Many of the anesthetic considerations for fetal procedures and surgery are identical to those for nonobstetric surgery during pregnancy, including concern for maternal safety, avoidance of both teratogenic drugs and fetal asphyxia, and the prevention of preterm labor and delivery. Anesthesia is required for the mother and quite often the fetus to perform many fetal procedures. Fetal procedures and surgery can be divided into subgroups according to their anesthetic requirements. For example: procedures that only require a needle insertion into the uterus but not into the fetus, such as intrauterine infusions; laser surgical photocoagulation of the communicating placental circulation for twin-twin transfusion syndrome (TTTS) and radio-frequency umbilical cord ablation for managing twin reversed arterial perfusion (TRAP), which are not really fetal procedures, rather they are placental or cord procedures; surgical procedures performed directly on the fetus; and the EX-utero Intrapartum Treatment (EXIT) procedure. Anesthetic considerations also depend on other factors, such as the location of the placenta. Unlike maternal surgery, for fetal procedures, the fetus is not an innocent bystander for whom the least anesthetic interference is used. Instead, the fetus can be the primary patient and may benefit from anesthesia, with close monitoring of the anesthetic effects to ensure well-being. Fetal asphyxia, hypoxia, or distress can be most effectively recognized, predicted, and avoided by fetal monitoring. Monitoring is also crucial for assessing the fetal response to corrective maneuvers.
*Anesthesia ; Animal ; Female ; Fetal Diseases/*diagnosis/*therapy ; Fetus/*surgery ; Human ; Pregnancy ; *Prenatal Diagnosis

Adult ; Female ; Fetal Diseases ; prevention & control ; Fetal Heart ; surgery ; Gestational Age ; Heart Defects, Congenital ; prevention & control ; Humans ; Pregnancy ; Pulmonary Atresia ; prevention & control ; surgery

Fetal endoscopic surgery (FETENDO) involves many techniques that allow surgical procedures to be performed inside the uterus without an hysterotomy. The impetus for developing these minimal access techniques for fetal surgery is the unusual occurrence with an open hysterotomy of preterm labor, premature rupture of membranes, and maternal complications resulting from tocolytic therapy. The unique requirements of this approach necessitated a modification of existing endoscopic techniques, the development of novel fetoscopic instruments, and the inclusion of a wide variety of specialists. Technical expertise in the field and a natural evolution of techniques have given rise to innovative repairs previously not envisioned. Severe congenital diaphragmatic hernia, diseases of monochorionic twins, and obstructive uropathy have already been successfully treated using fetoscopic surgical techniques. Fetoscopic correction of many other non-life threatening anomalies continues to evolve. The future of fetoscopic surgical intervention depends on the continual evolution of novel approaches to disease, the elucidation of the pathophysiology and treatment of other fetal disorders, and a better understanding of treatment of complications of such intervention.
Anesthesia ; Endoscopes ; Female ; Fetal Diseases/*surgery ; Fetoscopy/*methods ; Human ; Intraoperative Period ; Operating Rooms ; Pregnancy ; Tocolysis ; Ultrasonography, Prenatal

In utero hematopoietic stem cell transplantation (IUHSCTx) is a promising approach for the treatment of a potentially large number of fetuses affected by congenital hematologic disorders. With technical advances in prenatal diagnosis and fetal intervention, the majority of these diseases can now be diagnosed early in gestation, allowing consideration of prenatal treatment. It, therefore, stands to reason that there is increasing interest in performing in utero hematopoietic stem cell transplantation at many centers around the world. Although the approach remains experimentally promising, expansion of clinical application will depend on improved understanding of the biological barriers to engraftment in the fetus as well as on the development of effective clinical strategies based on the hematopoietic biology of individual disorders.
Animal ; Bioethics ; Fetal Diseases/*surgery ; Fetus/immunology ; *Hematopoietic Stem Cell Transplantation/adverse effects ; Human ; Risk Factors ; Transplantation Immunology

