INTRODUCTION:The first wave of the COVID-19 pandemic caused the cancellation of elective interventions. After the improvement of the epidemiological situation, new models of care were applied in hospitals to restart the programmed surgical activity. The aim was to evaluate the effectiveness of the organizational model established to recover surgical activity during the transition period of the COVID-19 pandemic. METHODS:Retrospective observational study comparing patients who underwent schedule surgery from September 1 until October 31, 2020, study group, with a control group of the same period of time corresponding to the year 2019 at the General Hospital from the Vall d'Hebron University Hospital. RESULTS:The total population included 1,825 patients, 888 in the study group and 937 in the control group. Global surgical activity decreased 6.43% during the study period compared to the same period in 2019, with a 25.5% decrease in cancer surgeries. Seven patients became infected with SARS-CoV-2 during their hospital stay. In hospital mortality was 0.9% in the study group compared to 0.7% in control group (p=0.8). The survival rate in cancer patients at 90 days was lower in the study group (95.7% vs 98.7%; p=0.02). CONCLUSIONS:The change in the management model during the transition period of the COVID-19 pandemic allowed the recovery of programmed surgical activity to levels similar to those existing prior to the pandemic with a greater impact on cancer surgery.

BACKGROUND:During fetal surgery, the haemodynamic stability of the fetus depends on the haemodynamic stability of the mother. The primary objective of this study was to assess changes in fetal heart rate (FHR) throughout the different stages of surgery. The secondary objective was to assess potential changes in maternal physiological parameters and their association with FHR.METHODS:This was a single-center observational cohort study conducted between 2015 and 2019 in 26 women undergoing intra-uterine fetoscopic repair of open spina bifida. The primary outcome was FHR. Maternal physiologic parameters were measured at the beginning, during and after surgery. The linear mixed-effects model fitted by maximum likelihood was used to assess changes in each variable at specific times throughout the surgery, and the repeated measures correlation coefficient was used to study the association between FHR and maternal physiological parameters.RESULTS:One (3.8%) case of fetal bradycardia (FHR <110 beats per minute) required the administration of intramuscular atropine. No other significant FHR changes were observed during surgery. Maternal oesophageal temperature (P <0.001), lactate levels (P=0.002), and mean arterial pressure (P=0.016) changed significantly during surgery, although none of these changes was clinically relevant. The FHR showed a significant association with maternal carbon dioxide tension (r=0.285, 95% CI 0.001 to 0.526) and maternal heart rate (r=0.302, 95% CI 0.025 to 0.535).CONCLUSION:The FHR remained stable during intra-uterine fetoscopic repair of open spina bifida. Maternal carbon dioxide tension and heart rate may have a mild influence on FHR.

COVID 19 infection also affects obstetric patients. Regular obstetric care has continued despite the pandemic. Case series of obstetric patients have been published. Neuroaxial techniques appear to be safe and it is important to obtain the highest possible rate of success of the blocks before a cesarean section. For this reason, it is recommended that the blocks be carried out by senior anesthesiologists. The protection and safety of professionals is a key point and in case of general anesthesia, so it is also recommended to call to the most expert anesthesiologist. Seriously ill patients should be recognized quickly and early, in order to provide them with the appropriate treatment as soon as possible. Susceptibility to thrombosis makes prophylactic anticoagulation a priority.

