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The uterus serves as an incubator for the fetus during pregnancy. Within this incubator, the placenta is the main connection between the mother and the fetus and is integral to the survival of the fetus as it is an important source of fetal nutrients and oxygen. The proper development of the placenta allows it to support the fetus throughout pregnancy and expulsion or removal of a normal placenta following delivery, helps prevent postpartum complications. Maintenance of uteroplacental flow during pregnancy and during fetal surgery is important for the survival of the fetus and especially for the remainder of the pregnancy following fetal surgery. Serial monitoring of umbilical artery flow, a marker for uteroplacental insufficiency, is helpful to monitor fetal well-being. Physiology of the fetus correlates with the different stages of development in different organs and in many instances changes at delivery. The prevention of pain or the effects of noxious stimuli during fetal surgery serves many benefits, which include but are not limited to, prevention of release of stress hormones which can play a role in preterm labor and also prevention of long-term neurodevelopmental effects in the fetus.
Prenatal myelomeningocele has rapidly become the most common in-utero surgery performed following the results of the multi-center, myelomeningocele study. In-utero surgery has greatly improved the prognosis of babies with spina bifida or myelomeningocele. The eligibility criteria for this surgery has also evolved as some centers are now operating on mothers with increased body mass index (BMI). A BMI greater than 40 was not incorporated into the original study. In addition, fetoscopic repair of the myelomeningocele is also being performed, allowing for a decrease in the risk for uterine dehiscence and also offering mothers the opportunity to have a vaginal delivery following in-utero surgery.
In this chapter, the critical topic of congenital diaphragmatic hernia is reviewed. The diagnosis and pathophysiology are discussed in relation to organ systems effected and prognostic factors. The author covers the prenatal diagnostic evaluations as well as fetal interventions. The anesthetic implications and management of these patients if examined in detail from ventilatory goals to ECMO.
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