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Imad Yamout - One of the best experts on this subject based on the ideXlab platform.
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obstetric hemorrhage during an EXIT Procedure for severe fetal airway obstruction
Canadian Journal of Anaesthesia-journal Canadien D Anesthesie, 2009Co-Authors: Alexander J Butwick, Pedram Aleshi, Imad YamoutAbstract: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.
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Obstetric hemorrhage during an EXIT Procedure for severe fetal airway obstruction
Canadian Journal of Anesthesia Journal canadien d'anesthésie, 2009Co-Authors: Alexander J Butwick, Pedram Aleshi, Imad YamoutAbstract:Objectif Nous rapportons un cas d’hémorragie obstétricale massive survenue pendant un accouchement par césarienne pour une procédure de traitement ex utero intrapartum (EXIT). Nous discutons des méthodes pour optimiser la prise en charge anesthésique, obstétricale et périnatale. Éléments cliniques Une parturiente en bonne santé a subi une procédure EXIT d’urgence à 32 semaines de grossesse en raison d’une masse géante sur le cou du fœtus. Pendant la période peropératoire, une hémorragie peropératoire grave est survenue au site de l’incision chirurgicale. Aucune évidence de saignement placentaire, de séparation prématurée du placenta ou de relaxation inadéquate de l’utérus n’a été observée pendant la période périopératoire. Le placement d’un dispositif d’agrafage utérin n’a pas permis d’obtenir une hémostase chirurgicale appropriée. Les premières tentatives de prise en charge des voies aériennes du fœtus avec soutien placentaire par laryngoscopie ou bronchoscopie rigide n’ont pas réussi, et il a fallu interrompre le soutien placentaire de façon précoce en raison de la gravité des pertes sanguines maternelles. Après l’accouchement du nouveau-né et l’interruption du soutien placentaire, la ventilation néonatale à l’aide d’un masque a réussi tout comme l’intubation endotrachéale lors d’une seconde bronchoscopie. Conclusion Le risque d’hémorragie obstétricale en raison de la relaxation utérine ou une hémostase chirurgicale insuffisante chez les patientes subissant une procédure EXIT sont peu documentés. Afin de réduire les conséquences néfastes pour la mère et l’enfant, l’interruption prématurée du soutien placentaire pendant une procédure EXIT peut s’avérer nécessaire dans un contexte d’hémorragie obstétricale grave. 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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obstetric hemorrhage during an EXIT Procedure for severe fetal airway obstruction hemorragie obstetricale pendant une Procedure de traitement ex utero intrapartum en raison d une obstruction grave des voies respiratoires du fœtus
2009Co-Authors: Alexander J Butwick, Imad YamoutAbstract: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.
Timothy M. Crombleholme - One of the best experts on this subject based on the ideXlab platform.
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Massive facial teratoma managed with the ex utero intrapartum treatment (EXIT) Procedure and use of a 3-dimensional printed model for planning of staged debulking
Journal of Pediatric Surgery Case Reports, 2017Co-Authors: Maggie M. Hodges, Timothy M. Crombleholme, Ahmed I. Marwan, David M. Mirsky, Mariana L. Meyers, Nicholas Behrendt, Brooke French, Peggy E. Kelley, Kenneth W. LiechtyAbstract:Abstract Teratomas are the most frequent solid tumor found in neonates. However, only 1.5% of neonatal teratomas originate from facial structures. Neonatal facial teratomas are associated with polyhydramnios, preterm birth, pulmonary hypoplasia, cleft palate, cleft lip, and life-threatening airway compromise. The overall survival reported with these lesions has been between 17 and 87.5%; however survival in the setting of antenatally diagnosed facial teratomas has only been described anecdotally. We present a case of an antenatally diagnosed massive facial teratoma originating from the pterygomaxillary fossa, which was associated with polyhydramnios and pre-term birth. We managed this complex tumor with an ex utero intrapartum treatment (EXIT) Procedure, multidisciplinary medical and surgical team, and staged excision and reconstruction aided by use of a 3-dimensional printed model. Here we review the surgical management of this rare and complex tumor.
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The EXIT Procedure: principles, pitfalls, and progress.
