Enhanced Recovery after Surgery: Benefits for the Fetal Surgery Patient.

BACKGROUND: The fetoscopic approach to the prenatal closure of a neural tube defect (NTD) may offer similar advantages to the newborn compared to prenatal open closure of a NTD, with a reduction in maternal risks. Enhanced recovery after surgery (ERAS) protocols have been applied to different surgical procedures with documented advantages. We modified the perioperative care of patients undergoing in utero repair of myelomeningocele with the goal of enhancing the recovery. A retrospective study comparing traditional management to the ERAS protocol was conducted. AIMS: Primary aim was to evaluate the length of stay (LOS). Secondary outcomes included pain scores, time to oral intake, opioid-induced side effects, and respiratory complications. METHODS: Thirty patients who underwent a mid-gestation fetoscopic closure of a NTD were included. Data analyzed include demographics, comorbidities, LOS, anatomical location of the NTD, magnesium sulfate doses and duration of administration, oxygen requirements, duration of the postoperative epidural infusion, duration of surgery and anesthesia, incidence of postoperative nausea and vomiting, respiratory complications, time to oral intake, pain scores, and sedation scores. Differences between the treatment groups were compared using the independent sample t-test or Mann-Whitney Ʋ test. RESULTS: Of the 30 patients, 10 patients were managed according to the ERAS protocol and 20 patients according to the traditional management (1:2 ratio). The mean gestational age at the time of intervention for the traditional and ERAS groups was 24.9 ± 0.5 weeks and 24.8 ± 0.5 weeks, respectively. Compared to the traditional group, the LOS was reduced in the ERAS group to 112.5 ± 12.6 h (4.7 ± 0.5 days) from 179.7 ± 87.9 h (7.5 ± 3.7 days) (p = 0.012). The time to oral intake was also shorter 502.6 ± 473.4 min versus 1015.6 ± 698.2 min; p = 0.049. Oxygen requirements were prolonged in the traditional group (1843.7 ± 1262.6 min vs. 1051.7 ± 1078.1 min p = 0.052). The total duration of magnesium sulfate was longer for patients in the traditional group (2125.6 ± 727.1 min vs. 1429.5 ± 553.8 min; p = 0.006). No statistically significant difference in pain scores was observed between the groups. CONCLUSIONS: Establishing an ERAS protocol for fetoscopic in utero repair of NTDs approach is feasible with the advantages of decreased postoperative LOS, reduced oxygen requirements, lower duration of magnesium sulfate infusion, and facilitation of earlier oral intake without compromising the pain scores.

Anesthesia-Related Factors Associated with Preterm Labor and Delivery after Open Fetal Surgery.

BACKGROUND: Fetal surgery, such as for meningomyelocele repair, has a clear clinical fetal benefit. In patients who undergo in utero repair of meningomyelocele, for example, there is reduced long-term disease morbidity. However, despite the beneficial effects of early intervention, women who undergo fetal interventions have an increased risk of preterm labor and delivery. Several surgery-related factors have been described but no specific anesthesia-related factors. OBJECTIVE: The aim of this study was to determine if any aspects of the perioperative anesthetic management influenced maternal complications following in utero surgery. METHODS: This was a retrospective chart review of the anesthetic management of mothers and fetuses who presented for open and fetoscopic myelomeningocele repair, between 2011 and 2015, at Texas Children's Fetal Center®. RESULTS: Forty-six women underwent open or fetoscopic repair of neural tube defects at our institution. We found the maternal heart rate in the postoperative period to be associated with a higher likelihood of preterm labor, but not delivery. The odds of having preterm delivery was higher for nulliparous patients and those with lower intraoperative diastolic pressure. CONCLUSIONS: Our findings confirm what has been previously reported regarding the association of nulliparity with preterm delivery. Additionally, this study highlights the importance of maintaining stable perioperative hemodynamics during the intraoperative and postoperative phases of care for patients undergoing in utero surgery.