ABSTRACTObjectiveFetoscopy for closure of open neural tube defects (NTD) remains controversial, as the use of patches or single‐layer closure is not considered to meet the standards of good neurosurgical reconstruction. In this study, we describe a fetoscopic two‐layer (myofascial and skin) closure technique for the treatment of NTD in five patients and report the preliminary anatomical outcome at birth.MethodsFrom February to September 2017, five pregnant women with a fetus with a NTD, including three cases of myelomeningocele and two cases of myelocele, were operated on using a fetoscopic two‐layer closure technique. In this technique, with the uterus exteriorized and using three 10‐Fr ports, the placode is dissected from the surrounding tissue and detethered, removing the cystic tissue. The skin is undermined by blunt dissection and the defect is sutured to the midline in two layers (myofascial and skin) using a running 4/0 resorbable barbed suture.ResultsMedian gestational age at the procedure was 24 + 3 (range, 23 + 5 to 27 + 3) weeks. Surgery was successful in all cases, without any intraoperative complications. Median time in surgery was 180 (range, 140–180) min and median time for fetoscopy was 105 (range, 65–120) min. In terms of obstetric complications, three cases of premature rupture of membranes and one case of chorioamnionitis were recorded. Median gestational age at delivery was 34 + 1 (range, 25 + 4 to 37 + 2) weeks and two patients delivered vaginally. The closed defect was watertight with good quality tissue in all cases.ConclusionFetoscopic two‐layer closure of NTD may improve the quality of the tissue covering the defect, diminishing the need for postnatal surgical revision, and preserving the well‐documented beneficial effects of prenatal closure on the neural tissue and hindbrain herniation. However, this technique may not be appropriate for those cases with wide diastasis of the myofascial layer or with a low quantity of available tissue. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Background/objectiveSeveral risk scores (RSs) have been used to stratify risk of cardiac complications (CCs) in pregnant patients with heart disease. We aimed to compare and contrast the accuracy of several RSs for predicting CC in this population.MethodsProspective inclusion of all consecutive pregnant patients with heart disease, and follow-up until 6months postpartum. CCs were defined as primary if admission was required due to heart failure, arrhythmia or thromboembolic events, and secondary if the decline in NYHA class compared with baseline was >2 or urgent invasive cardiac procedures were needed. The discriminatory power of each RS was assessed by the area-under-the receiver-operating characteristic (ROC) curve (AUC).Results179 patients, mean age: 32years, accounted for 13.4% of CC (primary 11.7%, secondary 1.7%); the main diagnosis was congenital heart disease (CHD) in 68% followed by valvulopathies in 16%, arrhythmia in 7% and myocardiopathies in 5%. 22% (n=40) were classified as mWHO=1, 59% (n=105) mWHO=2 including subgroup 2–3, 14% (n=26) mWHO=3 and 4%(n=7) mWHO=4; 1 patient was unclassifiable. mWHO showed a better AUC (0.763) than CARPREG (0.67). For the CHD population, ZAHARA RS showed an AUC of 0.74, and Khairy an AUC of 0.632.ConclusionsmWHO was better at predicting CC than CARPREG; mWHO was also better at predicting CC than the specific CHD RS in the CHD subgroup.PracticeThere are an increasing number of pregnant women with HD.ImplicationsImproved prediction of CC risk during pregnancy can provide better preconception assessment in women with HD.

Puyo, M.1; Garcia-Orellana, M.2; González-Núñez, M.1; Manrique, S.3; Suescun, M. C.3; Trillo, L.2 Author Information

Advances in prenatal diagnosis and surgical techniques have resulted in an increasing number of fetal interventions. 1 Sydorak R.M. Hedrick M.H. Longaker M.T. Albanese C.T. Pathophysiologic patterns influencing fetal surgery. World J Surg. 2003; 27: 45-53 Crossref PubMed Scopus (4) Google Scholar We describe a fetoscopic cord occlusion procedure performed in a twin pregnancy that resulted in acute hemorrhage and the need for intrauterine fetal resuscitation.

Recessive dystrophic epidermolysis bullosa is inherited as a rare autosomal disorder which causes blisters to form in the skin. We describe the treatment of a 39-year-old parturient with this condition. She was scheduled for elective cesarean section at 37 weeks' gestation. The patient had widespread skin lesions, had lost fingers, and had esophageal stenosis. The cesarean was performed under spinal anesthesia without complications. Recessive dystrophic epidermolysis bullosa requires adaptation of anesthetic technique that includes control over posture and careful handling of the skin. Material for attaching monitoring devices and inserting venous lines must be adapted to the particular deformities and skin lesions present.

Recessive dystrophic epidermolysis bullosa is inherited as a rare autosomal disorder which causes blisters to form in the skin. We describe the treatment of a 39-year-old parturient with this condition. She was scheduled for elective cesarean section at 37 weeks' gestation. The patient had widespread skin lesions, had lost fingers, and had esophageal stenosis. The cesarean was performed under spinal anesthesia without complications. Recessive dystrophic epidermolysis bullosa requires adaptation of anesthetic technique that includes control over posture and careful handling of the skin. Material for attaching monitoring devices and inserting venous lines must be adapted to the particular deformities and skin lesions present.

