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Porter H, Trivedi A, Marquez M, Gibson P, Melov SJ, Mishra U, Jani P, Cheng AT, Nayyar R, Alahakoon TI. Changing indications and antenatal prognostic factors for EXIT procedures. Prenat Diagn 2022; 42:1420-1428. [PMID: 36045557 DOI: 10.1002/pd.6230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 07/26/2022] [Accepted: 08/15/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE In cases of suspected neonatal airway obstruction, the ex-utero intrapartum treatment (EXIT) procedure is used to secure the airway while a fetus remains on placental circulation. We report indications and outcomes from all EXIT procedures at a tertiary obstetric unit between 1997 and 2020. METHOD Retrospective cohort study with data collected from maternal and neonatal medical records. RESULTS Indications for EXIT procedures were: micrognathia (n=7), lymphatic malformations (n=5), cervical teratomas (n=4), goiters (n=2) and intra-oral epulis (n=1). Infants with a fetal teratoma were delivered earliest due to 75% presenting with preterm premature rupture of membranes or pre-term labor. Low birth weight was found in 75% of these neonates; these did not survive one year. Intubation at EXIT occurred for 58% (n=11) of babies and six neonates required a tracheostomy. In four cases of fetal micrognathia, the inferior facial angle (IFA) was noted to be <5th centile. All but one micrognathia cases had polyhydramnios. Of the total cohort, 75% of neonates were alive at one year. CONCLUSION Risks for neonatal demise with EXIT include fetal teratoma, low birth weight and prematurity. Micrognathia has become an increasingly valid indication for the procedure. The combination of polyhydramnios and IFA <5% correlates well with severe airway obstruction and suggests consideration of EXIT. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Hugh Porter
- Westmead Institute for Maternal and Fetal Medicine, Women's and Newborn Health, Westmead Hospital, Hawkesbury Rd, Westmead, NSW, 2145, Australia
| | - Amit Trivedi
- Grace Centre for Newborn Care, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | | | - Peter Gibson
- Department of Anaesthesia, The Children's Hospital, Westmead, Australia
| | - Sarah J Melov
- Westmead Institute for Maternal and Fetal Medicine, Women's and Newborn Health, Westmead Hospital, Hawkesbury Rd, Westmead, NSW, 2145, Australia.,Discipline of Obstetrics Gynaecology and Neonatology, Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Umesh Mishra
- Neonatal Intensive Care Unit, Westmead Hospital, Westmead, New South Wales, Australia
| | - Pranav Jani
- Discipline of Obstetrics Gynaecology and Neonatology, Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Neonatal Intensive Care Unit, Westmead Hospital, Westmead, New South Wales, Australia
| | - Alan T Cheng
- Discipline of Child and Adolescent Health, University of Sydney, Sydney, NSW, Australia
| | - Roshni Nayyar
- Westmead Institute for Maternal and Fetal Medicine, Women's and Newborn Health, Westmead Hospital, Hawkesbury Rd, Westmead, NSW, 2145, Australia
| | - Thushari I Alahakoon
- Westmead Institute for Maternal and Fetal Medicine, Women's and Newborn Health, Westmead Hospital, Hawkesbury Rd, Westmead, NSW, 2145, Australia.,Grace Centre for Newborn Care, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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Novoa RH, Quintana W, Castillo-Urquiaga W, Ventura W. EXIT (ex utero intrapartum treatment) surgery for the management of fetal airway obstruction: A systematic review of the literature. J Pediatr Surg 2020; 55:1188-1195. [PMID: 32151401 DOI: 10.1016/j.jpedsurg.2020.02.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 11/24/2019] [Accepted: 02/11/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE To provide a comprehensive overview of the perinatal and maternal outcomes of fetuses undergoing EXIT surgery for the management of fetal airway obstruction secondary to cervical or oral tumors. METHODS A comprehensive search from inception to September 2018 was conducted on databases including MEDLINE, EMBASE, Cochrane Library and LILACS. All studies that reported an EXIT surgery in singleton were considered eligible. A descriptive analysis was performed. RESULTS Out of the 250 full-text study reports, 120 articles reporting 235 cases of EXIT surgery were included. EXIT surgery was performed at 35.1 weeks of gestation on average. The most frequent diagnosis was teratoma (46.4%, n = 109/235). There were 13 adverse maternal events, and the most frequent one was postpartum hemorrhage (4.7%, n = 11/235). No maternal death was reported. Fetal and neonatal death occurred in 17% (40/235) of the cases. There were 29 adverse fetal events (12.2%), and the most frequent one was the failure of intubation or tracheostomy (3.4%, n = 8/235). CONCLUSION EXIT surgery could be considered for the management of an oral or cervical tumor that's highly suspicious of blocking the fetal airway. This systematic review reports that EXIT surgery poses substantial risks of maternal and fetal adverse events, including neonatal death. LEVEL OF EVIDENCE IV case series with no comparison group.