Seminars in pediatric surgery, 2006Co-Authors: Ahmad Marwan, Timothy M. CrombleholmeAbstract:Although performing Procedures on a fetus before severing the umbilical cord has previously been reported, the principles of the ex utero intrapartum treatment (EXIT) Procedure were first fully developed for reversing tracheal occlusion in fetuses with severe congenital diaphragmatic hernia. The EXIT Procedure offers the advantage of insuring uteroplacental gas exchange while on placental support. The lessons learned in the development of the principles that underlie the EXIT Procedure have improved outcomes when applied in other conditions, most notably in cases of airway obstruction. The range of indications for the EXIT Procedure has expanded and currently includes giant fetal neck masses, lung or mediastinal tumors, congenital high airway obstruction syndrome, and EXIT to ECMO (extracorporeal membrane oxygenation), among others. This review summarizes the underlying principles of the EXIT Procedure, the expanding indications for its use, the pitfalls of management, and the progress that has been made in its successful application.
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Severe pulmonary hypoplasia associated with giant cervical teratomas
Journal of pediatric surgery, 2006Co-Authors: Kenneth W. Liechty, Lori J. Howell, Alan W. Flake, Timothy M. Crombleholme, Mark P. Johnson, Holly L. Hedrick, R. Douglas Wilson, Ann M. Hubbard, Eduardo Ruchelli, N. Scott AdzickAbstract:Abstract Background The use of the ex utero intrapartum treatment (EXIT) Procedure has salvaged many fetuses with giant neck masses. Despite an adequate airway, a subset of these patients die from an inability to achieve adequate gas exchange. Methods We reviewed our experience with the EXIT Procedure from 1996 to 2004. The EXIT was used to deliver 23 fetuses with giant neck masses. Results Three fetuses with giant cervical teratomas died of severe pulmonary hypoplasia. On postmortem, these patients had severe airway distortion by the mass. The carina was retracted superiorly to the first or second rib resulting in compression of the lungs in the apices of the chest and pulmonary hypoplasia. Hypoplasia was reflected in the lung weights of 24 vs 38 g and 17 vs 34 g for age-matched normal lung. Conclusions Unsuspected obstructive fetal neck masses can be fatal because of an inability to secure an airway. Prenatal ultrasonography can identify fetuses at risk, allowing the fetus to be salvaged using the EXIT Procedure. Despite obtaining airway control, a subset of these patients will die because of pulmonary hypoplasia. When counseling patients with large cervical masses it is important to discuss potential pulmonary hypoplasia in these patients.
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The ex utero intrapartum therapy Procedure for high-risk fetal lung lesions
Journal of pediatric surgery, 2005Co-Authors: Holly L. Hedrick, Lori J. Howell, Alan W. Flake, Timothy M. Crombleholme, Mark P. Johnson, R. Douglas Wilson, N. Scott AdzickAbstract:Abstract Background Indications for the ex utero intrapartum therapy (EXIT) Procedure have expanded to include any fetal anomaly in which resuscitation of the neonate may be compromised. Methods We reviewed the medical records of 9 patients after resection of lung lesions during the EXIT Procedure. Results The mean gestational age at EXIT Procedure was 35.4 weeks. All lung masses maintained large sizes late into gestation with mean mass volume/head circumference ratio of 2.5 at presentation and 2.2 at EXIT. Seven of 9 fetuses demonstrated hydropic changes (n = 6) and/or polyhydramnios (n = 5), and underwent prenatal intervention including thoracentesis, thoracoamniotic shunt placement, amnioreduction, and/or betamethasone administration. Overall survival after EXIT for lung mass resection was 89%. The average time on placental bypass was 65 minutes. Postnatal complications included reoperation for air leak (n = 1), reoperation for bleeding (n = 1), and death from sepsis and prematurity (n = 1). Venoarterial extracorporeal membrane oxygenation was used in 4 neonates for persistent pulmonary hypertension. Maternal prenatal complications included polyhydramnios (n = 5), preterm labor (n = 4), and chorioamnionitis (n = 1). One mother required perioperative blood transfusion. Conclusion The EXIT Procedure allows for controlled resection of large fetal lung lesions at delivery, avoiding acute respiratory decompensation related to mediastinal shift, air trapping, and compression of normal lung.
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The ex-utero intrapartum treatment.
