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Maternal anesthesia for EXIT procedure: a systematic review of the literature
Abstract Number: T 22
Abstract Type: Meta Analysis/Review of the Literature
The ex utero intrapartum treatment (EXIT) procedure allows airway establishment for fetuses with life threatening conditions while maintaining placental support. Maternal anesthesia is challenging. Anesthetic goals include uterine relaxation, maintenance of uteroplacental perfusion, and fetal anesthesia. General anesthesia (GA) is often advocated. Recently, there have been reports of the use of regional anesthesia (RA). The aim of this article is to review the literature and compare both techniques with respect to maternal and fetal outcomes.
Multiple electronic databases were searched using the terms “Ex-utero intrapartum treatment” and “Anesthesia/anaesthesia”. The search was limited to English language. Reference lists of retrieved articles were searched to identify other studies. This review included all reports that described anesthetic techniques as well as maternal and fetal outcomes.
We found a total of 24 reports of 129 patients. Nineteen reports described the use of GA in 120 patients and five reports described RA in nine patients. The most common GA technique was balanced anesthesia with Desflurane. There were 3 reports of the use of total intravenous anesthesia (TIVA). In the RA group, combined spinal epidural (CSE) was used in 8 patients while one patient had a continuous spinal catheter. There were no conversions from RA to GA.
NTG iv was the most common uterine relaxant agent in all RA and TIVA cases. It was used as an adjunct to inhalational agents in 5 cases.
Duration of placental support ranged from 3 to 93 minutes in the GA group and 1 to 21 minutes in the RA group. Fetal monitoring was achieved with pulse oximetry in most cases. Supplemental fetal anesthesia was not commonly required in either GA or RA groups .
Oxytocin was the primary uterotonic in all cases. Additional uterotonics were more often used in the RA group. Six maternal hemorrhages were reported in the GA group and 5 patients required blood transfusions. There were no maternal hemorrhages in the RA group. One patient in the GA group required ICU admission vs. no ICU admissions in the RA group.
There were no maternal or fetal complications due to anesthesia in either group.
GA with inhalational agents is commonly reported for EXIT procedure. RA with CSE appears to be well tolerated. Nitroglycerine iv is often required with both techniques. There have been no reports of maternal hemorrhage or ICU admission with RA.