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Maternal Flash Pulmonary Edema During Fetoscopic Laser Ablation for Twin-Twin-Transfusion Syndrome
Abstract Number: RF3AC-377
Abstract Type: Case Report Case Series
As rates of fetal surgery increase, so does the recognition of risk associated with these highly complex procedures. Incidence of maternal post operative pulmonary edema during fetal myelomeningocele (MMC) surgery has varied incidence of 3.3%-6% (2-4); with few case reports of pulmonary edema with cases involving twin-twin-transfusion syndrome (TTTS) (1,4). We present a case of maternal flash pulmonary edema during fetoscopic laser ablation for TTTS.
33 year old female G6P1 at 21 weeks with monochorionic diamniotic twins with stage 3 TTTS, and a past medical history notable for depression and former tobacco use. Preoperative physical exam was unremarkable. Her surgery was planned under epidural anesthesia and catheter placement was uncomplicated. Operation was initiated with notable difficultly in fetoscope trochar placement. Port site fluid leakage required higher than usual infusion rates with Belmont infuser. Roughly 90 minutes into the case, the patient complained of shoulder pain which was treated with fentanyl. Shortly after, she had persistent desaturation to 85-90% despite supplemental oxygen. Lung auscultation was initially clear bilaterally. Following the operation, she developed tachypnea and tachycardia when sitting upright. Lungs exam was repeated, now with bilateral crackles. She was given 40mg IV furosemide. Intraoperative chest x-ray was obtained and demonstrated bilateral pulmonary edema. Total intrauterine fluid given via Belmont was 11L with 2L suspected to have been lost to suction/leakage. Total IVF given was 1500 mL LR with UOP of 875ml in OR. She had significant improvement in respiratory status following furosemide and was weaned of supplemental oxygen that day. She was discharged on POD#1 without pulmonary symptoms.
While fetal surgery is classified as minimally invasive surgery, there are a number of associated anesthetic complications. Among them, post-operative pulmonary edema remains a serious concern. The incidence during fetal MMC surgery is well-described with a higher incidence with increased volume of amniotic infusion (2-4). Fetal TTTS laser cases typically require smaller amniotic infusion rates, however this case illustrates that flash pulmonary edema can occur. One must remain vigilant in the early recognition and treatment in addition to minimizing amnioinfusion rates as feasible.
1) Katz SG, Somerville KP, Welsh A. Maternal pulmonary oedema during foetoscopic surgery. Anaesth Intensive Care 2015.
2) Nivatpumin P, Pangthipampai P, et al.Anesthetic Techniques and Incidence of Complications in Fetoscopic Surgery. J Med Assoc Thai 2016.
3) Adzick NS, Thom EA, et al. A randomized trial of prenatal versus postnatal repair of myelomeningocele. N Engl J Med 2011.
4) Duron VD, Watson-Smith D, et al. Maternal and fetal safety of fluid-restrictive general anesthesia for endoscopic fetal surgery in monochorionic twin gestations. J Clin Anesth 2014.