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Affiliation(s)
- Rommy H Novoa
- Resident trainee in Ob/Gyn Department of Obstetrics and Gynecology, InstitutoNacional Materno Perinatal, Lima, Peru; Faculty of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Willy Quintana
- Resident trainee in Ob/Gyn Department of Obstetrics and Gynecology, InstitutoNacional Materno Perinatal, Lima, Peru; Faculty of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | | | - Walter Ventura
- Fetal Medicine Unit, Instituto Nacional Materno Perinatal, Lima, Peru; Fetal Medicine Unit, Clinica Delgado, Grupo AUNA, Lima, Peru.
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3
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Jiang S, Yang C, Bent J, Yang CJ, Gangar M, Nassar M, Suskin B, Dar P. Ex utero intrapartum treatment (EXIT) for fetal neck masses: A tertiary center experience and literature review. Int J Pediatr Otorhinolaryngol 2019; 127:109642. [PMID: 31479918 DOI: 10.1016/j.ijporl.2019.109642] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 07/17/2019] [Accepted: 08/09/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Currently no established criteria exist to guide use of ex utero intrapartum treatment (EXIT) for fetal neck mass management. This study aims to correlate prenatal radiographic findings with incidence of ex utero intrapartum treatment and necessity of airway intervention at delivery. METHODS We reviewed our EXIT experience between 2012 and 17. Furthermore, we performed a literature review of articles reporting incidences of fetal neck masses considered for EXIT. Articles that were included (1) discussed prenatal radiographic findings such as size, features, and evidence of compression and (2) reported extractable data on delivery outcomes and airway status. RESULTS Ten cases at our institution were reviewed. Another 137 cases across 81 studies met inclusion criteria. These studies showed aerodigestive tract compression to be significantly associated with neck masses undergoing EXIT. Additionally, there was significantly higher incidence of airway intervention in cases where polyhydramnios, anatomic compression, and solid masses were seen on prenatal diagnostic imaging, while mass location and size did not correlate with airway intervention. CONCLUSION With this data, we propose that any neck mass with anatomic compression on fetal imaging in the 3rd trimester should be considered for EXIT. When radiographic findings do not show compression but do display polyhydramnios or a solid neck mass (regardless of polyhydramnios), an airway surgeon should be available for perinatal airway assistance.
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Affiliation(s)
- Sydney Jiang
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA; Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA.
