Anesthetic management of the exit (Ex Utero intrapartum treatment) procedure

Schwartz, Donald; Moriarty, Kevin P.; Tashjian, David B.; Wool, Robert S; Parker, Robert K.; Markenson, Glenn; Rothstein, Robert W; Shah, Bhavash L; Connelly, Neil Roy; Courtney, Richard

doi:10.1016/s0952-8180(01)00287-2

Cited by 39 publications

(39 citation statements)

References 10 publications

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“…While some previous reports recommended giving 100% oxygen, 1,5,9 an inspired oxygen concentration of 50% also provided adequate fetal oxygenation. 6,11 In retrospect, it would have probably been prudent to administer 100% oxygen, especially since we were unable to reliably monitor the fetal oxygen saturation during the procedure. In the first two cases we attempted to monitor fetal oxygen saturation but it was difficult, since the skin was not dry and the fetus was continuously handled by the surgeons.…”

Section: Discussionmentioning

confidence: 98%

“…This procedure's indications have grown to include a variety of pathologies including fetal neck masses, congenital high airway obstruction, and dysgnathia complex. [2][3][4][5][6][7] Management of the EXIT procedure requires extensive multidisciplinary planning and coordination involving the obstetric, anesthetic, ENT, and pediatric teams. In addition to the usual anesthetic considerations for any CD, specific aims for the EXIT procedure include attaining maximal uterine relaxation and fetal anesthesia.…”

Section: Discussionmentioning

confidence: 99%

“…Uterine relaxation is necessary to prevent placental separation from the endometrium, thereby maintaining placental perfusion and fetal oxygenation allowing the delivery, either partial or full, of the fetus and appropriate airway management. 1,[4][5][6]8,11 Since the inception of fetal surgery in 1981, relatively high concentrations of volatile anesthetics (1.5-3 minimal alveolar concentration) have been used routinely to provide surgical tocolysis. 8,12 The literature is replete with case reports of general anesthesia for EXIT procedures.…”

Section: Discussionmentioning

confidence: 99%

“…Some institutions infuse crystalloid into the uterine cavity to preserve uterine volume to aid in preventing placental separation. 2,6,11 Fetal anesthesia may be supplemented with im opioids, ketamine, and muscle relaxants. 8 Epidural catheters have been placed for perioperative analgesia, but regional anesthesia has not been commonly used as the sole anesthetic modality.…”

Section: Discussionmentioning

confidence: 99%

“…While this procedure originally gained popularity for establishing a patent airway and removal of tracheal occluding plugs used for the treatment of congenital diaphragmatic hernia, 1 indications have now grown to include a variety of congenital airway obstructions. [2][3][4][5][6][7] A deep general anesthetic with halogenated agents has been the anesthetic technique of choice for EXIT procedures. The halogenated agents provide the necessary uterine relaxation for partial fetal delivery and preventing placental disruption while also providing fetal anesthesia.…”

mentioning

confidence: 99%

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Case series: Combined spinal epidural anesthesia for Cesarean delivery andex utero intrapartum treatment procedure

George

Melnick

Rose

et al. 2007

Can J Anesth/J Can Anesth

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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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Section: Discussionmentioning

confidence: 98%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Case series: Combined spinal epidural anesthesia for Cesarean delivery andex utero intrapartum treatment procedure

George

Melnick

Rose

et al. 2007

Can J Anesth/J Can Anesth

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Changing indications and antenatal prognostic factors for ex‐utero intrapartum treatment procedures

Porter

Trivedi

Márquez³

et al. 2022

Prenatal Diagnosis

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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 preterm labor. Low birth weight was found in 75% of these neonates; they did not survive 1 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 case had polyhydramnios. Of the total cohort, 75% of neonates were alive at 1 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. Key points What's already known about this topic?� Ex-utero Intrapartum Treatment (EXIT) remains a potentially life-saving procedure for fetuses with airway obstruction. Indications for EXIT have broadened over the past 20 years. What does the study add?� Fetal teratoma, low birth weight, and prematurity should inform prenatal counseling as predictors for fetal and neonatal mortality.� To improve multidisciplinary management, all neonates with suspected fetal airway obstruction should have ultrasound and MRI imaging.� Micrognathia is now a common indication for EXIT. In cases of micrognathia, inferior facial angle (IFA) <5% in conjunction with polyhydramnios appears predictive of a difficult airway.

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The History of Neonatal Anesthesia

Steward

2023

Neonatal Anesthesia

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Anesthetic management of the exit (Ex Utero intrapartum treatment) procedure

Cited by 39 publications

References 10 publications

Case series: Combined spinal epidural anesthesia for Cesarean delivery andex utero intrapartum treatment procedure

Case series: Combined spinal epidural anesthesia for Cesarean delivery andex utero intrapartum treatment procedure

Changing indications and antenatal prognostic factors for ex‐utero intrapartum treatment procedures

The History of Neonatal Anesthesia

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