, and drug adminis-
tration during the EXIT procedure.
Prior to hysterotomy, the uterus is relaxed with high-
dose volatile agent. If additional relaxation is required,
nitroglycerin boluses can be given. However, longer act-
ing agents, such as magnesium sulfate, are avoided as
return of uterine tone will be required after fetal deliv-
ery. After hysterotomy, the fetal head, arms, and upper
torso are partially delivered to access the fetal airway.
Minimizing fetal exposure is essential to maintain uter-
ine volume and prevent fetal hypothermia. An intramus-
cular fetal cocktail is administered into the fetal
shoulder to ensure fetal analgesia and immobilization.
Regardless of the indication for the EXIT procedure,
354
M.A. Hoagland and D. Chatterjee
securing the fetal airway should be the first step, in case
the surgery is abandoned early secondary to placental
abruption or prolonged fetal distress. Direct laryn-
goscopy and endotracheal intubation of the fetus are
performed using sterile equipment on the surgical field.
In fetuses with distorted airway anatomy, additional
maneuvers including rigid bronchoscopy, release of neck
strap muscles, partial mass resection, retrograde wire
intubation, or tracheostomy may be necessary for secur-
ing the airway (6). After securing the fetal airway, the
position of the endotracheal tube must be confirmed
with a flexible bronchoscope. If clinically indicated, sur-
factant may be administered through the endotracheal
or tracheostomy tube. However, the lungs are not venti-
lated until just prior to delivery, as that would begin the
process of transitional circulation and placental separa-
tion (17). Monitoring is achieved with continuous fetal
pulse oximetry and frequent echocardiography while the
surgical intervention is performed. A fetal peripheral
intravenous line is placed for drug and volume adminis-
tration. Further fetal interventions, such as resection of
thoracic masses or placement of ECMO cannulas, are
performed while still on placental support.
Upon conclusion of the fetal procedure, the volatile
agent is discontinued to allow return of uterine tone.
The fetus is then delivered and neonatal resuscitation is
continued by the neonatology or second anesthesia
team. Immediately after delivery of the newborn, utero-
tonic drugs are administered and uterine massage is ini-
tiated to prevent excessive maternal hemorrhage. A
separate team of surgeons, anesthesiologists, and nurses
must be available for completion of surgery on the new-
born, should the EXIT procedure be terminated earlier
than planned. After bolusing the epidural catheter and
reversing muscle paralysis, the mother is extubated when
fully awake and following commands. Similar to an
open mid-gestation procedure, postoperative analgesia
is achieved using an epidural infusion of local anesthetic
and narcotic.
Randomized trials
Due to the relatively rare occurrence of congenital
anomalies that are amenable to fetal intervention and
the ethical considerations of conducting medical trials in
this patient population, randomized controlled trials for
fetal interventions are difficult to perform. However,
multicenter, randomized trials have been performed for
the treatment of two common anomalies—twin-to-twin
transfusion syndrome (TTTS) and MMC.
Twin-to-twin transfusion syndrome is a serious com-
plication of monochorionic twin pregnancies in which
the maternal blood supply is not shared equally between
© 2017 John Wiley & Sons Ltd
Pediatric Anesthesia 27 (2017) 346–357
M.A. Hoagland and D. Chatterjee
twins. Blood is shunted between twins through intertwin
placental vascular anastomoses, resulting in a donor
twin that develops hypovolemia, oliguria, growth
restriction, and oligohydramnios, while the recipient
twin develops hypervolemia, polyhydramnios, hyperten-
sive cardiomyopathy, and hydrops. Left untreated, the
mortality of this condition is over 80% and approxi-
mately 30% of survivors have neurodevelopmental
abnormalities (22). Fetal interventions for the manage-
ment of TTTS include serial amnioreduction, selective
fetoscopic laser photocoagulation (SFLP), and selective
fetal reduction via radiofrequency ablation or fetoscopic
cord coagulation. Serial amnioreduction of the polyhy-
dramniotic fluid sac is performed for maternal comfort
and potentially improves uteroplacental blood flow by
reducing intra-amniotic and placental intravascular
pressures. SLFP involves selective coagulation of inter-
twin placental vessels that are thought to be contribut-
ing to abnormal intertwin blood flow. The Eurofoetus
trial and NIH-sponsored TTTS trial are the two largest
prospective, randomized controlled trials comparing
amnioreduction and laser photocoagulation. The Euro-
foetus trial demonstrated that SFLP was superior to
serial amnioreduction with improved perinatal survival
and fewer short-term neurologic abnormalities (23). An
NIH-sponsored TTTS trial in highly selected cases of
severe TTTS showed no statistical significance in the 30-
day postnatal survival between serial amnioreduction
and SFLP and concluded that advanced cases of TTTS
were associated with significant mortality with recipient
twin fetal losses occurring at different times depending
on the treatment. The recipient twin fetal losses in the
SFLP group usually occurred within 24 h of the proce-
dure and losses in the amnioreduction group occurred
later from progressive cardiomyopathy (24).
