IN THE NAME OF GOD

Analgesia for External Cephalic Version Dr.H-Kayalha Anesthesiologist

Obstetricians have shown renewed interest in external cephalic version (ECV) in an attempt to decrease the cesarean section rate because of breech presentation. Recent published studies have demonstrated increased success rates for ECV, versus those in matched historical controls, when epidural or CSE analgesia is provided.

Provision of maternal analgesia with CSE creates a suitable environment for ECV; unlike older regional anesthesia techniques, it limits the use of excessive force by the obstetrician. If a serious complication occurs during ECV, the epidural catheter may be used to provide anesthesia for emergency cesarean section and avoid the complications of general anesthesia.

Fetal Surgery

Advances in prenatal diagnosis with the use of modern technology (1-ultrasonography, 2- fetal echocardiography, 3-fetal MRI, 4- amniocentesis, 5-umbilical blood sampling, 6- chorionic villus sampling) and the development of open fetal surgical techniques now permit the treatment of fetal conditions that would otherwise have caused progressive, irreversible damage and possible intrauterine fetal demise if left untreated.

Such abnormalities include: - congenital diaphragmatic hernia - hydronephrosis - twin-twin transfusion syndrome - hydrothorax.

Fetal Surgery (Diaphragmatic Hernia)

DEFECTS DETECTED IN UTERO BUT BEST CORRECTED AFTER TERM DELIVERY -Esophageal, duodenal, and Intestinal atresia -Meconium ileus -Enteric Duplication and cysts -Small intact omphalocele, meningocele -Unilateral hydronephrosis, multicystic kidney -Small sacrococcygeal teratoma, cystic hygroma, -Benign cysts (ovarian, mesenteric, choledochal) -Craniofacial, limb, and chest wall deformities

DEFECTS USUALLY MANAGED BY ELECTIVE ABORTION -Anencephaly, -Severe chromosomal anomalies (trisomy 13) -Bilateral renal agenesis, infantile polycystic kidney -Severe untreatable inherited metabolic disorders (Tay-sachs disease) -Lethal bone dysplasias (recessive osteogenesis imperfecta)

DEFECTS THAT MAY LEAD TO CAESAREAN DELIVERY -Conjoined twins -Giant omphalocele, ruptured omphalocele. Gastroschisis -Severe hydrocephalus, large or ruptured meningomyelocele -Large sacrococcygeal teratoma or cervical cystic hygroma

It is important for the anesthesiologist to understand the fetal lesion and the surgical approach because they determine the type of anesthetic care offered to the mother.

Key issues for the anesthesiologist include: - maternal safety - uterine relaxation - fetal immobility - anesthesia.

Intensive monitoring of uterine activity and the use of tocolytic agents (e.g., the volatile agents, terbutaline and nitroglycerin) are often necessary to prevent the associated high risk of premature labor.

The patient has an increased risk of pulmonary edema in the postoperative period as a result of aggressive tocolytic therapy; thus, close attention to fluid balance is warranted.

Fetal surgery Management of Mother and Fetus PRETERM LABOUR / FETAL SURGERY -Preoperative indomethacin (Constrict fetal ductus arteriosus) -Intraoperative deep halogenated anesthesia, nitric oxide and nitroglycerine (Fetal and maternal myocardial depression and affects placental perfusion). -Postoperative indomethacin, magnesium sulfate, nitroglycerine and betamimetics (Maternal pulmonary edema)

The future of fetal intervention The observation that the fetal incisions heal without scarring has provided new insights into the biology of wound healing and has stimulated efforts to mimic the fetal process postnatally.

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