| | - Catherina Yang
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - John Bent
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Christina J Yang
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Mona Gangar
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Michel Nassar
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Barrie Suskin
- Department of Obstetrics and Gynecology, Stamford Hospital, One Hospital Plaza, Whittingham Pavilion, Stamford, CT, 06902, USA
| | - Peer Dar
- Division of Fetal Medicine and OB-Gyn Ultrasound, Albert Einstein College of Medicine / Montefiore Medical Center, 1695 Eastchester Road Room L4, Bronx, NY, 10461, USA
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Sacco A, Van der Veeken L, Bagshaw E, Ferguson C, Van Mieghem T, David AL, Deprest J. Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta-analysis. Prenat Diagn 2019; 39:251-268. [PMID: 30703262 PMCID: PMC6492015 DOI: 10.1002/pd.5421] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To establish maternal complication rates for fetoscopic or open fetal surgery. METHODS We conducted a systematic literature review for studies of fetoscopic or open fetal surgery performed since 1990, recording maternal complications during fetal surgery, the remainder of pregnancy, delivery, and after the index pregnancy. RESULTS One hundred sixty-six studies were included, reporting outcomes for open fetal (n = 1193 patients) and fetoscopic surgery (n = 9403 patients). No maternal deaths were reported. The risk of any maternal complication in the index pregnancy was 20.9% (95%CI, 15.22-27.13) for open fetal and 6.2% (95%CI, 4.93-7.49) for fetoscopic surgery. For severe maternal complications (grades III to V Clavien-Dindo classification of surgical complications), the risk was 4.5% (95% CI 3.24-5.98) for open fetal and 1.7% (95% CI, 1.19-2.20) for fetoscopic surgery. In subsequent pregnancies, open fetal surgery increased the risk of preterm birth but not uterine dehiscence or rupture. Nearly one quarter of reviewed studies (n = 175, 23.3%) was excluded for failing to report the presence or absence of maternal complications. CONCLUSIONS Maternal complications occur in 6.2% fetoscopic and 20.9% open fetal surgeries, with serious maternal complications in 1.7% fetoscopic and 4.5% open procedures. Reporting of maternal complications is variable. To properly quantify maternal risks, outcomes should be reported consistently across all fetal surgery studies.
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Affiliation(s)
- Adalina Sacco
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Lennart Van der Veeken
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
| | - Emma Bagshaw
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Catherine Ferguson
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Tim Van Mieghem
- Department of Obstetrics and GynaecologyMount Sinai Hospital and University of TorontoTorontoOntarioCanada
| | - Anna L. David
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- National Institute for Health ResearchUniversity College London Hospitals Biomedical Research CentreLondonUK
| | - Jan Deprest
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- Clinical Department Obstetrics and GynaecologyUniversity Hospitals LeuvenLeuvenBelgium
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A Novel and Multidisciplinary Strategy for Cesarean Delivery With Placenta Percreta: Intraoperative Embolization in a Hybrid Suite. ACTA ACUST UNITED AC 2017; 7:135-8. [PMID: 27464941 DOI: 10.1213/xaa.0000000000000375] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cesarean deliveries in patients with placenta accreta often are accompanied by life-threatening bleeding and sometimes death. A novel, multidisciplinary approach that uses uterine embolization after cesarean delivery recently has been advocated; however, embolization in the radiology department requires transfer of postoperative patients, which could increase maternal mortality and morbidity. In a case of severe placenta accreta, we planned a stepwise treatment, including cesarean delivery without separation of the placenta followed by intraoperative uterine arterial embolization in a hybrid operating room, followed by hysterectomy a few weeks after cesarean delivery. With no postpartum bleeding, complete hysterectomy was performed uneventfully 25 days later.
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Ex utero intrapartum treatment procedure for management of congenital high airway obstruction syndrome in a vertex/breech twin gestation. Int J Pediatr Otorhinolaryngol 2013; 77:439-42. [PMID: 23260572 DOI: 10.1016/j.ijporl.2012.11.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Revised: 11/10/2012] [Accepted: 11/17/2012] [Indexed: 11/20/2022]
Abstract
Congenital high airway obstruction syndrome (CHAOS) is one indication for the ex utero intrapartum treatment (EXIT), which is used to secure the fetal airway, while fetal oxygenation is maintained by uteroplacental circulation. We report a successful EXIT procedure in a twin gestation in which one child had CHAOS while the other was a healthy child without any congenital abnormalities. After version of Twin B to allow for delivery of Twin A, Twin B underwent airway evaluation and tracheostomy for laryngeal atresia prior to delivery.
