İntrauterin Cerrahilerde Anestezi Yaklaşımı: Vezikoamniyotik Şant Uygulaması Örneği
Özet
Alt üriner sistem obstrüksiyonu tanısı konulan 18 haftalık fetus için, gebeliğin 18. haftasında vezikoamniyotik şant (VAŞ) yerleştirilmesi planlanan 32 yaşındaki, Tip 1 Diabetes Mellitus tanılı gebe hastaya genel anestezi altında işlem uygulandı. Anestezi indüksiyonu hızlı ardışık teknikle gerçekleştirildi; Sevofluran ile uteroplasental perfüzyon korunarak yeterli anestezi derinliği sağlandı. Fetal hareketsizliğin temini ve analjezi gerekliliği göz önünde bulundurularak multidisipliner ekip eşliğinde genel anestezi tercih edildi. Cerrahi girişim 40 dakika sürdü, operasyon boyunca maternal ve fetal parametreler stabil izlendi. Postoperatif dönemde hasta sorunsuz şekilde izlenip obstetri servisine transfer edildi. Bu olgu, minimal invaziv fetal cerrahilerde maternal ve fetal hemodinaminin eş zamanlı yönetildiği, genel anestezi altında başarıyla uygulanan bir VAŞ örneği sunmaktadır.
Referanslar
Duci M, Pulvirenti R, Fascetti Leon F, et al. Anesthesia for fetal operative procedures: A systematic review. Frontiers in Pain Research. 2022;3: 935427. doi:10.3389/fpain.2022.935427
Pierucci UM, Paraboschi I, Lanfranchi G, et al. Indications and Outcomes of Fetal Cystoscopy for Lower Urinary Tract Obstruction: A Comprehensive Review. Prenatal Diagnosis. 2025;45(1): 89–101. doi:10.1002/pd.6721
Moldenhauer JS, Adzick NS. Fetal surgery for myelomeningocele: After the Management of Myelomeningocele Study (MOMS). Seminars in Fetal & Neonatal Medicine. 2017;22(6): 360–366. doi:10.1016/j.siny.2017.08.004
Deprest J, Gratacos E, Nicolaides KH. Fetoscopic tracheal occlusion (FETO) for severe congenital diaphragmatic hernia: evolution of a technique and preliminary results. Ultrasound in Obstetrics & Gynecology. 2004;24(2): 121–126. doi:10.1002/uog.1711
Adzick NS. Management of Fetal Lung Lesions. Clinics in Perinatology. 2009;36(2): 363–376. doi:10.1016/j.clp.2009.03.001
Cruz-Martínez R, Martínez-Rodríguez M, Gámez-Varela A, et al. Fetoscopic urethral meatotomy in fetuses with lower urinary tract obstruction by congenital megalourethra. Prenatal Diagnosis. 2021;41(6): 772–777. doi:10.1002/pd.5946
Martínez JM, Masoller N, Devlieger R, et al. Laser Ablation of Posterior Urethral Valves by Fetal Cystoscopy. Fetal Diagnosis and Therapy. 2015;37(4): 267–273. doi:10.1159/000367805
Zhao L, Wang L, Xia H, et al. Prognosis and outcome of intrauterine treatment of fetuses with critical congenital heart disease. Chinese Medical Journal. 2024;137(12): 1431. doi:10.1097/CM9.0000000000002796
McElhinney DB, Marshall AC, Wilkins-Haug LE, et al. Predictors of Technical Success and Postnatal Biventricular Outcome After In Utero Aortic Valvuloplasty for Aortic Stenosis With Evolving Hypoplastic Left Heart Syndrome. Circulation. American Heart Association; 2009;120(15): 1482–1490. doi:10.1161/CIRCULATIONAHA.109.848994
Müllers SM, McAuliffe FM, Kent E, et al. Outcome following selective fetoscopic laser ablation for twin to twin transfusion syndrome: an 8 year national collaborative experience. European Journal of Obstetrics and Gynecology and Reproductive Biology. Elsevier; 2015;191: 125–129. doi:10.1016/j.ejogrb.2015.05.019
Stellon MA, Joshi DS, Beninati MJ, et al. Management of Twin Reversed Arterial Perfusion Sequence: A Systematic Review and Meta-Analysis. Fetal Diagnosis and Therapy. 2024;52(2): 207–222. doi:10.1159/000542841
Marwan A, Crombleholme TM. The EXIT procedure: principles, pitfalls, and progress. Seminars in Pediatric Surgery. 2006;15(2): 107–115. doi:10.1053/j.sempedsurg.2006.02.008
Hirose S, Harrison MR. The ex utero intrapartum treatment (EXIT) procedure. Seminars in Neonatology. Elsevier; 2003;8(3): 207–214. doi:10.1016/S1084-2756(03)00029-0
Medicine SFM-F, Planning SOF, Norton ME, et al. Society for Maternal-Fetal Medicine Consult Series #59: The use of analgesia and anesthesia for maternal-fetal procedures. Contraception. 2022;106: 10–15. doi:10.1016/j.contraception.2021.10.003
Faruja A, Idelson A, Azem K, et al. Anesthetic management for fetal surgery: lessons from a single-center experience (2019–2023). International Journal of Obstetric Anesthesia. 2025;61: 104284. doi:10.1016/j.ijoa.2024.104284