The development and evolution of fetal surgery and the recognition of the fetus as a patient came from two sources. First, were those obstetricians and perinatologists who detected life threatening anomalies before birth, and re-described a hidden mortality arising from death in utero. Ultrasonography, color Doppler ultrasound and ultrafast fetal magnetic resonance imaging have since enhanced the accuracy of prenatal evaluation. Second, were those pediatricians responsible for treating newborn infants with extremely serious problems, and that appeared untreatable, although, it was believed that they could have been treated at an earlier stage of development. After the natural history of several correctable lesions had been determined and the selection criteria for intervention developed, fetal surgery emerged as a means of improving the overall morbidity and mortality rates.
Cystic Adenomatoid Malformation of Lung, Congenital/surgery ; Fetal Diseases/*surgery ; Fetus/*surgery ; Hernia, Diaphragmatic/congenital/surgery ; Human ; Postoperative Care ; Preoperative Care ; Sacrococcygeal Region ; Spinal Neoplasms/embryology/surgery ; Teratoma/embryology/surgery

Ovarian cysts are the most frequent, prenatally diagnosed intra-abdominal cysts. Fetal ovarian cyst often presents complication such as torsion and seems to be an indication for surgical intervention. In this study, we reviewed pre- and post-natal medical records and ultrasonography of 17 fetuses that were diagnosed with ovarian cysts. In a total of 17 cases, postnatal surgery was performed in 7 infants. Of these cases, four cases of ovarian cyst torsion were confirmed. In the remaining 10 fetuses, one case regressed completely during pregnancy, and the other nine cases including two complex cysts resolve spontaneously after birth. Postnatal symptomatic cysts or cysts with a diameter greater than 5 cm that do not regress or enlarge should be treated, but uncomplicated asymptomatic cysts less than 5 cm in diameter should only be observed and reassessed by serial ultrasonography. If they regress spon-taneously, no surgical intervention is necessary independent of their sonographic findings.
Ultrasonography, Prenatal/*methods ; Remission, Spontaneous ; Pregnancy ; Ovariectomy/methods ; Ovarian Cysts/*diagnosis/surgery ; Infant, Newborn ; Infant ; Humans ; Gestational Age ; Fetal Diseases/*diagnosis/surgery ; Female

A 27-yr-old woman who had been taking warfarin for 10 yr after mitral valve replacement became pregnant. After knowing her pregnancy, she received heparinization for nine weeks instead of warfarin, and took oral anticoagulant again. At 24 weeks of gestation, fetal ultrasound and MRI showed a left subdural hematoma, and the pregnancy was terminated. Subdural hematoma was demonstrated on autopsy. Fatal bleeding of the fetus is a rare complication of maternal warfarin medication, occurring mostly in the second or third trimester. There is no alternative regimen available, so that regular monitoring by fetal ultrasound and strict control of warfarin dose with regular measurement of prothrombin time are the best way to prevent intrauterine fetal death due to bleeding.
Adult ; Anticoagulants/*adverse effects ; Ductus Arteriosus, Patent/surgery ; Female ; Fetal Diseases/*chemically induced ; Heart Valve Diseases/therapy ; Hematoma/chemically induced ; Heparin/adverse effects ; Human ; Intracranial Hemorrhages/*chemically induced ; Maternal Exposure ; Pregnancy ; Pregnancy Complications, Hematologic ; Prothrombin Time ; Warfarin/*adverse effects

Animals ; Aortic Valve ; surgery ; Aortic Valve Stenosis ; congenital ; therapy ; Balloon Valvuloplasty ; methods ; Cardiac Surgical Procedures ; adverse effects ; methods ; Catheterization ; adverse effects ; methods ; Female ; Fetal Diseases ; therapy ; Fetal Heart ; surgery ; Heart Defects, Congenital ; therapy ; Humans ; Postoperative Complications ; epidemiology ; Pregnancy ; Pregnancy Trimester, Second ; Ultrasonography, Interventional ; methods

AIMTo repopulate the liver of mice with acute liver injury and to make mouse models with chimeric liver by using human umbilical cord blood (hUCB)-derived mononuclear cells.

METHODSFifteen acute liver injury mouse models were induced by carbon tetrachloride intraperitoneal injection followed by two-thirds hepatectomy and all mice were divided into three groups: cell transplantation group (n = 7), negative control group (n = 3) and blank control group (n = 5). HUCB cell preparations were transplanted into mouse spleens of cell transplantation group and phosphate bufferd saline (PBS) was injected into spleens of negative controls. Neither cell suspension nor PBS was given to the blank controls. Pathological changes were observed 7, 14 and 21 days after cell transplantation. Human albumin (ALB) and cytokeratin 19 (CK19) were also detected in the mouse sera and liver tissues.

RESULTSAll mice showed histological features of acute liver injury. Positive expression of human ALB and CK19 were observed in liver tissues of cell transplantation group 7, 14 and 21 days after cell transplantation. Human ALB could be detected from the sera and liver homogenates of cell-transplanted mice. No positive expression of human ALB and CK19 were observed in liver tissues and no human ALB was detected in sera of negative control group.

