Morbidity Still A Concern in Fetal Surgeries


RENO, NEV. — Newer, less invasive techniques have decreased morbidity associated with fetal surgery, but morbidity is still a concern in these surgeries, Robert H. Bell, M.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

The morbidity data come from a retrospective study of all fetal surgeries at the University of California, San Francisco, between July 1985 and May 2003, said Dr. Bell of the university.

During the early days of fetal surgery, most of the procedures involved open hysterotomy. Then fetal endoscopy (FETENDO) became popular, and now ultrasound-guided radiofrequency ablation (RFA) is the dominant procedure.

In all, 187 women with a mean maternal age of 29 (range 19-43) were treated during this period. Nine cases were marked by procedure-related fetal demise. Of the remaining 178 procedures, 79 involved a laparotomy and hysterotomy, 68 involved FETENDO, and 31 involved RFA.

Indications for the procedures included congenital diaphragmatic hernia in 38% of cases, monochorionic twin complications in 31%, hydrops in 11.8%, meningomyelocele in 8.6%, teratomas in 6.4%, and urinary obstruction in 2.1%.

The average gestational age for both hysterotomy and FETENDO was about 25 weeks, but RFA was done significantly earlier, at an average gestational age of about 21 weeks.

There were no significant differences in gestational age at delivery, with hysterotomy patients delivering at an average of 30.1 weeks, FETENDO patients delivering at 30.4 weeks, and RFA patients delivering at 32.7 weeks.

“Premature delivery, sadly, at this point is [a matter of] 'when' and not 'if,'” Dr. Bell said, although he pointed out that the data, averaged over a number of years of surgical experience, do not reflect recent improvements in lengthening pregnancies.

Premature rupture of membranes (PROM) is the primary cause of preterm delivery in these cases, and the rates of PROM are 52% in hysterotomy patients, 44% in FETENDO patients, and a significantly lower 13% in RFA patients.

About a quarter of the hysterotomy and FETENDO patients suffered pulmonary edema, a complication Dr. Bell attributed to deep inhalational anesthesia in the hysterotomy patients and the use of tocolytics in both hysterotomy and FETENDO patients.

None of the RFA patients suffered pulmonary edema (a statistically significant difference), reflecting recent changes in the treatment algorithm for preterm labor.

Another impressive improvement occurred in the average length of the patient's hospital stay. Although Dr. Bell said that clinicians at his institution are very cautious in managing patients in terms of surveillance and limitations of movement, the average length of stay has declined significantly from 11.9 days in the hysterotomy patients, to 7.9 days in the FETENDO patients, to 2.5 days in the RFA patients. And this understates the degree of improvement, since many RFA patients can now go home within 24 hours.

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