Myelomeningocele, the most severe form of spina
bifida, results in several lifelong disabilities, including
paraplegia, hydrocephalus, neurogenic bowel and blad-
der, cognitive impairment, and sexual dysfunction.
Almost all patients with MMC have Chiari II malforma-
tion and most develop obstructive hydrocephalus, which
requires ventriculoperitoneal (VP) shunt placement.
There is substantial evidence, both experimental and
clinical, to support a two-hit hypothesis to explain the
spinal cord injury. The first hit is the failure of the neural
tube to close by the fourth week of embryonic life and
the second hit is the chemical damage and trauma to the
exposed spinal cord (25). Prenatal MMC repair at mid-
gestation offers the possibility of limiting the damage
caused by prolonged exposure of the spinal cord as well
as improving hindbrain herniation prior to delivery.
The Management of Myelomeningocele Study
(MOMS) was a prospective, randomized trial conducted
© 2017 John Wiley & Sons Ltd
Pediatric Anesthesia 27 (2017) 346–357
Anesthesia for fetal surgery
at three centers in the United States over a period of
7 years in which patients were randomized to prenatal
repair before 26 weeks GA or standard postnatal repair.
The study was stopped early for efficacy of prenatal
repair and showed that prenatal repair was associated
with a 50% reduction in the need for VP shunt place-
ment at 12 months (82% in the postnatal repair group
vs 40% in the prenatal repair group), an improvement
in a composite score for mental development and motor
function at 30 months, and an increased rate of unas-
sisted ambulation at 30 months. However, these benefits
were achieved at the expense of higher rates of preterm
birth (average gestational age at delivery was 34 weeks
for prenatal repair vs 37 weeks for postnatal repair) and
an increase in maternal complications, such as pul-
monary edema (6%), oligohydramnios (21%),
chorioamniotic separation (26%), placental abruption
(6%), spontaneous labor (38%), partial or complete
uterine scar dehiscence noted at the time of delivery
(35%), and maternal transfusion requirement at delivery
(9%) (26). Subsequent analysis of this cohort demon-
strated that surgery at an earlier gestational age and
chorioamniotic membrane separation were risk factors
for spontaneous rupture of membranes; oligohydram-
nios was associated with an increased risk for preterm
delivery; and nulliparity was a risk factor for nonintact
hysterotomy site at the time of delivery (27). These fac-
tors should all be taken into account when counseling
mothers regarding the risks and benefits of fetal surgery.
A subsequent analysis of 100 prenatal MMC repairs
enrolled after the MOMS trial documented a similar
rate of obstetric complications and fetal outcomes, with
slight improvements in premature rupture of mem-
branes, maternal pulmonary edema, and transfusion
requirements at delivery (28). Forty percent of fetuses
in that cohort had evidence of moderate to severe ven-
tricular dysfunction on fetal echocardiography and
seven fetuses experienced serious cardiovascular events
that affected the conduct of surgery and/or outcome.
Of these, four patients required chest compressions, one
fetus had an intrauterine demise, and one delivered
9 days postoperatively and died due to complications
of prematurity (14). As previously discussed, these
events may be decreased when a SIVA technique is used
(20). Evaluations of the long-term neurologic effects of
prenatal MMC repair that were performed prior to the
MOMS trial also show promising results. At a median
follow-up of 10 years, 79% of patients who underwent
fetal repair were community ambulators and 26% had
normal bladder function, which represent improve-
ments over historic controls. Predictive factors for poor
neurologic outcome include poor function at 5 years of
age, spinal cord tethering, and the need for a VP shunt.
355
Anesthesia for fetal surgery
The shunt rate remained stable at 43%, similar to the
MOMS trial results, and all of those shunts were placed
prior to 12 months of age. Patients in this study were
more likely to show borderline or clinically significant
impairment in executive functioning and behavioral
adaptive skills compared to population norms. How-
ever, this study is limited by lack of a contemporary
control group of children who underwent postnatal
MMC repair (29). Further analysis of the MOMS
cohort may provide better evidence for long-term bene-
fit after prenatal MMC repair.
