Anestesia y monitorización intraoperatoria en la cirugía intrauterina de los defectos del tubo neural

Abstract

Spina bifida represents the most serious congenital neural tube deffect compatible with life. Its most frequent form is myelomeningocele, which is caracterized by the lack of closure of the posterior vertebral arch during third-fourth embrionary development weeks, moment in which the neural plate wouldn't complete its development causing an open spinal canal, with exposure to the amniotic fluid of the meninges and other neural elements during the rest of the pregnancy. The benefits of the prenatal surgery of the neural tube deffects and, specifically of the myelomeningocele, have been widely demostrated, providing a closure of the deffect to protect the neurological elements devoid of it, to prevent the leak of cerebrospinal fluid and to decrease the risk of infection, with the minimal possible maternal-fetal morbidity. In the Materno-fetal Unit of Vall d'Hebron Hospital it is offered to pregnant women the possibility of intrauterine surgery of the neural tube deffects. The surgical approach of intrauterine surgery can be performed through fetoscopic surgery or open fetal surgery, being the general objective of this study the analysis of the anesthetic management in these two types of surgery. We believe that continous monitoring of maternal-fetal binomial would allow us to anticipate and adapt in an individualized way the doses of vaoactive drugs and fluids, minimizing episodes of maternal hypotension and therefore, of placental hypoperfusion, as well as decrease respiratory complications during the perioperative period. We also consider that fetoscopic surgery for the intrauterine correction of neural tube deffects would be associated with fewer hemodynamic maternal changes than open surgery, with the consequent effect about the decrease of the requirements of vasoactive drugs and about maternal-fetal associated morbimortality. Therefore, we have carried out a retrospective descriptive study in Vall d'Hebron Hospital, Barcelona, during the period between years 2011-2016, being our main conclusions: - In the intrauterine fetal myelomeningocele correction through open surgery or fetoscopic, no differences were found in the maternal morphic doses neither muscle relaxants between two types of surgery. There were differences between the required dose of halogenated and nytroglicerin, being higher in open surgery. - Fluidotherapy with crystalloids wasn't different between groups, while the administered volum of colloids was lower in the pregnant women of the fetoscopic surgery group. The consumption of vasoconstrictors was directly related to the uterine exposure time, without finding differences between both groups. - The mean arterial blood pressure of the patients urdergoing open surgery was lower than in the fetoscopic group, and this group of patients experienced more episodes of arterial hypotension. The arterial tensions systolics, diastolics and mean decreased in both groups during the uterine exteriorization and this decrease was higher in the open surgery group. - No differences were found in gasometric maternal parameters during the CO2 insufflation in fetoscopic surgery. - The rate of premature rupture of membranes was similar in both groups. The rate of olighydramnios and the need for tocolytics in the postoperative period was higher in the open surgery group. - The fetal heart rate remained stable in both types of surgery. The prematurity rate was higher in the open surgery group.

Date of Award	7 Feb 2018
Original language	English
Supervisor	Maria Elena Carreras Moratonas (Director) & Myriam de Nadal Clanchet (Director)