Current opinion in pediatrics, 2002Co-Authors: Tippi C. Mackenzie, Timothy M. Crombleholme, Alan W. FlakeAbstract:Advances in prenatal diagnosis, combined with a better understanding of the natural history of prenatally diagnosed anomalies, are providing increasing opportunities to consider fetal intervention in selected cases of life-threatening malformations. Accurate prenatal diagnosis can now accurately identify fetal pathophysiology that poses an immediate threat to the life of the newborn infant on separation from the placental circulation. In this circumstance, the ex-utero intrapartum treatment (EXIT) Procedure, which maintains intrapartum uteroplacental support, can be life saving. The most common indications for the EXIT Procedure are fetal lesions causing extrinsic or intrinsic airway obstruction. However, fetuses with other anomalies that may compromise neonatal resuscitation can also benefit from this approach. The EXIT Procedure differs significantly from a cesarean delivery, and caution must be taken to avoid maternal morbidity. As with all endeavors involving maternal-fetal intervention, a team approach is crucial to ensure accurate diagnosis and optimal perinatal management.
Alexander J Butwick - One of the best experts on this subject based on the ideXlab platform.
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obstetric hemorrhage during an EXIT Procedure for severe fetal airway obstruction
Canadian Journal of Anaesthesia-journal Canadien D Anesthesie, 2009Co-Authors: Alexander J Butwick, Pedram Aleshi, Imad YamoutAbstract: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.
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Obstetric hemorrhage during an EXIT Procedure for severe fetal airway obstruction
Canadian Journal of Anesthesia Journal canadien d'anesthésie, 2009Co-Authors: Alexander J Butwick, Pedram Aleshi, Imad YamoutAbstract:Objectif Nous rapportons un cas d’hémorragie obstétricale massive survenue pendant un accouchement par césarienne pour une procédure de traitement ex utero intrapartum (EXIT). Nous discutons des méthodes pour optimiser la prise en charge anesthésique, obstétricale et périnatale. Éléments cliniques Une parturiente en bonne santé a subi une procédure EXIT d’urgence à 32 semaines de grossesse en raison d’une masse géante sur le cou du fœtus. Pendant la période peropératoire, une hémorragie peropératoire grave est survenue au site de l’incision chirurgicale. Aucune évidence de saignement placentaire, de séparation prématurée du placenta ou de relaxation inadéquate de l’utérus n’a été observée pendant la période périopératoire. Le placement d’un dispositif d’agrafage utérin n’a pas permis d’obtenir une hémostase chirurgicale appropriée. Les premières tentatives de prise en charge des voies aériennes du fœtus avec soutien placentaire par laryngoscopie ou bronchoscopie rigide n’ont pas réussi, et il a fallu interrompre le soutien placentaire de façon précoce en raison de la gravité des pertes sanguines maternelles. Après l’accouchement du nouveau-né et l’interruption du soutien placentaire, la ventilation néonatale à l’aide d’un masque a réussi tout comme l’intubation endotrachéale lors d’une seconde bronchoscopie. Conclusion Le risque d’hémorragie obstétricale en raison de la relaxation utérine ou une hémostase chirurgicale insuffisante chez les patientes subissant une procédure EXIT sont peu documentés. Afin de réduire les conséquences néfastes pour la mère et l’enfant, l’interruption prématurée du soutien placentaire pendant une procédure EXIT peut s’avérer nécessaire dans un contexte d’hémorragie obstétricale grave. 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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obstetric hemorrhage during an EXIT Procedure for severe fetal airway obstruction hemorragie obstetricale pendant une Procedure de traitement ex utero intrapartum en raison d une obstruction grave des voies respiratoires du fœtus
2009Co-Authors: Alexander J Butwick, Imad YamoutAbstract: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.
Pedram Aleshi - One of the best experts on this subject based on the ideXlab platform.
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obstetric hemorrhage during an EXIT Procedure for severe fetal airway obstruction
Canadian Journal of Anaesthesia-journal Canadien D Anesthesie, 2009Co-Authors: Alexander J Butwick, Pedram Aleshi, Imad YamoutAbstract: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.
