Foetal surgery: Anaesthetic implications and strategic management

Intrauterine surgery is being performed with increasing frequency. Correction of foetal anomalies in utero can result in normal growth of foetus and a healthier baby at delivery. Intrauterine surgery can also improve the survival of babies who would have otherwise died at delivery, or in the neonatal period. There are three commonly used approaches to correct foetal anomalies: open surgery, where the foetus is exposed through hysterotomy; percutaneous approach, where needle or foetoscope is inserted through the abdominal wall and the uterine wall; finally, ex utero intrapartum treatment (EXIT) surgery, where the intervention is performed on the baby before terminating the maternal umbilical support to the baby. Anaesthetic management of the mother and the foetus requires good understanding of maternal physiology, foetal physiology, and pharmacological and surgical implications to the foetus. Uterine relaxation is a critical requisite for open foetal procedures and EXIT procedures. General anaesthesia and/or regional anaesthesia can be used successfully depending on the nature of foetal intervention. Foetal surgery poses complications not only to the foetus but also to the mother. Therefore, the decision for undertaking foetal surgery should always consider the risk to the mother versus benefit to the foetus.