Preparation for Surgery for Fetal Myelomeningocele Repair

Indications for Procedure

Indications and contraindications for fetal myelomeningocele repair are discussed at length in Presentation of Fetal Myelomeningocele and Evaluation of Fetal Myelomeningocele.

Preoperative Orders

• Relocation near fetal center: At our institution, we ask the patient to relocate close to the Fetal Center at Vanderbilt for the time between fetal intervention and delivery.
• Coordination of multiple surgical specialties: A Fetal Center representative coordinates among all the surgical subspecialties to determine the date of surgery most optimal for all involved surgeons and the patient.
• Immediate preoperative ultrasound: On the day before surgery, ultrasonic imaging is used to assess the fetus’s positioning in utero and to obtain the most up-to-date estimated fetal weight.
• Consent: Surgical and research consents are obtained.
• Laboratory assessment: Routine serum studies (including CBC, basic metabolic panel and coagulation studies) and a blood type and screen are performed on the mother.

Anesthetic Considerations

• Premedication: Cephazolin (1000 mg IV) is administered.
• Combined general and epidural anesthesia: An indwelling epidural catheter permits continuous, controlled postoperative analgesia.
• Fetal echocardiography: A member of the pediatric cardiology team closely monitors fetal cardiac function throughout the procedure via transvaginal and transmural means.

Devices to be Implanted

• Dural substitute: In the event of a tenuous, patulous, or otherwise incompetent dural closure, a synthetic dural substitute may be applied over the placode.

Ancillary/Specialized Equipment

• Ultrasound: The intrauterine fetal position is assessed with intraoperative ultrasonography and the hysterotomy site is planned to orient the spinal defect in the center of the incision. Fetal echocardiography is used throughout the procedure.
• Neonatal warming unit: In the unlikely event of fetal delivery, both a neonatology specialist and a neonatal bed are present in the operating room to facilitate resuscitation and stabilization of the premature infant.