CONCLUSIONSHUCB-derived mononuclear cells can differentiate into functional human hepatocytes and biliary cells in large quantity in mouse models with acute liver injury, thus a great progress were made in establishing mouse models with chimeric liver.

Animals ; Carbon Tetrachloride ; toxicity ; Cell Proliferation ; Cell Transplantation ; methods ; Cells, Cultured ; Female ; Fetal Blood ; cytology ; metabolism ; Humans ; Immunohistochemistry ; Keratin-19 ; analysis ; blood ; Leukocytes, Mononuclear ; cytology ; metabolism ; transplantation ; Liver ; drug effects ; pathology ; surgery ; Liver Diseases ; blood ; surgery ; Male ; Mice ; Mice, Inbred BALB C ; Mice, SCID ; Pregnancy ; Serum Albumin ; analysis ; Transplantation Chimera ; blood ; metabolism

OBJECTIVES: The aims of the study show the effect of cardiac disease of pregnant women on the perinatal complications and pregnancy outcomes. METHODS: From Jan. 2001 to Nov. 2005, 29 cases of pregnant women with cardiac disease were enrolled and classified by the NYHA (New York Heart Association) classes under the supervision of cardiologist and cardiothoracic surgeon. The average age of all cases is 29.9 years olds and it consists of 13 primigravida and 16 multigravida. For the examination of cardiac function during the pregnancy, the echocardiography was performed. We evaluated the cardiac disease of pregnant woman with the underlying causes, clinical manifestations during the pregnancy, delivery mode, gestational age at birth, birth weight, Apgar score and perinatal complication. RESULTS: All 29 cases with cardiac diseases are composed of 21 cases of NYHA class I (72.7%), 4 case of NYHA class II (13.7%) and 4 cases of NYHA class III (13.7%). There are 11 cases with congenital heart disease (37.9%), 6 cases with acquired heart disease (20.6%), 9 cases with arrhythmia (31.0%), and 3 cases with other cardiac disease (10.3%). Before the pregnancy, 6 cases of 11 cases with congenital heart disease and 5 cases of 6 cases with acquired heart disease performed the corrected cardiac surgery. Echocardiography was performed on 24 cases. It showed average ejection fraction in left ventricle of NYHA class I (13 cases) and NYHA class II, III (8 cases) were 61.5% and 52.6%, respectively. 7 cases of NYHA class I and 1 case of class II was done on the vaginal delivery. 14 cases of class I pregnant woman were performed the cesarean section according to obstetric indications but 3 cases of class II were performed the cesarean section for the prevention of cardiac risks. 4 cases of class III were performed the cesarean section according to obstetrics indications (2 cases) and for the prevention of cardiac risks (2 cases). For gestational age at birth, the average of NYHA class I was 38.1 weeks and the average of NYHA class II, III was 35.4 weeks. The average birth weight showed 3,022 gm in class I and 2,446 gm in class II and class III. Preterm birth were 3 cases (class II; 1 case, class III ; 2 cases). Low birth weight infant were 5 cases (class I; 3 cases, class II 2 cases). Intrauterine fetal death was a case (class I). Congenital abnormalities at birth were not observed in our study. Although no maternal mortality was observed, 2 cases of pulmonary edema caused by cardiomyopathy in NYHA class III and 1 case of Eisenmenger Syndrome caused by PDA in NYHA class II were developed during the labor. CONCLUSION: In this study, the majority of pregnant women with cardiac disease had the congenital heart diseases. It also showed that they can expect good perinatal outcomes by the adequate prenatal care including cardiac surgery before the pregnancy.
Apgar Score ; Arrhythmias, Cardiac ; Birth Weight ; Cardiomyopathies ; Cesarean Section ; Congenital Abnormalities ; Echocardiography ; Eisenmenger Complex ; Female ; Fetal Death ; Gestational Age ; Heart ; Heart Defects, Congenital ; Heart Diseases* ; Heart Ventricles ; Humans ; Infant, Low Birth Weight ; Infant, Newborn ; Maternal Mortality ; Obstetrics ; Organization and Administration ; Parturition ; Pregnancy ; Pregnancy Outcome ; Pregnant Women* ; Premature Birth ; Prenatal Care ; Pulmonary Edema ; Thoracic Surgery