Patient Education and Consent

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

Preprocedural Planning

Appropriate consultations are made with the pediatric surgeon, perinatologist, neonatologist, anesthesiologist, and social worker.

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 antenatal sonogram is reviewed and indications for surgery are confirmed.

Preoperative laboratory tests include a complete blood count (CBC), blood type and screen, and urinalysis. Activity is ad libitum, and bedrest exercises are reviewed.

Patient Preparation

The patient is kept on nil per os (NPO) status for 8 hours before surgery. Immediately before surgery, indomethacin for tocolysis may be administered, and perioperative antibiotics are given.

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 (US) 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 lateral positioning. Owing to potential pulmonary edema, fluids are restricted to 3 L/day 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 1, the patient is allow to ambulate, and a CBC is performed.

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.

Technique

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Media Gallery

Schematic of fetal tracheal balloon occlusion, using a catheter-based detachable balloon that is placed through the side channel of the fetoscope.
The fetoscope enters the oropharynx and passes through the glottis into the trachea. The mainstem bronchi are seen, and then the detachable balloon is passed through a side-channel of the fetoscope into the trachea, inflated, and detached in an appropriate position. The fetoscope is then removed and ultrasound confirms the balloon position in the trachea. Current practice is to repeat fetoscopy and remove the balloon after 4-6 weeks. Video courtesy of Division of Pediatric Surgery, University of California, San Francisco, School of Medicine.
Fetoscopic images of landmarks during percutaneous fetal tracheal balloon occlusion. From top left to right bottom: epiglottis, vocal cords, trachea, carina, inflated and detached balloon, vocal cords about to close over the balloon. Image courtesy of Division of Pediatric Surgery, University of California, San Francisco, School of Medicine.