A recent survey of principal investigators from the
Fetal Myelomeningocele Consortium has shown that as
the number of centers offering fetal MMC repair has
grown, the strict inclusion and exclusion criteria used
for the MOMS study are being expanded. There is sig-
nificant variation between centers in terms of fetal diag-
nostic protocols, indications for fetal repair, and
acceptable maternal comorbidities (21). It remains to
be seen how these changes will affect both the maternal
and fetal outcomes following repair. More recently, a
fetoscopic approach to MMC repair is being devel-
oped, with the most experience reported from centers
in Germany and Brazil (30,31). Compared to open fetal
surgery, fetoscopic MMC repair has been associated
with longer operative times, increased risk of mem-
brane rupture, and earlier GA at birth. The inability to
obtain a ‘water-tight’ seal during closure of the defect
is another significant challenge with the fetoscopic
approach (32).
Summary
Fetal therapy is an exciting field of medicine. Advances
in prenatal imaging and continued innovations in surgi-
cal and anesthetic techniques have resulted in a wide
range of fetal interventions including minimally inva-
sive, open mid-gestation, and EXIT procedures. The
potential for maternal morbidity is significant and must
be carefully weighed against claimed benefits to the
fetus. Appropriate patient selection is critical and a mul-
tidisciplinary team-based approach is strongly recom-
mended. The anesthetic management should focus on
maintaining uteroplacental circulation, achieving pro-
found uterine relaxation, optimizing surgical conditions,
monitoring fetal hemodynamics, and minimizing mater-
nal and fetal risk.
Reflective questions (Supplementary Audio S1)
1 What are the key anesthetic considerations during an
EXIT procedure?
356
M.A. Hoagland and D. Chatterjee
EXIT procedures are typically performed under gen-
eral anesthesia with an epidural infusion for postopera-
tive analgesia. Key anesthetic considerations include:
• Maintaining adequate uteroplacental blood flow and
stable maternal hemodynamics
• Minimizing fetal cardiac dysfunction
• Preserving uterine volume by partially delivering fetus
and continuous amnioinfusion of warmed fluids
• Providing complete uterine relaxation prior to
hysterotomy and during fetal intervention
• Ensuring return of uterine tone immediately before
clamping of the umbilical cord and delivery of the
newborn
2 What interventions should be performed in the event
of fetal bradycardia during an open fetal MMC
repair?
Fetal bradycardia is a reliable indicator of fetal dis-
tress that warrants prompt attention. Umbilical cord
compression must be ruled out by repositioning the fetus
and increasing uterine volume via amnioinfusion.
Maternal inspired oxygen and hemodynamics should be
optimized to maintain adequate uteroplacental blood
flow. In the presence of uterine contractions, the concen-
tration of the volatile agent must be increased and addi-
tional boluses of nitroglycerin must be administered. If
the fetal bradycardia does not improve with these mea-
sures, resuscitation doses of epinephrine and atropine
must be administered via intramuscular route. Initiating
chest compressions and delivering the fetus are usually
reserved for severe fetal bradycardia that does not
improve with the aforementioned measures.
3 What are the options for monitoring the fetus during
fetal interventions?
Fetal monitoring during most minimally invasive fetal
interventions usually consists of intermittent measure-
ment of FHR using Doppler ultrasound. During open
mid-gestation and EXIT procedures, continuous fetal
echocardiography is used to monitor FHR, ventricular
function, atrioventricular valve competence, and ductal
patency. In addition, during EXIT procedures, fetal
pulse oximetry can be used to measure oxygen satura-
tion and heart rate after partial delivery of the fetus.
Ethics approval
Not applicable for educational reviews.
Funding
The study received no external funding.
© 2017 John Wiley & Sons Ltd
Pediatric Anesthesia 27 (2017) 346–357
M.A. Hoagland and D. Chatterjee Anesthesia for fetal surgery

Key learning points • Fetal bradycardia is a reliable indicator of fetal dis-

tress and must be immediately addressed.
• The three broad categories of fetal interventions are
minimally invasive, open mid-gestation and EXIT
procedures. Conflicts of interest
• Maternal safety is paramount and the risk of maternal
complications must be weighed against potential ben- The authors report no conflict of interest.
efits to the fetus.
• Patient selection and a multi-disciplinary team based Supporting information
approach is critical.
• Key anesthetic considerations include maintaining Additional Supporting Information may be found in the
adequate uteroplacental blood flow, minimizing fetal online version of this article:
cardiac dysfunction and providing complete uterine Audio S1. Audio podcast on ‘Anesthesia for fetal
relaxation prior to hysterotomy. surgery’.

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