# Development of Carbon Dioxide Embolism During Partial Amniotic Carbon Dioxide Insufflation for Fetoscopic Laser Photocoagulation: A Case Report

## TL;DR

A case report describes a CO2 embolism during a fetal surgery procedure, highlighting the risks and successful management using ultrasound.

## Contribution

This case highlights the risk of CO2 embolism during fetal surgery and emphasizes the importance of early detection via ultrasound.

## Key findings

- CO2 embolism occurred during manual CO2 insufflation for fetal surgery.
- Point-of-care ultrasonography confirmed CO2 bubbles in the heart.
- Immediate intervention led to rapid recovery without neurological deficits.

## Abstract

Partial amniotic carbon dioxide (CO2) insufflation during fetoscopic laser photocoagulation (FLP) can improve surgical visibility. However, this procedure poses risks of gas embolism.

A 27-year-old woman underwent FLP for twin-to-twin transfusion syndrome under combined spinal-epidural anesthesia. Owing to turbid amniotic fluid, CO2 was manually insufflated. Due to intraoperative respiratory discomfort, the anesthesia was converted to general anesthesia with endotracheal intubation. After a 15° lateral table tilt, the patient developed sudden hypotension and hypoxia. A waterwheel murmur was heard on auscultation. Urgent transthoracic echocardiography confirmed CO2 bubbles in the right side of the heart with paradoxical migration to the left atrium through a patent foramen ovale. Immediate gas aspiration and head-down positioning led to rapid recovery. The patient was extubated without neurological deficits.

Intrauterine CO2 insufflation can cause systemic gas embolism, particularly with manual injection and postural changes. Early diagnosis using point-of-care ultrasonography is crucial for successful management.