OBJECTIVES To evaluate survival and lung growth in fetuses with severe congenital diaphragmatic hernia (CDH) treated with fetoscopic tracheal occlusion (FETO) compared with control fetuses and to analyze possible complications of the anesthetic techniques used. PATIENTS AND METHODS This prospective study was performed on fetuses with CDH. FETO was undertaken before the 29th week of gestation on fetuses with a lung-to-head ratio (LHR) less than 1. FETO was not performed on fetuses with an LHR between 1.0 and 1.5 or those with an LHR less than 1 where consent was not given. Lung growth was monitored by means of LHR. FETO was performed under fetal intramuscular anesthesia and maternal epidural anesthesia and sedation with remifentanil. RESULTS Seventeen fetuses were included in the study. FETO was performed on 11 fetuses and was effective in 9. The median percentage difference between LHR at diagnosis and prior to FETO was 1.15% (P=.183); between diagnosis and before removing the balloon, the difference was 130.5% (P=.003); and between diagnosis and before delivery, 90.18% (P=.003). In the control group (n=6), the median percentage difference between LHR at diagnosis and before delivery was 49.25% (P=.028). No significant hemodynamic or respiratory changes occurred in either mother or fetus during fetoscopy. All the fetuses in the control group died; 45.5% of those in the FETO group survived. CONCLUSIONS The use of FETO in cases of CDH appears to increase survival and lung growth. Fetal anesthesia in association with maternal epidural anesthesia and sedation makes it possible to place and remove the endotracheal balloon via fetoscopy with acceptable maternal comfort and without notable complications.

An ex utero intrapartum treatment (EXIT) procedure provides sufficient time to gain control of the potentially obstructed fetal upper airway while uterine placental circulation is maintained during cesarean section. We report 2 cases in which fetal congenital upper airway obstruction was managed without complications during EXIT procedures. We also discuss general considerations concerning the obstetric patient and the performance of intramuscular fetal anesthesia. Before the hysterotomy, sevoflurane at 1.5 minimum alveolar concentration was administered to assure sufficient uterine relaxation during EXIT. The 2 parturients remained hemodynamically stable during the procedure and uterine and placental perfusion was adequate. Nasotracheal intubation was possible in 1 fetus after a cervical mass was dissected. In the other, a tracheostomy was created. After the umbilical cord was clamped, the concentration of sevoflurane anesthetic gas was reduced and oxytocin and methylergometrine were administered to induce adequate uterine contractions within a few minutes. Both neonates survived the EXIT procedure with no complications.

Resumen El procedimiento E.X.I.T. (“Ex-Utero Intrapartum Treatment”) proporciona un tiempo adecuado para conseguir el control de una via aerea fetal potencialmente obstruida mientras se mantiene la circulacion utero-placentaria durante la cesarea. Describimos dos casos clinicos de fetos con obstruccion congenita de la via aerea alta en los que la estrategia E.X.I.T. permitio permeabilizar con exito y sin complicaciones en la via aerea. Ademas de tomarse las consideraciones generales de la paciente obstetrica y de realizarse anestesia fetal intramuscular, previamente a la histerotomia se administro sevofluorano a 1,5 CAM para conseguir una adecuada relajacion uterina durante el procedimiento. Las dos gestantes permanecieron hemodinamicamente estables durante el procedimiento con una adecuada perfusion utero-placentaria. En un feto la intubacion nasotraqueal fue posible tras disecar la masa cervical mientras que en el otro se realizo una traqueostomia. Tras el clampaje del cordon umbilical se redujo la concentracion de halogenado y se administraron oxitocina y metilergometrina para conseguir una contraccion uterina adecuada en pocos minutos. Ambos neonatos sobrevivieron al procedimiento sin complicaciones.

2 cm line, colored green, drawn on the dorsum of hand during outpatient clinic visit, acted as reinforcer in group I. Results: Both the groups were comparable for age, sex, body weight, parental literacy, socio-economic status, proposed procedure, surgical history and preoperative anxiety. Anxiety levels in pre-anesthesia room decreased in both the groups, though significant only in group I (p 0.001), when compared to the baseline. The time, in seconds, for parental separation and induction were significantly higher in group II (111.75 50.22 and 187.5 25.92) as compared to group I (63.81 35.49 and 140.31 40.64) (p 0.01). Children in group I were also more cooperative during induction. Conclusion(s): Behavioral reinforcement when added to play results in lesser anxiety, faster parental separation and induction time as compared to play alone in pediatric outpatients. References: 1 Saile H, Burgmeier R, Schmidt LR. Psychol Health 1997; 2: 107–32. 2 Kain ZN, Wang SM, Mayes LC, et al. Anesth Analg 1999; 88: 1042–47.

Manrique, S.; Munar, F.; Andreu, E.; Paños, M. L.; Peiró, J. L.; Montferrer, N.; Hervás, C.; Roigé, J. Author Information

Conesa, A.; Gracia, C.; Pelavski, A.; Suescun, M.; Mateo, D.; Manrique, S.; Andreu, E.; Lopez, R.; Vilardell, E.; Castellano, D.; Viedma, S.; Hervas, C. Author Information