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Maternal and fetal safety of fluid-restrictive general anesthesia for endoscopic fetal surgery in monochorionic twin gestations
Abstract Number: T-28
Abstract Type: Original Research
Recent studies suggest that regional anesthesia is safer than general anesthesia in endoscopic fetal surgery, citing more maternal complications, including pulmonary edema. We have recently revised our general anesthesia protocol to limit intra-operative hydration and liberalize vasopressor use. In this study, we review our experience with general anesthesia in endoscopic fetal surgery for twin-to-twin transfusion syndrome (TTTS), and compare feto-maternal outcomes before and after protocol implementation.
Consecutive cases of endoscopic fetal surgery for TTTS between 2000 and 2011 were reviewed. Patients were divided into early (before 2008) and late groups (after implementation of fluid restriction general anesthesia protocol). Intra-operative hemodynamic parameters, post-operative maternal complications, and fetal and neonatal outcomes were compared using student t-test or chi-square analysis, as appropriate.
There were 55 patients in the early group and 22 in the late group. There was no significant difference in maternal age, ASA class, gestational age, or TTTS stage between groups. Patients in the early group received 1,634 ± 949 mL of crystalloid fluid, compared with 516 ± 258 mL (P<0.001) in the late group. Episodes of intra-operative hypotension (SBP<90 mmHg) were similar in both groups (3.3 episodes/patient versus 2.8, P=0.486), as was the percentage of patients requiring vasopressors (P=0.248). Survival of more than 1 twin was 79.2% and 77.3%, respectively (P=0.93). Delivery within 7 days of surgery was similar in both groups (5% and 9%, respectively, P=0.56). Post-operative maternal pulmonary edema was seen in 5.5% of patients of the early group and in none of the late group. Similarly, any episode of respiratory distress was documented in 11% of early group patients and none of late group patients.
Although regional anesthesia for endoscopic fetal surgery is often perceived to be safer, general anesthesia offers uterine relaxation and other advantages – and is mandatory in fetal spina bifida repair. Judicious fluid management during general anesthesia minimizes maternal morbidity, and fetal and neonatal outcomes compare favorably with series in the literature where regional anesthesia was used.