S. Backley, E. Bergh, J. Garnett, R. Li, V. Maroufy, R. Jain, S. Fletcher, K. Tsao, M. Austin, A. Johnson, R. Papanna

Fetal cardiovascular changes during open and fetoscopic in‐utero spina bifida closure

  • Obstetrics and Gynecology
  • Radiology, Nuclear Medicine and imaging
  • Reproductive Medicine
  • General Medicine
  • Radiological and Ultrasound Technology

ABSTRACTObjectiveLaparotomy‐assisted fetoscopic closure of spina bifida utilizing heated‐humidified carbon dioxide gas has been associated with less maternal morbidity than open in‐utero spina bifida closure. Fetal cardiovascular changes during these surgical interventions are not well defined. Our objective was to compare fetal bradycardia (defined as fetal heart rate (FHR)<110 bpm over 10 minutes) and changes in umbilical artery Doppler parameters throughout open in‐utero closure with those observed during laparotomy‐assisted fetoscopic closure.MethodsWe conducted a prospective cohort study of 22 open and 46 fetoscopic consecutive in‐utero closures between 2019 and 2023. Both cohorts had similar preoperative counseling and clinical management. FHR and umbilical artery velocimetry were systematically obtained during preoperative assessment, every 5 minutes during the intraoperative period, and in the postoperative assessment. FHR, pulsatility indexes and end‐diastolic flows were segmented into hourly periods during surgery, and the lowest values were averaged for analysis. Umbilical vein maximum velocities were measured in the fetoscopic cohort. Each fetal heart rate recording time point was correlated to maternal parameters, including heart rate, systolic and diastolic blood pressures.ResultsFetal bradycardia occurred in 4/22 cases (18.2%) of open in‐utero closure and in 21/46 cases (45.7%) of fetoscopic closure. FHR gradually decreased in both cohorts after general anesthesia and decreased further during surgery. FHR were significantly lower after two hours of surgery in the fetoscopic closure than in the open in‐utero closure group. In addition, the FHR (BPM) change in the final stages of the fetal surgery from the baseline FHR was significantly lower in the fetoscopic cohort (‐32.3 (‐35.7, ‐29.1)) compared to the open cohort (‐23.5 (‐28.1, ‐18.8)) (p=0.002). Abnormal end‐diastolic flow (defined as absent or reversed end‐diastolic flow) in the umbilical artery Doppler velocity occurred in 3/22 (13.6%) of the open closure cohort and in 23/46 (50%) of the fetoscopic closure cohort (p=0.004). There were no differences in umbilical artery end‐diastolic flow and pulsatility index between closure techniques during the various stages of assessment.ConclusionsWe observed a decrease in the FHR and abnormalities in umbilical artery Doppler parameters in both open in‐utero and fetoscopic closure groups. Fetal bradycardia was more prominent during fetoscopic closure following heated‐humidified carbon dioxide insufflation, but the FHR recovered after cessation of the heated‐humidified carbon dioxide. Changes in FHR and umbilical artery Doppler parameters during in‐utero spina bifida closure were observed to be transient, no cases required emergency delivery and no fetoscopic closure were converted to open closure. These observations should inform algorithms for perioperative management of fetal bradycardia associated with in‐utero spina bifida closure.This article is protected by copyright. All rights reserved.

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