Doppler changes in umbilical artery, middle cerebral artery, cerebroplacental ratio and ductus venosus during open fetal microneurosurgery for intrauterine open spina bifida repair.

OBJECTIVE: To describe changes in fetal Doppler parameters during a novel technique for open fetal microneurosurgery for open spina bifida (OSB) repair. METHODS: This was a prospective study of 44 fetuses undergoing open fetal surgery for OSB repair using a novel microneurosurgery approach that is characterized by a mini-hysterotomy (diameter of 15 mm), minimal fetal manipulation and maintenance of a constant normal amniotic fluid volume throughout the procedure. Doppler velocimetry of the umbilical artery (UA), fetal middle cerebral artery (MCA) and ductus venosus (DV) was performed before the start of surgery and at prespecified timepoints during fetal surgery. UA pulsatility index (PI) > 95th percentile, DV-PI > 95th percentile, MCA-PI < 5th percentile and cerebroplacental ratio (CPR) < 5th percentile were considered abnormal. RESULTS: Median gestational age at fetal surgery was 25.2 weeks (range, 22.9-27.9 weeks). Doppler recordings were successfully obtained in all cases during all timepoints throughout the surgery. As compared with Doppler values before surgery, there was a significant increase in the proportion of fetuses with MCA-PI < 5th percentile (63.6% vs 13.6%; P < 0.001), CPR < 5th percentile (65.9% vs 15.9%; P < 0.001) and DV-PI > 95th percentile (22.7% vs 0%; P = 0.01) and a non-significant increase in the proportion of fetuses with UA-PI > 95th percentile (11.4% vs 0%; P = 0.12) during fetal surgery. None of the fetuses showed absent or reversed end-diastolic velocity in the UA or absent or reversed DV a-wave at any stage during OSB repair. All abnormal Doppler parameters returned to normal after surgery. CONCLUSIONS: During open fetal surgery for OSB repair, a small hysterotomy, reduced fetal manipulation and maintenance of a normal amniotic fluid volume seem to prevent severe fetal Doppler abnormalities. The mild Doppler changes observed during fetal surgery could be a manifestation of fetal adaptation to the stress of fetal surgery. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

[Acute pulmonary edema due to airway obstruction during postanesthetic recovery]. / Edema agudo pulmonar por obstrucción de la vía aérea en el periodo postanestésico inmediato.

We report a postanesthetic complication that has not been described in the literature. A 22-year-old man (ASA 1) developed acute pulmonary edema on awakening from balanced anesthesia for scheduled sagittal mandibular ramus osteotomy and implantation of a paranasal graft. We discuss the role of airway obstruction, which can generate high intrathoracic negative pressures and lead to acute pulmonary edema. We also review the differential diagnosis of possible causes of acute pulmonary edema during the postanesthetic recovery. The postoperative course in this case was good.

Edema agudo pulmonar por obstrucción de la vía aérea en el periodo postanestésico inmediato / Acute pulmonary edema due to airway obstruction during postanesthetic recovery

Se comunica una complicación postanestésica no reportada en la literatura médica, en un paciente de 22 años de edad, estado físico ASA 1, programado para osteotomía sagital de rama mandibular y colocación de injerto paranasal, bajo anestesia general balanceada que presentó al despertar edema agudo de pulmón. Se discute el papel de la obstrucción de la vía aérea que puede generar una elevada presión negativa intratorácica y subsecuentemente un edema agudo pulmonar, así como el diagnóstico diferencial acerca de las posibles causas de un edema agudo pulmonar durante el periodo postanestésico inmediato. La evolución postoperatoria fue satisfactoria(AU)

We report a postanesthetic complication that has not been described in the literature. A 22-year-old man (ASA 1) developed acute pulmonary edema on awakening from balanced anesthesia for scheduled sagittal mandibular ramus osteotomy and implantation of a paranasal graft. We discuss the role of airway obstruction, which can generate high intrathoracic negative pressures and lead to acute pulmonary edema. We also review the differential diagnosis of possible causes of acute pulmonary edema during the postanesthetic recovery. The postoperative course in this case was good(AU)