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Helfer DC, Clivatti J, Yamashita AM, Moron AF. Anesthesia for Ex Utero Intrapartum Treatment (EXIT procedure) in Fetus with Prenatal Diagnosis of Oral and Cervical Malformations: Case Reports. Braz J Anesthesiol 2012; 62:411-23. [DOI: 10.1016/s0034-7094(12)70141-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 08/03/2011] [Indexed: 11/15/2022] Open
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Remifentanil for fetal immobilization and analgesia during the ex utero intrapartum treatment procedure under combined spinal–epidural anaesthesia †. Br J Anaesth 2011; 106:851-5. [DOI: 10.1093/bja/aer097] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Lee H, Ryu JW, Kim DY, Lee GY. Anesthetic management of the ex utero intrapartum treatment (EXIT) procedure -A case report-. Korean J Anesthesiol 2010; 59 Suppl:S154-7. [PMID: 21286428 PMCID: PMC3030024 DOI: 10.4097/kjae.2010.59.s.s154] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 05/24/2010] [Accepted: 06/05/2010] [Indexed: 11/10/2022] Open
Abstract
The ex utero intrapartum treatment (EXIT) procedure is a very rare technique performed in cases of fetal congenital malformations. The EXIT procedure increases the rate of survival at delivery by maintaining the uteroplacental circulation until the airway of the fetus is secured. To maintain the uteroplacental circulation, a higher dose of inhalational anesthetics and/or intravenous nitroglycerin can be used as compared to conventional Cesarean section. The aim of this report is to share our anesthetic experience during the EXIT procedure with members of the Korean society of anesthesiology for the first time, and to highlight the maternal implications of the use of inhalational anesthetics and nitroglycerin during Cesarean section for the EXIT procedure.
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Affiliation(s)
- Heeseung Lee
- Department of Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
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10
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Comparison of the effects of sevoflurane and isoflurane anesthesia on the maternal-fetal unit in sheep. J Anesth 2009; 23:392-8. [DOI: 10.1007/s00540-009-0763-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2008] [Accepted: 03/09/2009] [Indexed: 10/20/2022]
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Butwick A, Aleshi P, Yamout I. Obstetric hemorrhage during an EXIT procedure for severe fetal airway obstruction. Can J Anaesth 2009; 56:437-42. [PMID: 19396506 DOI: 10.1007/s12630-009-9092-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Revised: 03/03/2009] [Accepted: 03/05/2009] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To report a case of massive obstetric hemorrhage occurring during Cesarean delivery for an ex utero intrapartum treatment (EXIT) procedure. Methods to optimize the anesthetic, obstetric, and perinatal management are discussed. CLINICAL FEATURES A healthy parturient underwent an urgent EXIT procedure at 32 weeks gestation for a giant fetal neck mass. During the intraoperative period, severe intraoperative hemorrhage occurred from the site of the uterine incision. No evidence of placental bleeding, premature placental separation, or inadequate uterine relaxation was observed during the perioperative period. Placement of a uterine stapling device was unsuccessful in achieving adequate surgical hemostasis. Initial attempts with laryngoscopy and rigid bronchoscopy to secure the fetal airway on placental support were unsuccessful, and early termination of placental support was deemed necessary due to the severity of maternal blood loss. After full delivery of the neonate and termination of placental support, neonatal ventilation with bag-mask ventilation was achieved and successful endotracheal intubation occurred during repeat bronchoscopy. CONCLUSIONS The risk of obstetric hemorrhage due to uterine relaxation and inadequate surgical hemostasis in patients undergoing EXIT procedures is poorly reported. To reduce adverse maternal and neonatal outcomes, the premature termination of placental support during EXIT procedures may be required in the setting of severe obstetric hemorrhage.
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Affiliation(s)
- Alexander Butwick
- Department of Anesthesia (MC:5640), Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.