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Obstetric hemorrhage during an EXIT Procedure for severe fetal airway obstruction
Canadian Journal of Anesthesia Journal canadien d'anesthésie, 2009Co-Authors: Alexander J Butwick, Pedram Aleshi, Imad YamoutAbstract:Objectif Nous rapportons un cas d’hémorragie obstétricale massive survenue pendant un accouchement par césarienne pour une procédure de traitement ex utero intrapartum (EXIT). Nous discutons des méthodes pour optimiser la prise en charge anesthésique, obstétricale et périnatale. Éléments cliniques Une parturiente en bonne santé a subi une procédure EXIT d’urgence à 32 semaines de grossesse en raison d’une masse géante sur le cou du fœtus. Pendant la période peropératoire, une hémorragie peropératoire grave est survenue au site de l’incision chirurgicale. Aucune évidence de saignement placentaire, de séparation prématurée du placenta ou de relaxation inadéquate de l’utérus n’a été observée pendant la période périopératoire. Le placement d’un dispositif d’agrafage utérin n’a pas permis d’obtenir une hémostase chirurgicale appropriée. Les premières tentatives de prise en charge des voies aériennes du fœtus avec soutien placentaire par laryngoscopie ou bronchoscopie rigide n’ont pas réussi, et il a fallu interrompre le soutien placentaire de façon précoce en raison de la gravité des pertes sanguines maternelles. Après l’accouchement du nouveau-né et l’interruption du soutien placentaire, la ventilation néonatale à l’aide d’un masque a réussi tout comme l’intubation endotrachéale lors d’une seconde bronchoscopie. Conclusion Le risque d’hémorragie obstétricale en raison de la relaxation utérine ou une hémostase chirurgicale insuffisante chez les patientes subissant une procédure EXIT sont peu documentés. Afin de réduire les conséquences néfastes pour la mère et l’enfant, l’interruption prématurée du soutien placentaire pendant une procédure EXIT peut s’avérer nécessaire dans un contexte d’hémorragie obstétricale grave. 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.
Holly L. Hedrick - One of the best experts on this subject based on the ideXlab platform.
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Ex utero intrapartum treatment in the management of giant cervical teratomas
Journal of pediatric surgery, 2012Co-Authors: Pablo Laje, Lori J. Howell, Alan W. Flake, Mark P. Johnson, Holly L. Hedrick, Michael Bebbington, N. Scott AdzickAbstract:Abstract Purpose The purpose of this study is to present the outcome and technical details of the Ex Utero Intrapartum Treatment (EXIT) Procedure performed in the management of the fetus with a giant cervical teratoma. Methods A retrospective review of the medical records of patients undergoing the EXIT Procedure between September 1995 and September 2010 was performed. Results Eighty-seven EXIT Procedures were performed. In 20% of cases (17/87), the indication was giant cervical teratoma. There were 10 females and 7 males. Polyhydramnios was present in 82%. Median gestational age at EXIT was 35 weeks (range, 30-39 weeks). Median birth weight was 2.5 kg (range, 1.7-3.7 kg). Access to the airway under placental support was established in all cases via direct laryngoscopy/bronchoscopy in 8 patients (47%) and via surgical exploration (tracheostomy or retrograde intubation) in 9 patients (53%). The mortality rate under placental support was zero. Seven patients had the tumors resected immediately after the EXIT, 6 patients had the resection later, and 4 patients died before resection. The neonatal mortality rate was 23% (4/17 patients). Patients who died had severe pulmonary hypoplasia that resulted from the upward traction by the giant cervical mass on the airway and compression of the lungs against the thoracic apex. Conclusions We conclude that the EXIT Procedure continues to be the optimal delivery strategy for patients with prenatally diagnosed giant cervical teratomas and potential airway obstruction at birth. A thorough evaluation of the prenatal images and an experienced multidisciplinary team are key factors for an effective approach to the obstructed fetal airway.
