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Fetal Surgery for Congenital Diaphragmatic

Hernia Periprocedural Care
Updated: Aug 21, 2013
Author: Doug N Miniati, MD; Chief Editor: Hanmin Lee, MD more...

PERIPROCEDURAL CARE

Patient Education & Consent

The risks, benefits, and potential complications are thoroughly reviewed with the patient.

Pre-Procedure Planning
Appropriate consultations are made with the pediatric surgeon, perinatologist, anesthesiologist,
and social worker.

Patient Preparation
The patient is admitted to the obstetrical unit, and a baseline physical assessment is performed,
including fetal heart rate and uterine contraction monitoring. The latest prenatal sonogram is
reviewed and indications for surgery are confirmed.

Preoperative laboratory tests include a complete blood cell count, blood type and screen, and
urinalysis. Activity is ad lib and bedrest exercises are reviewed.

The patient is kept nil per os for 8 hours before surgery.

Immediately before surgery, indomethacin for tocolysis may be administered, and perioperative
antibiotics are given.

Anesthesia

Depending on the surgeon's choice, anesthesia can range from local to locoregional to general.

Monitoring & Follow-up

After the procedure, the patient is readmitted to the obstetrical unit for monitoring.

Daily ultrasonography and fetal echocardiography (if indicated) are performed. After the procedure
on the day of surgery, the patient's diet is advanced as tolerated, and she remains in bed with

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Fetal Surgery for Congenital Diaphragmatic Hernia Periprocedural Care:... http://emedicine.medscape.com/article/2109500-periprocedure#showall

lateral positioning. Owing to potential pulmonary edema, fluids are restricted to 3 L/d if the patient
is treated with magnesium sulfate. Incentive spirometry and continuous pulse oximetry are
instituted.

Fetal heart rate and uterine contractions are monitored until discontinued by the fetal treatment
team. Tocolysis is achieved with indomethacin, magnesium sulfate, or nifedipine, as dictated by
the fetal treatment team. On postoperative day number 1, the patient is allow to ambulate and
undergoes a complete blood cell count.

The patient is discharged when she is ambulatory, is tolerant of a diet, is spontaneously voiding,
has good pain control with oral medications, is afebrile with normal vital signs and reassuring
physical examination findings, and has a normal fetal heart rate and minimal uterine contractions.
Oral tocolysis is continued as needed.

Reversal Procedure
Since the development of the fetal tracheal occlusion technique, reversal of the occlusion has
been recognized as an important part of the therapy, both to avoid the necessity of an ex utero
intrapartum treatment (EXIT) procedure [22] for delivery and to allow the lungs to recover from the
distention forces that result in lung growth. [23]

Reversal is achieved by repeat fetoscopy and balloon removal 4-6 weeks after the initial
procedure. In the future, more sophisticated tracheal occlusion devices may allow for more
physiologic lung growth and development. [24]

Technique

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