Intrauterine Repair at 25 Weeks For Myelomeningocele. Case Report With Video

Background: Neural tube closure defects, such as myelomeningocele, represent serious congenital malformations that can result in significant neurological sequelae. Intrauterine surgical correction has emerged as a promising strategy to improve fetal prognosis by treating the defect before birth.

Case Report: This study reports a healthy 35-year-old patient with gestational age (GA) of 25 weeks plus 4 days, with no history of anesthetics, physical status ASA 1 who underwent surgery for intrauterine correction of myelomeningocele under balanced general anesthesia associated with continuous epidural anesthesia. Preoperatively, omeprazole 40 mg, metoclopramide 10 mg, cimetidine 100 mg and, as pre-anesthetic medication, midazolam 3 mg were administered. The epidural puncture was performed in L1-L2 intervertebral space after sedation with midazolam and fentanyl, in a single attempt with a Touhy needle, infused with 0.1% ropivacaine, followed by the passage of an epidural catheter 20G for postoperative analgesia. Anesthetic induction was in rapid sequence with propofol 150mg, lidocaine 80mg, remifentanil Minto´s model target controlled and rocuronium and maintenance of anesthesia with 3 to 4% Sevoflurane. After hysterotomy and exposure of the fetal gluteal region, anesthesia and fetal immobility were guaranteed with intramuscular injection of fentanyl 12μg and pancuronium 80μg. Maternal hemodynamic stability was guaranteed with a systolic target above 100mmHg with crystalloid infusion and norepinephrine bolus. At the end of the procedure, the amniotic fluid was replaced with warmed 0,9% saline solution. The procedure was completed without complications and the patient was sent to the Intensive Care Unit for immediate post-operative care with continuous infusion of ropivacaine into the epidural catheter for analgesia.

Conclusion: Anesthesia for fetal surgery involves anesthesia with an emphasis on the care of the mother-fetus binomial, the preservation of good uteroplacental flow, the adoption of tocolysis measures and the prevention of anesthetic and surgical complications. There is a need for multidisciplinary monitoring, with a team of anesthesia, neurosurgery, pediatrics and obstetrics.

Keywords: Myelomeningocele, Fetal Anesthesia, Intrauterine Surgery, Neural Tube Defect.