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Anesthesia For Minimally-Invasive Fetal Surgery: A Retrospective Review
Abstract Number: S-18
Abstract Type: Original Research
Introduction: Fetal surgery offers options for treatment of twin-to-twin transfusion syndrome (TTTS) and twin-reversed-arterial-perfusion sequence (TRAP) and often utilizes selective fetoscopic laser photocoagulation (SFLP) and radio-frequency ablation (RFA) respectively. If untreated, TTTS carries a >80% fetal mortality rate with significant morbidity in surviving neonates. TRAP results in a nonviable “recipient twin” with a viable twin mortality rate > 50% if untreated. Currently, these minimally-invasive fetal surgeries are completed under either MAC or spinal anesthesia, largely based on provider and institutional preference alone. Our aim was to compare the association of anesthetic choice and a variety of fetal and maternal outcomes to determine if one may be more beneficial.
Methods: Following IRB approval, we reviewed all minimally invasive fetal surgeries at our center from 2011-2014. Records of patients with either TTTS or TRAP who underwent RFA or SFLP were identified and reviewed. We collected patient demographic information (age, weight, BMI, baseline vitals, and gestational age at time of surgery), intra-operative data (anesthetic type, procedure times, pressor administration, fluid administration, hemodynamic variation, and conversion to general anesthesia) and fetal outcome (death within 24-hours of surgery). Data were analyzed utilizing univariate methods.
Results: Cases (n=85) included 54 spinal anesthetics and 31 under MAC with significant associations between spinal anesthesia and SFLP and MAC with RFA (p<.0001). Although there was no difference between anesthetic choice and fetal death within 24-hours (p=0.36) or need for conversion to general anesthesia (p=1.0), we did find a significant relationship between the use of spinal anesthesia and intra-operative hypotension, increased fluid administration, and greater pressor use (see Table).
Discussion: Although no significant difference between MAC and spinal anesthesia regarding fetal demise or conversion to general anesthesia was noted, the association between spinal anesthesia and greater intra-operative hypotension, greater fluid administration and greater use of pressors suggests that the effect of anesthetic technique on the fetus are potentially significant during surgical manipulation of the fetal blood supply. These results highlight the need for further investigation of anesthesia considerations for minimally invasive fetal procedures.