Presentation on theme: "Myelomeningocele: Prenatal and Postnatal Treatment and Complications Alyssa Brzenski."— Presentation transcript:
Myelomeningocele: Prenatal and Postnatal Treatment and Complications Alyssa Brzenski
Case A 25 year old G1P0 at 18 weeks gestation, with no previous past medical history, was found during routine screening to have a fetus with T12-S1 myelomeningocele(MMC). The fetus, during a detailed prenatal ultrasound, is found to have Arnold-Chiari malformation but no other congenital abnormalities.
Basics of MMC 3.4:10,000 births Related to low folate levels, anticonvulsants (carbamazepine, valproic acid) Previous child with same partner is a risk factor
Co-morbidities Sensory motor deficits Bowel and Bladder Incontinence Arnold Chiari Type II – Caudal displacement of cerebellar vermis, fourth ventricle, and lower brainstem Hydrocephalus Cognitive delay – Lower risk if no VP Shunt needed
Latex Allergies All patients with MMC are labeled as latex allergic High rates due to recurrent procedures including urinary catheterization Cross reaction to avocados, banana, passion fruit, kiwi, banana
Maternal Physiology Physiology of Pregnancy – Airway/Pulm Smaller swollen airway Decreased FRC, Increased Oxygen Consumption Respiratory Alkalosis – Cardiac Decreased SVR Increased CO Left Uterine Displacement – GI Full Stomach – MAC Decreased anesthetic requirements
Fetal Physiology Cardiac- – Fetus heart rate dependent – Slowing during the procedure detrimental Heme- – Fetal Blood Volume= 120-160 mL/kg – Hgb = 11.5-12.5 g/dL – Fetal synthesis of clotting factors decreased Oxygen Delivery – Dependent on placental perfusion Thermoregulation – Fetus unable to maintain temperature – Must warm any fluid administered to mom and amniotic fluid replacement
Mid-gestation Fetal Surgery Epidural for Mom- post-op pain control GA for MOM during the procedure with maintence of Uterine-placental perfusion Must have profound uterine relaxation- Can use high inspired volatile (2MAC) +/- nitroprusside Fetus paralyzed and monitored during surgery Minimize fluid administration to avoid pulm edema Mom must receive tocolysis prior to awakening and will be monitored for pre-term labor
Post-natal MMC Repair Infants repaired early after birth Must be cautious to not injury the neural tissue during moving or intubation Routine ASA monitors Prone position for repair May or may not receive VP Shunt at the same time Typically remain intubated as infant should not lie supine for the first day
Sources Adzick S et al. A Randomized Trial of Prenatal vs Postnatal Repair of Myelomeningocele. New England Journal of Medicine 2011; 364: 993-1004. Golombeck K et al. Maternal morbidity after maternal-fetal surgery. AM J Obstet Gynecol 2006; 194: 834-9. Ferschl M et al. Anesthesia for In-utero repair of myelomeningocele. Anesthesiology 2013; 118: 1211-23.