Anesthesia For Intrauterine Myelomeningocele Correction. Case Report [anestesia Para Correção Intra-útero De Mielomeningocele. Relato De Caso]

BACKGROUND AND OBJECTIVES: Fetal surgery is the treatment of choices for prenatal malformations that are not adequately corrected after birth and aims at treating or preventing the progression of the abnormalities. This report describes a case of anesthesia for intrauterine correction of a myelomeningocele. CASE REPORT: Pregnant patient, 19 years old, 23 weeks of gestational age, without previous anesthetic history, physical status ASA I, submitted to intrauterine fetal surgery under general anesthesia associated to continuous epidural continuous anesthesia. The patient was premedicated with rectal indomethacin (50 mg), intravenous metoclopramide (10 mg) and cimetidine (50 mg), in addition to intravenous midazolam (2 mg). The patient received 0.25% bupivacaine with epinephrine (25 mg) associated to fentanyl (100 μg) epidurally, followed by cephalic catheter insertion for postoperative analgesia. The uterus was left-displace with a Crawford's wedge. Rapid sequence anesthesia was induced with fentanyl, propofol and rocuronium, and was maintained with 2.5% - 3% isoflurane in O2 and N2O. After stapling hysterectomy to promote homeostasis, fetal operative site was exposed and fetal analgesia and immobility was obtained with the association of fentanyl (10 μg.kg-1) and pancuronium (0.1 mg.kg-1) administered on fetal gluteus muscle. Maternal systolic blood pressure was maintained above 100 mmHg with bolus ephedrine (5 mg), colloids and crystalloids. Lost amniotic fluid was replaced with warm saline. After correction of the fetal defect, both uterus and amniotic membrane were closed in two planes with vicryl suture and fibrin glue. Afterwards, isoflurane concentration was gradually decreased and bolus magnesium sulfate (4 g/20 minutes) followed by continuous infusion was administered to maintain uterine relaxation (2 g/hour). Morphine (2 mg) was administered via epidural catheter at the end of surgery for postoperative analgesia. CONCLUSIONS: Anesthesia for fetal surgery involves two individuals the mother and the fetus, an anesthetic management requires: maternal-fetal safety, fetal anesthesia and immobility, uterine relaxation, prevention of premature labor and postoperative analgesia. © Sociedade Brasileira de Anestesiologia, 2005.553329335Liley, A.W., Intrauterine transfusion of foetus in haemolytic disease (1963) Br Med J, 2, pp. 1107-1109Myers, L.B., Cohen, D., Galinkin, J., Anaesthesia for fetal surgery (2002) Paediatr Anaesth, 12, pp. 569-578Cauldwell, C.B., Anesthesia for fetal surgery (2002) Anesthesiol Clin North America, 20, pp. 211-226Simpson, J.L., Fetal surgery for myelomeningocele: Promise, progress, and problems (1999) JAMA, 282, pp. 1873-1874Gaiser, R.R., Kurth, C.D., Anesthetic considerations for fetal surgery (1999) Semin Perinatol, 23, pp. 507-514Spielman, F.J., Seeds, J.W., Corke, B.C., Anaesthesia for fetal surgery (1984) Anaesthesia, 39, pp. 756-759Schwarz, U., Galinkin, J.L., Anesthesia for fetal surgery (2003) Semin Pediatr Surg, 12, pp. 196-201Archer Jr., W.A., Marx, G.F., Arterial oxygen tension during apnoea in parturient women (1974) Br J Anaesth, 46, pp. 358-360Abouleish, E., Abboud, T., Lechevalier, T., Rocuronium (Org 9426) for caesarean section (1994) Br J Anaesth, 73, pp. 336-341Rychik, J., Tian, Z.Y., Cohen, D.E., Hemodynamic changes during human fetal surgery (1998) Circulation, 98, p. 1481Riley, E.T., Spinal anaesthesia for Caesarean delivery: Keep the pressure up and don't spare the vasoconstrictors (2004) Br J Anaesth, 92, pp. 459-461Fan, S.Z., Susetio, L., Tsai, M.C., Neuromuscular blockade of the fetus with pancuronium or pipecuronium for intra-uterine procedures (1994) Anaesthesia, 49, pp. 284-286Anand, K.J., Hickey, P.R., Pain and its effects in the human neonate and fetus (1987) N Engl J Med, 317, pp. 1321-1329Rosen, M.A., Anesthesia for fetal surgery (1999) Obstetric Anesthesia. Principles and Practice. 2st Ed., pp. 110-121. , Chestnut DH, Philadelphia. MosbySabik, J.F., Assad, R.S., Hanley, F.L., Halothane as an anesthetic for fetal surgery (1993) J Pediatr Surg, 28, pp. 542-54