In utero intervention for fetal anomalies or abnormal placentation should only occur for conditions known to result in ongoing irreversible harm to the fetus or increased risk to the mother. For in utero fetal treatment procedures there should be evidence that potential harm from the fetal lesion is best mitigated by intervention at a gestational age with superior outcomes than ex utero neonatal treatment. Although most fetal anomalies are not amenable to in utero treatment, two conditions with significant evidence of improved outcomes include use of fetoscopic laser photocoagulation to treat twin-to-twin transfusion syndrome and mid-gestational in utero open fetal surgery to treat myelomeningocele. Minimally invasive fetal treatment techniques are typically performed under local or regional anesthesia, while open fetal procedures are done under general anesthesia. Successful fetal intervention requires extensive multidisciplinary planning and collaboration. In addition to anesthetic considerations employed for nonobstetric surgery during pregnancy, fetal anesthesia and analgesia, fetal monitoring, uterine relaxation, and preparation for emergent maternal and fetal events are all necessary. Future research into anesthetic techniques for various maternal-fetal procedures is key to optimizing clinical outcomes and advancing the field of fetal surgery and maternal-fetal medicine.

The uterus serves as an incubator for the fetus during pregnancy. Within this incubator, the placenta is the main connection between the mother and the fetus and is integral to the survival of the fetus as it is an important source of fetal nutrients and oxygen. The proper development of the placenta allows it to support the fetus throughout pregnancy and expulsion or removal of a normal placenta following delivery, helps prevent postpartum complications. Maintenance of uteroplacental flow during pregnancy and during fetal surgery is important for the survival of the fetus and especially for the remainder of the pregnancy following fetal surgery. Serial monitoring of umbilical artery flow, a marker for uteroplacental insufficiency, is helpful to monitor fetal well-being. Physiology of the fetus correlates with the different stages of development in different organs and in many instances changes at delivery. The prevention of pain or the effects of noxious stimuli during fetal surgery serves many benefits, which include but are not limited to, prevention of release of stress hormones which can play a role in preterm labor and also prevention of long-term neurodevelopmental effects in the fetus.

Despite advances in neonatal and surgical care, the outcome of severe congenital diaphragmatic hernia (CDH) is still quite poor. Improvements in the ability to diagnose and risk stratify CDH prenatally have led to investigations into whether the more severe forms of CDH may benefit from in-utero intervention to ameliorate the accompanying pulmonary hypoplasia. Fetal endoscopic tracheal occlusion (FETO) is an example of a prenatal surgical intervention that was made possible by the technological advancements in endoscopic surgery. FETO is generally performed in fetuses with more severe forms of CDH to stimulate prenatal lung growth. While FETO is still considered investigational therapy and has not attained standard of care status, the results from published data to date have been promising. The complexity of FETO, coupled with the surgical and anesthetic risk to the mother and fetus requires a highly functional multidisciplinary fetal team, which includes obstetrics, pediatric surgery, and anesthesiology. This chapter will provide an in-depth understanding of the history of fetal endoscopic tracheal occlusion for CDH, the operative and anesthetic approach to FETO and associated perioperative considerations. Congenital diaphragmatic hernia continues to be a disease that perplexes obstetricians, neonatologists, surgeons, anesthesiologists, and the entire care team.

The focus of this chapter is to discuss a multidisciplinary approach to maternal-fetal patients undergoing minimally invasive (shunt or fetoscopic) procedures, open fetal surgery, or the ex-utero intrapartum therapy (EXIT) procedure. The team requires a diverse group of personnel. We will discuss the nature of this team and the pertinent aspects of the preoperative, intraoperative, and postoperative phase of care for the maternal-fetal patient. The preparation required for the team members providing care for these patients as well as the long-term follow-up and research aspects are outlined. Comprehensive expert care for these interventions requires administrative, institutional, research, and philanthropic support.

The founding physicians of fetal surgery recognized that experimental procedures involving a fetus were morally sensitive and would require a formal review to assess their ethical justification. A Fetal Therapy Board (FTB) is one of the groups assembled to provide such formal ethical reviews; and as such, this group would logically have members representing certain medical/surgical specialties beyond the fetal surgeon. A framework to be used by a FTB as applied to the fetal status, the components of an ethical justification, and the informed consent process for fetal interventions is presented. In addition, some hypothetical examples of a FTB review are provided to highlight specific ethical dilemmas.

Prenatally diagnosed congenital lung malformations represent a wide variety of fetal pulmonary and airway anomalies, some of which may require close monitoring and perinatal follow-up. Historically these masses were only typically seen when they were very large, at which point they were associated with a high incidence of hydrops and a high termination rate; therefore a diagnosis of a fetal lung mass had a guarded prognosis. Widespread use of prenatal ultrasound improved detection of these masses and advances in surgical techniques have allowed for intervention in the fetal period. More recently, a better understanding of fetal physiology and the use of prenatal steroids has reduced the number of fetuses requiring in-utero intervention. When indicated, in-utero treatment requires a multidisciplinary approach with close attention given to the fetal physiology, risk of maternal complications, and unique anesthetic considerations.

This chapter provides an in-depth discussion on the complexities associated with the Ex-Utero Intrapartum Therapy; EXIT procedure. The authors provide a thorough analysis of patient and procedural considerations from the maternal and fetal aspects. The perioperative approach for these procedures is reviewed in detail with respect to fetal and maternal anesthetic goals.