Naus CA, Mann DG, Andropoulos DB, et al. “This is how we do it” Maternal and fetal anesthetic management for fetoscopic myelomeningocele repairs: the Texas Children’s Fetal Center protocol. International Journal of Obstetric Anesthesia. Elsevier; 2025;61. doi:10.1016/j.ijoa.2024.104316
Arens C, Koch C, Veit M, et al. Anesthetic Management for Percutaneous Minimally Invasive Fetoscopic Surgery of Spina Bifida Aperta: A Retrospective, Descriptive Report of Clinical Experience. Obstetric Anesthesia Digest. 2018;38(1): 22. doi:10.1097/01.aoa.0000529985.72045.d9
Chatterjee D, Arendt KW, Moldenhauer JS, et al. Anesthesia for Maternal–Fetal Interventions: A Consensus Statement From the American Society of Anesthesiologists Committees on Obstetric and Pediatric Anesthesiology and the North American Fetal Therapy Network. Anesthesia & Analgesia. 2021;132(4): 1164. doi:10.1213/ANE.0000000000005177
Na S. Surgery on the Unborn: Anesthesia for Intrauterine and Fetal Surgery – A Review. Anaesthesia & Critical Care Medicine Journal. 2023;8(2): 1–7. doi:10.23880/accmj-16000226
Chatterjee D, Arendt KW, Moldenhauer JS, et al. Anesthesia for Maternal–Fetal Interventions: A Consensus Statement From the American Society of Anesthesiologists Committees on Obstetric and Pediatric Anesthesiology and the North American Fetal Therapy Network. Anesthesia & Analgesia. 2021;132(4): 1164. doi:10.1213/ANE.0000000000005177
Rutledge J, Bricker JT. Congenital Diseases of the Heart. Texas Heart Institute Journal. 2001;28(3): 237. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC101193/
Ferschl M, Ball R, Lee H, et al. Anesthesia for In Utero Repair of Myelomeningocele. Anesthesiology. 2013;118(5): 1211. doi:10.1097/ALN.0b013e31828ea597
Nelson O, Lin EE. Anesthesia for fetal interventions: Caring for mother and fetus prior to birth. Journal of Anesthesia and Translational Medicine. 2025;4(1): 18–24. doi:10.1016/j.jatmed.2025.02.004
Use of fetal analgesia during prenatal surgery: The Journal of Maternal-Fetal & Neonatal Medicine: Vol 26, No 1. [Online] https://www.tandfonline.com/doi/10.3109/14767058.2012.718392?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
Oliveira E, Pereira P, Retroz C, et al. Anesthesia for EXIT procedure (ex utero intrapartum treatment) in congenital cervical malformation – a challenge to the anesthesiologist. Brazilian Journal of Anesthesiology (English Edition). 2015;65(6): 529–533. doi:10.1016/j.bjane.2013.07.020
Upadya M, Saneesh PJ. Anaesthesia for non-obstetric surgery during pregnancy. Indian Journal of Anaesthesia. 2016;60(4): 234. doi:10.4103/0019-5049.179445
Stohl SM, Stohl HE, Weintraub AY, et al. The EXIT procedure. Anesthesia and the Fetus. John Wiley & Sons, Ltd; 2013. p. 183–191. doi:10.1002/9781118477076.ch20
Subramanian R, Mishra P, Subramaniam R, et al. Role of anesthesiologist in ex utero intrapartum treatment procedure: A case and review of anesthetic management. Journal of Anaesthesiology Clinical Pharmacology. 2018;34(2): 148. doi:10.4103/joacp.JOACP_239_16
Gadsden J, Hart S, Santos AC. Post-Cesarean Delivery Analgesia. Anesthesia & Analgesia. 2005;101(5S): S62. doi:10.1213/01.ANE.0000177100.08599.C8
Chatterjee D, Arendt KW, Moldenhauer JS, et al. Anesthesia for Maternal–Fetal Interventions: A Consensus Statement From the American Society of Anesthesiologists Committees on Obstetric and Pediatric Anesthesiology and the North American Fetal Therapy Network. Anesthesia & Analgesia. 2021;132(4): 1164–1173. doi:10.1213/ANE.0000000000005177
Keil C, Köhler S, Sass B, et al. Implementation and Assessment of a Laparotomy-Assisted Three-Port Fetoscopic Spina Bifida Repair Program. Journal of Clinical Medicine. Multidisciplinary Digital Publishing Institute; 2023;12(15): 5151. doi:10.3390/jcm12155151
Balayla J, Shrem G. Use of artificial intelligence (AI) in the interpretation of intrapartum fetal heart rate (FHR) tracings: a systematic review and meta-analysis. Archives of Gynecology and Obstetrics. 2019;300(1): 7–14. doi:10.1007/s00404-019-05151-7
Leon RL, Ortigoza EB, Ali N, et al. Cerebral Blood Flow Monitoring in High-Risk Fetal and Neonatal Populations. Frontiers in Pediatrics. Frontiers; 2022;9. doi:10.3389/fped.2021.748345