The Ex utero intrapartum treatment (EXIT) procedure: case report of a multidisciplinary team approach The Ex utero intrapartum treatment (EXIT) procedure

Main Article Content

Marina Sangaletti
Simone Garzon
Ricciarda Raffaelli
Roberto D’Alessandro
Mariachiara Bosco
Jvan Casarin
Antonio Simone Laganà
Irene Sibona
Paolo Biban
Massimo Franchi

Keywords

EXIT procedure; cesarean section; fetus; multidisciplinary management; case report.

Abstract

Background and aim of the work: The EXIT-to-airway procedure is aimed to provide the time required to secure airways when an extrinsic or intrinsic fetal mass raise concerns about airways control at delivery. Due to the rarity of the procedure, we aim to provide a summary of the appropriate prenatal planning by a multidisciplinary team. Methods: Report of a case of EXIT-to-airway procedure. Results: A 30 years-old woman, G2P1 with previous cesarean section, was referred to our Unit at 34 gestational weeks due to a fetal cervical mass of 7cm. An EXIT-to-airways procedure was performed by a multidisciplinary team after accurate preoperative planning and the practice simulations. The partial fetal extraction and the amnioinfusion of pre-heated saline were used to prevent fetal complications. The use of supplemental intravenous anesthesia with remifentanil and better control of uterine tone with nitroglycerin allowed to reduce the exposure to volatile halogen for both the mother and the fetus. The accurate preoperative planning and the practice simulations allowed us to perform the treatment safely in urgency due to the onset of spontaneous labor at 37 weeks and 6 days. Conclusions: The strong cooperation among specialists, accurate prenatal planning, and adopting all the required procedures and precautions are of paramount importance to successfully perform the EXIT-to-airway procedure.


 

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References

1 Mychaliska GB, Bealer JF, Graf JL, Rosen MA, Adzick NS, Harrison MR. Operating on placental support: The ex utero intrapartum treatment procedure. J Pediatr Surg 1997;32:227–31.
2 Bence CM, Wagner AJ. Ex utero intrapartum treatment (EXIT) procedures. Semin Pediatr Surg 2019;28:150820.
3 Liechty KW. Ex-utero intrapartum therapy. Semin Fetal Neonatal Med 2010;15:34–9.
4 Jiang S, Yang C, Bent J, et al. Ex utero intrapartum treatment (EXIT) for fetal neck masses: A tertiary center experience and literature review. Int J Pediatr Otorhinolaryngol 2019;127:109642.
5 Mohammad S, Olutoye OA. Airway management for neonates requiring ex utero intrapartum treatment (EXIT). Paediatr Anaesth 2020;30:248–56.
6 Boat A, Mahmoud M, Michelfelder EC, et al. Supplementing desflurane with intravenous anesthesia reduces fetal cardiac dysfunction during open fetal surgery. Paediatr Anaesth 2010;20:748–56.
7 DWYER R, FEE JPH, MOORE J. Uptake of halothane and isoflurane by mother and baby during Caesarean section. Br J Anaesth 1995;74:379–83.
8 Taghavi K, Beasley S. The ex utero intrapartum treatment (EXIT) procedure: application of a new therapeutic paradigm. J Paediatr Child Health 2013;49:E420-427.
9 Morris LM, Lim F-Y, Crombleholme TM. Ex Utero Intrapartum Treatment Procedure: A Peripartum Management Strategy in Particularly Challenging Cases. J Pediatr 2009;154:126-131.e3.
10 Lazar DA, Cassady CI, Olutoye OO, et al. Tracheoesophageal displacement index and predictors of airway obstruction for fetuses with neck masses. J Pediatr Surg 2012;47:46–50.
11 Kelly MF, Berenholz L, Rizzo KA, Greco R, Wolfson P, Zwillenberg DA. Approach for oxygenation of the newborn with airway obstruction due to a cervical mass. Ann Otol Rhinol Laryngol 1990;99:179–82.
12 Lazar DA, Olutoye OO, Moise KJ, et al. Ex-utero intrapartum treatment procedure for giant neck masses—fetal and maternal outcomes. J Pediatr Surg 2011;46:817–22.
13 Hirose S, Sydorak RM, Tsao K, et al. Spectrum of intrapartum management strategies for giant fetal cervical teratoma. J Pediatr Surg 2003;38:446–50.
14 Liechty KW, Crombleholme TM, Flake AW, et al. Intrapartum airway management for giant fetal neck masses: The EXIT (ex utero intrapartum treatment) procedure. Am J Obstet Gynecol 1997;177:870–4.
15 Laje P, Johnson MP, Howell LJ, et al. Ex utero intrapartum treatment in the management of giant cervical teratomas. J Pediatr Surg 2012;47:1208–16.
16 MacKenzie TC, Crombleholme TM, Flake AW. The ex-utero intrapartum treatment. Curr Opin Pediatr 2002;14:453–8.
17 Hirose S, Farmer DL, Lee H, Nobuhara KK, Harrison MR. The ex utero intrapartum treatment procedure: Looking back at the EXIT. J Pediatr Surg 2004;39:375–80; discussion 375-380.
18 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;doi: 10.1016/j.jpedsurg.2020.02.011.
19 Kerner B, Flaum E, Mathews H, et al. Cervical teratoma: Prenatal diagnosis and long-term follow-up. Prenat Diagn 1998;18:51–9.
20 Rollins MD. 2020. Anesthesia for fetal surgery and other intrauterine procedures. David H. Chestnut. Chestnut’s Obstetric Anesthesia: Principles and Practice, 6th Edition. pag 132-154 n.d.
21 Bilotta F, Evered LA, Gruenbaum SE. Neurotoxicity of anesthetic drugs: An update. Curr Opin Anaesthesiol 2017;30:452–7.
22 Dinges E, Heier J, Delgado C, Bollag L. Multimodal general anesthesia approach for Ex Utero Intrapartum Therapy (EXIT)procedures: two case reports. Int J Obstet Anesth 2019;38:142–5.
23 Van De Velde M. The use of remifentanil during general anesthesia for caesarean section. Curr Opin Anaesthesiol 2016;29:257–60.
24 Riley ET, Flanagan B, Cohen SE, Chitkarat U. Intravenous nitroglycerin: a potent uterine relaxant for emergency obstetric procedures. Review of literature and report of three cases. Int J Obstet Anesth 1996;5:264–8.
25 Caughey AB. The Safe Prevention of the Primary Cesarean. Clin Obstet Gynecol 2015;58:207–10.
26 Franchi M, Raffaelli R, Baggio S, et al. Unintentional transvesical caesarean section: incidence, risk factors, surgical technique and post-operative management. Eur J Obstet Gynecol Reprod Biol 2019;236:26–31.
27 Ellwood D, Oats J. Every caesarean section must count. Aust N Z J Obstet Gynaecol 2016;56:450–2.
28 Gregory KD, Jackson S, Korst L, Fridman M. Cesarean versus vaginal delivery: whose risks? Whose benefits? Am J Perinatol 2012;29:7–18.
29 Simpson LL. When is primary cesarean appropriate: fetal indications. Semin Perinatol 2012;36:328–35.
30 Wataganara T, Grunebaum A, Chervenak F, Wielgos M. Delivery modes in case of fetal malformations. J Perinat Med 2017;45:273–9.

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