Towards state-of-the-art anesthesia for fetal surgery: obstacles and opportunities.

Advances in obstetric anesthesia, which closely followed changes in maternal--fetal and neonatal medicine have been developing rapidly in recent years and will continue to do so in the future. Progress in prenatal diagnosis (e.g. refinement of imaging techniques) has led to early, more precise and more frequent detection of fetal anomalies, which if left untreated, would be fatal or lead to significant lifelong morbidity. Some of these malformations (e.g. twin-to-twin transfusion syndrome, and fetal myelomeningocele, fMMC) may be amenable to in-utero fetal surgical interventions. Intrauterine fetal interventions range from minimally invasive endoscopic procedures to full scale open fetal surgery. However, in addition to therapeutic advantages, increasing indications and applications of fetal surgery also pose new (e.g. anesthesia-related) challenges and raise new legal (e.g. judicially authorized cesarean deliveries) and ethical (e.g. fetal perception of pain and fetal interests vs. maternal choices) dilemmas, questions and concerns. In the near future, as we move from casuistic experience (case reports/case series) to collaborative multi-institutional studies the balance of risk to benefit will be struck and new standards of care will evolve. Perioperative care of thematernal/fetal dyad undergoing fetal surgery is challenging and requires a well-coordinated multidisciplinary team of experts. In the current issue of