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Myelomeningocele: Prenatal and Postnatal Treatment and Complications Alyssa Brzenski.

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Presentation on theme: "Myelomeningocele: Prenatal and Postnatal Treatment and Complications Alyssa Brzenski."— Presentation transcript:

1 Myelomeningocele: Prenatal and Postnatal Treatment and Complications Alyssa Brzenski

2 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.

3 What is Spina Bifida?

4 Varying Neural Tube Defects

5 Spina Bifida

6 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

7 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

8 Co-morbidities

9 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

10 Management of Myelomeningocele Study






16 What treatment would you recommend? How would you anesthetize the mother and fetus for the fetal surgery? What precautions would you take for a post- natal repair? Anesthetic plan?

17 Mid-gestational Open Fetal Procedures Significant risk to Mom- – Hemorrhage (13% required transfusion) – Infection (9% developed chorioamnionitis) – Pulmonary Edema (28%) – Premature delivery – Uterine Rupture No direct benefit to Mom


19 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

20 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

21 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

22 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

23 VP Shunts have Complications

24 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.

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