The uterus serves as an incubator for the fetus during pregnancy. Within this incubator, the placenta is the main connection between the mother and the fetus and is integral to the survival of the fetus as it is an important source of fetal nutrients and oxygen. The proper development of the placenta allows it to support the fetus throughout pregnancy and expulsion or removal of a normal placenta following delivery, helps prevent postpartum complications. Maintenance of uteroplacental flow during pregnancy and during fetal surgery is important for the survival of the fetus and especially for the remainder of the pregnancy following fetal surgery. Serial monitoring of umbilical artery flow, a marker for uteroplacental insufficiency, is helpful to monitor fetal well-being. Physiology of the fetus correlates with the different stages of development in different organs and in many instances changes at delivery. The prevention of pain or the effects of noxious stimuli during fetal surgery serves many benefits, which include but are not limited to, prevention of release of stress hormones which can play a role in preterm labor and also prevention of long-term neurodevelopmental effects in the fetus.

Despite advances in neonatal and surgical care, the outcome of severe congenital diaphragmatic hernia (CDH) is still quite poor. Improvements in the ability to diagnose and risk stratify CDH prenatally have led to investigations into whether the more severe forms of CDH may benefit from in-utero intervention to ameliorate the accompanying pulmonary hypoplasia. Fetal endoscopic tracheal occlusion (FETO) is an example of a prenatal surgical intervention that was made possible by the technological advancements in endoscopic surgery. FETO is generally performed in fetuses with more severe forms of CDH to stimulate prenatal lung growth. While FETO is still considered investigational therapy and has not attained standard of care status, the results from published data to date have been promising. The complexity of FETO, coupled with the surgical and anesthetic risk to the mother and fetus requires a highly functional multidisciplinary fetal team, which includes obstetrics, pediatric surgery, and anesthesiology. This chapter will provide an in-depth understanding of the history of fetal endoscopic tracheal occlusion for CDH, the operative and anesthetic approach to FETO and associated perioperative considerations. Congenital diaphragmatic hernia continues to be a disease that perplexes obstetricians, neonatologists, surgeons, anesthesiologists, and the entire care team.

Fetal cardiac intervention provides fetuses with certain cardiac anomalies, a greater likelihood of biventricular circulation and/or treatment options after delivery. Anesthesia care for mothers undergoing fetal cardiac intervention has evolved over the years and more recently involves the use of neuraxial anesthesia with sedation. The maternal fetal anesthesiologist caring for the patient undergoing fetal cardiac intervention should be conversant with the diagnosis, pathophysiology, and planned intervention. This is important for appropriate anticipation and treatment of hemodynamic changes that may occur in the fetus immediately following intervention.

Prenatally diagnosed congenital lung malformations represent a wide variety of fetal pulmonary and airway anomalies, some of which may require close monitoring and perinatal follow-up. Historically these masses were only typically seen when they were very large, at which point they were associated with a high incidence of hydrops and a high termination rate; therefore a diagnosis of a fetal lung mass had a guarded prognosis. Widespread use of prenatal ultrasound improved detection of these masses and advances in surgical techniques have allowed for intervention in the fetal period. More recently, a better understanding of fetal physiology and the use of prenatal steroids has reduced the number of fetuses requiring in-utero intervention. When indicated, in-utero treatment requires a multidisciplinary approach with close attention given to the fetal physiology, risk of maternal complications, and unique anesthetic considerations.