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12
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Manrique S, Munar F, Andreu E, Montferrer N, de Miguel M, López Gil V, Roigé J. [Fetoscopic tracheal occlusion for the treatment of severe congenital diaphragmatic hernia: preliminary results]. ACTA ACUST UNITED AC 2008; 55:407-13. [PMID: 18853678 DOI: 10.1016/s0034-9356(08)70611-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To evaluate survival and lung growth in fetuses with severe congenital diaphragmatic hernia (CDH) treated with fetoscopic tracheal occlusion (FETO) compared with control fetuses and to analyze possible complications of the anesthetic techniques used. PATIENTS AND METHODS This prospective study was performed on fetuses with CDH. FETO was undertaken before the 29th week of gestation on fetuses with a lung-to-head ratio (LHR) less than 1. FETO was not performed on fetuses with an LHR between 1.0 and 1.5 or those with an LHR less than 1 where consent was not given. Lung growth was monitored by means of LHR. FETO was performed under fetal intramuscular anesthesia and maternal epidural anesthesia and sedation with remifentanil. RESULTS Seventeen fetuses were included in the study. FETO was performed on 11 fetuses and was effective in 9. The median percentage difference between LHR at diagnosis and prior to FETO was 1.15% (P=.183); between diagnosis and before removing the balloon, the difference was 130.5% (P=.003); and between diagnosis and before delivery, 90.18% (P=.003). In the control group (n=6), the median percentage difference between LHR at diagnosis and before delivery was 49.25% (P=.028). No significant hemodynamic or respiratory changes occurred in either mother or fetus during fetoscopy. All the fetuses in the control group died; 45.5% of those in the FETO group survived. CONCLUSIONS The use of FETO in cases of CDH appears to increase survival and lung growth. Fetal anesthesia in association with maternal epidural anesthesia and sedation makes it possible to place and remove the endotracheal balloon via fetoscopy with acceptable maternal comfort and without notable complications.
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Affiliation(s)
- S Manrique
- Servicio de Anestesiología y Reanimación, Area Materno-Infantil, Hospital Universitario Vall d'Hebron, Barcelona.
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Ahn J, Kim JK, Yang M. Ex utero intrapartum treatment (EXIT) for fetal intubation with giant neck mass - A case report -. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2008.55.4.519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jihyun Ahn
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Kyoung Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mikyung Yang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Benonis JG, Habib AS. Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita, using continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation. Int J Obstet Anesth 2008; 17:53-6. [PMID: 17451933 DOI: 10.1016/j.ijoa.2007.01.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Accepted: 01/03/2007] [Indexed: 11/19/2022]
Abstract
The ex utero intrapartum treatment procedure allows for the controlled management of a potentially life-threatening difficult airway in the newborn. General anesthesia has previously been reported for the management of this procedure. We report the use of continuous spinal anesthesia in conjunction with intravenous nitroglycerin for the ex utero intrapartum treatment procedure in a woman with arthrogryposis multiplex congenita, a rare syndrome characterized by rigid joints and limb contractures.
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Affiliation(s)
- J G Benonis
- Division of Women's Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
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McDevitt H, Kubba H, Macara L, Reynolds B, Simpson J. Four cases of congenital airway obstruction: optimising perinatal management. Acta Paediatr 2007; 96:1542-5. [PMID: 17850403 DOI: 10.1111/j.1651-2227.2007.00177.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Congenital anomalies causing airway obstruction in the newborn are potentially fatal. However if an effective airway can be maintained the long-term prognosis is often excellent. We present four cases of airway obstruction, three of which were diagnosed antenatally. We discuss the role of antenatal imaging and review delivery options including the need for a multidisciplinary team approach. In conclusion, we recommend antenatal imaging with both ultrasound scan and magnetic resonance to inform perinatal management. Polyhydramnios, in association with suspected neonatal airway obstruction, should alert clinicians to a high-risk situation. We recognize that even in skilled hands, securing an airway can be very difficult and alternatives such as maintenance of the fetomaternal circulation or extra-corporeal life support should be considered.
