Impact of continuous intraoperative monitoring on outcomes in open fetal surgery.
OBJECTIVE
There are shifts in fetal hemodynamics during open fetal surgery that were not appreciated until the use of intraoperative fetal echocardiography. We have developed an intraoperative monitoring strategy to continuously assess fetal hemodynamics. We hypothesized that this approach would enhance intraoperative management and survival.


METHODS
Medical records of open fetal surgery patients were reviewed since the implementation of this approach. Intraoperative fetal monitoring was accomplished by continuous echocardiography, pulse oximetry, establishment of intravenous access, and arterial blood gas and hemoglobin measurement. Overall survival was compared to fetal surgeries performed prior implementation of this monitoring strategy.


RESULTS
Resections of a congenital cystic adenomatoid malformation or a sacrococcygeal teratoma in nine hydropic fetuses were performed while using this monitoring strategy. Intraoperative echocardiography resulted in a change of management in 7 of 9 fetuses. The main observations on fetal echocardiography resulting in intraoperative intervention were decreased ventricular filling, bradycardia, and decreased ventricular contractility. Therapy included administration of volume expanders and/or inotropic agents. Overall fetal survival was 78% compared to a survival of 42% prior to the implementation of this approach.


CONCLUSIONS
Continuous intraoperative fetal monitoring provides real time assessment of fetal hemodynamics which results in changes in intraoperative management. The overall outcomes in these critically ill fetuses have been improved.
Keswani
Sundeep G
SG
Center for Fetal Diagnosis and Treatment and Fetal Heart Program at the Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
Crombleholme
Timothy M
TM
Rychik
Jack
J
Tian
Zhiyun
Z
Mackenzie
Tippi C
TC
Johnson
Mark P
MP
Wilson
R Douglas
RD
Flake
Alan W
AW
Hedrick
Holly L
HL
Howell
Lori J
LJ
Adzick
N Scott
NS
D004452:Echocardiography; D005260:Female; D005313:Fetal Death; D005315:Fetal Diseases / Q000000981:diagnostic imaging* / Q000401:mortality / Q000601:surgery*; D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control*; D016343:Monitoring, Intraoperative; D011247:Pregnancy; D012189:Retrospective Studies