EXIT Procedure: Technique and Indications with Prenatal Imaging Parameters for Assessment of Airway Patency

Abstract

Successful management of fetal conditions in which airway obstruction is anticipated is now possible because of advances in prenatal imaging and the development of innovative techniques to secure the fetal airway before complete separation of the fetus from the maternal circulation. Fetal ultrasonography and fetal magnetic resonance imaging are complementary imaging modalities in the assessment of fetuses with potential airway obstruction. The ex utero intrapartum therapy (EXIT) procedure is used to secure the fetal airway before complete delivery of the fetus. However, successful intrapartum treatment of fetuses who may need prolonged placental support depends on a multidisciplinary assessment in which the benefits of the EXIT procedure for the fetus are weighed against the risk of maternal complications that may occur during prolongation of the intrapartum period to secure the fetal airway. This multidisciplinary approach requires an understanding of the types of lesions in which intrapartum fetal airway access would be beneficial, a knowledge of the prenatal images that would best delineate the anatomic defect and thus help guide the best approach to securing the airway, and consensus and coordination among medical ethicists, radiologists, obstetric anesthesiologists and obstetricians, pediatric surgeons and anesthesiologists, and neonatologists.

Maternal Iodine Exposure: A Case of Fetal Goiter and Neonatal Hearing Loss

“…As in this case, a fetal MRI may serve as an adjunct to ultrasound to better characterize soft tissue masses, the impact of masses on the trachea, and the cartilaginous structures of the upper airway. 15 Furthermore, a multidisciplinary team, including pediatric anesthesiologist, pediatric otolaryngologist, and neonatologist, should be involved in delivery planning. An EXIT procedure is used to secure the neonatal airway while fetal-placental circulation is preserved in cases of airway obstructions (eg, congenital airway obstructions, laryngeal atresia, micrognathia, fetal neck masses, and intrathoracic masses).…”

“…An EXIT procedure is used to secure the neonatal airway while fetal-placental circulation is preserved in cases of airway obstructions (eg, congenital airway obstructions, laryngeal atresia, micrognathia, fetal neck masses, and intrathoracic masses). 15 An EXIT procedure is associated with increased maternal hemorrhagic morbidity and risk of cesarean hysterectomy. 15 However, it should be considered and can decrease the mortality of neonates when airway compromise is possible.…”

“…15 An EXIT procedure is associated with increased maternal hemorrhagic morbidity and risk of cesarean hysterectomy. 15 However, it should be considered and can decrease the mortality of neonates when airway compromise is possible.…”

Congenital Epulis: a clinical case presentation

“…The fetal head is delivered while another team secures its airway. This allows time for the paediatric team to work on establishing the airway, and then complete delivery of fetus and placenta once the airway is secured 14 . …”

“…– 13 It was first described by Neumann in 1871 1 – 4 , 6 , 9 and as such it is also called Neumann's tumour or a congenital gingival granular cell tumour 5 9 , 12 , 13 , 14 …”