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Affiliation(s)
- Helen McDevitt
- Queen Mother's Hospital, Yorkhill Division, Glasgow, Scotland
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Chang LC, Kuczkowski KM. The ex utero intrapartum treatment procedure: anesthetic considerations. Arch Gynecol Obstet 2007; 277:83-5. [PMID: 17619892 DOI: 10.1007/s00404-007-0402-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Accepted: 05/30/2007] [Indexed: 11/29/2022]
Abstract
The ex-utero intrapartum treatment (EXIT) procedure is an uncommon operation indicated for fetal lesions with the potential to cause life-threatening airway obstruction immediately after delivery. By maintaining utero-placental circulation, the fetal airway can be evaluated and secured prior to delivery. The anesthetic goals for the EXIT procedure differ significantly from a cesarean delivery and include profound uterine relaxation, fetal anesthesia and maintenance of the maternal-fetal circulation. We present a case of an uneventful EXIT procedure and include a discussion of the anesthetic goals for this operation.
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Affiliation(s)
- Leon C Chang
- Departments of Anesthesiology and Reproductive Medicine, UCSD Medical Center, University of California-San Diego, 200 W. Arbor Drive, San Diego, CA 92103, USA
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Kuczkowski KM. Advances in obstetric anesthesia: anesthesia for fetal intrapartum operations on placental support. J Anesth 2007; 21:243-51. [PMID: 17458654 DOI: 10.1007/s00540-006-0502-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2006] [Accepted: 01/13/2007] [Indexed: 12/17/2022]
Abstract
Fetal intrapartum operations on placental support (OOPS), also known as ex-utero intrapartum treatment (EXIT) procedures, are very rare (and often challenging) surgical techniques designed to allow partial delivery (cesarean section) of a fetus with a potentially difficult airway, with subsequent management of the neonatal airway (direct laryngoscopy, fiberoptic bronchoscopy, or tracheostomy) while oxygenation is continuously maintained via the placenta (on placental support). The peripartum management of pregnant women and their fetuses undergoing OOPS is very complex and multidisciplinary, and differs greatly from that of standard cesarean sections. The goal of this article is to review the current recommendations for the peripartum anesthetic management of pregnant women carrying fetuses with fetal congenital malformations undergoing OOPS.
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Affiliation(s)
- Krzysztof M Kuczkowski
- Department of Anesthesiology, University of California, San Diego, San Diego, California 92103-8770, USA
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18
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George RB, Melnick AH, Rose EC, Habib AS. Case series: Combined spinal epidural anesthesia for Cesarean delivery and ex utero intrapartum treatment procedure. Can J Anaesth 2007; 54:218-22. [PMID: 17331934 DOI: 10.1007/bf03022643] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To report the use of regional anesthesia and iv nitroglycerin to provide anesthesia and uterine relaxation for three Cesarean deliveries (CD) involving ex utero intrapartum treatment (EXIT) of potentially life-threatening airway obstruction in the newborn. CLINICAL FEATURES Case 1--a 36-yr-old woman at 38 weeks' gestation was scheduled for an elective CD for fetal skeletal dysplasia and micrognathia. Case 2--a 34-yr-old woman at 35 weeks gestation had a fetal ultrasound revealing fixed neck flexion and micrognathia consistent with fetal arthrogryposis. Case 3--a 27-yr-old woman presented at 38 weeks gestation for CD for severe fetal micrognathia, with mandibular growth below the fifth percentile. For each case, a combined spinal epidural anesthetic was performed with 0.75% bupivacaine, fentanyl and morphine intrathecally followed by placement of a multiorifice epidural catheter. Prior to uterine incision patients received a loading dose followed by an iv infusion of nitroglycerin. Uterine relaxation was sufficient in all cases for delivery of the fetus, and allowed for evaluation by direct laryngoscopy and intubation while maintaining fetal-placental circulation. The surgical procedures were completed without incident. CONCLUSIONS Anesthesia and uterine relaxation for CD and EXIT procedures can be safely provided with regional anesthesia and iv nitroglycerin.
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Affiliation(s)
- Ronald B George
- Department of Anesthesiology, Women's Anesthesia and Critical Care, Box 3094, Duke University Medical Center, Durham, NC 27710, USA.
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Ducloy-Bouthors AS, Marciniak B, Vaast P, Fayoux P, Houfflin-Debarge V, Fily A, Rakza T. Anesthésie maternofœtale pour « ex utero intrapartum » traitement (EXIT) procédure : à propos de deux cas. ACTA ACUST UNITED AC 2006; 25:638-43. [PMID: 16698227 DOI: 10.1016/j.annfar.2006.02.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2005] [Accepted: 02/23/2006] [Indexed: 11/23/2022]
Abstract
The ex utero intrapartum treatment (EXIT) procedure is a surgical procedure maintaining utero-placental circulation during caesarean section. Anaesthetic implications are described: foetal transplacental anaesthesia to avoid first breathing and to permit surgical procedure on obstructed foetal airway, deep maternal haemodynamically stable anaesthesia to relax uterine smooth muscle during a long caesarean procedure but avoiding post-partum haemorrhage. Volatile anaesthesia with sevoflurane seems to be adequate for these aims. Two cases are described.
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Affiliation(s)
- A-S Ducloy-Bouthors
- Clinique d'Anesthésie-Réanimation, Hôpital Jeanne-de-Flandre, CHRU de Lille, 2 Avenue Oscar-Lambret, 59037 Lille Cedex, France.
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20
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Saad DF, Georgeson KE, Wulkan ML. How to make a graceful exit: lessons learned from 2 cases. Surgery 2006; 139:435-7. [PMID: 16546509 DOI: 10.1016/j.surg.2005.06.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2005] [Revised: 06/09/2005] [Accepted: 06/11/2005] [Indexed: 10/24/2022]
Affiliation(s)
- Daniel F Saad
- Division of Pediatric Surgery, Emory University, 2015 Uppergate Drive NE, Atlanta, GA 30322, USA
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Kill C, Gebhardt B, Schmidt S, Werner JA, Maier RF, Wulf H. Die EXIT-Prozedur als anästhesiologische Herausforderung. Anaesthesist 2005; 54:1105-10. [PMID: 16021389 DOI: 10.1007/s00101-005-0898-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The ex-utero intra-partum (EXIT) procedure enables the surgeon to perform invasive procedures in an infant during cesarean section before clamping the umbilical cord. Specific anesthesiological concepts are necessary for ensuring sufficient umbilical perfusion. We report the case of a 33-year-old female undergoing cesarean section in the 36th week of pregnancy because of a large fetal cervical tumor. The EXIT procedure was performed in order to secure the infant's airway during delivery. The anesthesiological management and interdisciplinary tasks are discussed in the literature review.
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Affiliation(s)
- C Kill
- Klinik für Anästhesie und Intensivtherapie, Philipps-Universität, Marburg.
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Eschertzhuber S, Keller C, Mitterschiffthaler G, Jochberger S, Kühbacher G. Verifying Correct Endotracheal Intubation by Measurement of End-Tidal Carbon Dioxide During an Ex Utero Intrapartum Treatment Procedure. Anesth Analg 2005; 101:658-660. [PMID: 16115970 DOI: 10.1213/01.ane.0000175206.91231.77] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The ex utero intrapartum treatment (EXIT) procedure provides time to secure the airway of the fetus while utero-placental circulation supplies the fetus with oxygen. We report the anesthetic management of a fetus with a large neck mass during an EXIT procedure in which the confirmation of correct endotracheal intubation was hampered by parts of the mass, blood, and other fluids. The use of a standard end-tidal carbon dioxide probe provided a reliable signal and proved the endotracheal position of the tube while utero-placental circulation was still intact.
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Affiliation(s)
- Stephan Eschertzhuber
- Department of Anaesthesia and Intensive Care Medicine, Leopold-Franzens University, Innsbruck, Austria
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Faria A, Fonseca C, Sampaio C, Abreu F, Tavares J. Ex utero intrapartum procedure for delivery of a fetus with a large cervical mass. Eur J Anaesthesiol 2005; 22:642-3. [PMID: 16119606 DOI: 10.1017/s0265021505251062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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