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Severe pulmonary hypoplasia associated with giant cervical teratomas
Journal of pediatric surgery, 2006Co-Authors: Kenneth W. Liechty, Lori J. Howell, Alan W. Flake, Timothy M. Crombleholme, Mark P. Johnson, Holly L. Hedrick, R. Douglas Wilson, Ann M. Hubbard, Eduardo Ruchelli, N. Scott AdzickAbstract:Abstract Background The use of the ex utero intrapartum treatment (EXIT) Procedure has salvaged many fetuses with giant neck masses. Despite an adequate airway, a subset of these patients die from an inability to achieve adequate gas exchange. Methods We reviewed our experience with the EXIT Procedure from 1996 to 2004. The EXIT was used to deliver 23 fetuses with giant neck masses. Results Three fetuses with giant cervical teratomas died of severe pulmonary hypoplasia. On postmortem, these patients had severe airway distortion by the mass. The carina was retracted superiorly to the first or second rib resulting in compression of the lungs in the apices of the chest and pulmonary hypoplasia. Hypoplasia was reflected in the lung weights of 24 vs 38 g and 17 vs 34 g for age-matched normal lung. Conclusions Unsuspected obstructive fetal neck masses can be fatal because of an inability to secure an airway. Prenatal ultrasonography can identify fetuses at risk, allowing the fetus to be salvaged using the EXIT Procedure. Despite obtaining airway control, a subset of these patients will die because of pulmonary hypoplasia. When counseling patients with large cervical masses it is important to discuss potential pulmonary hypoplasia in these patients.
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The ex utero intrapartum therapy Procedure for high-risk fetal lung lesions
Journal of pediatric surgery, 2005Co-Authors: Holly L. Hedrick, Lori J. Howell, Alan W. Flake, Timothy M. Crombleholme, Mark P. Johnson, R. Douglas Wilson, N. Scott AdzickAbstract:Abstract Background Indications for the ex utero intrapartum therapy (EXIT) Procedure have expanded to include any fetal anomaly in which resuscitation of the neonate may be compromised. Methods We reviewed the medical records of 9 patients after resection of lung lesions during the EXIT Procedure. Results The mean gestational age at EXIT Procedure was 35.4 weeks. All lung masses maintained large sizes late into gestation with mean mass volume/head circumference ratio of 2.5 at presentation and 2.2 at EXIT. Seven of 9 fetuses demonstrated hydropic changes (n = 6) and/or polyhydramnios (n = 5), and underwent prenatal intervention including thoracentesis, thoracoamniotic shunt placement, amnioreduction, and/or betamethasone administration. Overall survival after EXIT for lung mass resection was 89%. The average time on placental bypass was 65 minutes. Postnatal complications included reoperation for air leak (n = 1), reoperation for bleeding (n = 1), and death from sepsis and prematurity (n = 1). Venoarterial extracorporeal membrane oxygenation was used in 4 neonates for persistent pulmonary hypertension. Maternal prenatal complications included polyhydramnios (n = 5), preterm labor (n = 4), and chorioamnionitis (n = 1). One mother required perioperative blood transfusion. Conclusion The EXIT Procedure allows for controlled resection of large fetal lung lesions at delivery, avoiding acute respiratory decompensation related to mediastinal shift, air trapping, and compression of normal lung.
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Ex utero intrapartum therapy.
Seminars in pediatric surgery, 2003Co-Authors: Holly L. HedrickAbstract:Abstract The hallmark of ex utero intrapartum therapy (EXIT) Procedure is the maintenance of uteroplacental blood flow and gas exchange. This goal is achieved with the use of inhalational agents to relax uterine tone, a continuous amnioinfusion to stabilize uterine volume, and partial exposure of the fetus. From March 1996 to December 2002, 43 EXIT Procedures were performed at the Children’s Hospital of Philadelphia (CHOP). Indications included airway obstruction from fetal neck masses (n = 19), reversal of tracheal occlusion for congenital diaphragmatic hernia (CDH; n = 13), resection of massive congenital cystic adenomatoid malformation of the lung (n = 5), congenital high airway obstruction syndrome (n = 3), EXIT-to-extracorporeal membrane oxygenation for a fetus with CDH and a cardiac defect (n = 1), unilateral pulmonary agenesis (n = 1), and thoracoomphalopagus conjoined twins (n = 1). Eight fetuses required initial tracheotomy at the time of EXIT to secure the airway. One death occurred during the EXIT Procedure secondary to inability to secure the airway with parental refusal for tracheotomy. In all cases, the EXIT Procedure provided time on uteroplacental gas exchange to perform Procedures such as direct laryngoscopy, bronchoscopy, tracheotomy, arterial and venous access, resection of neck or lung masses, and ECMO cannulation, thereby converting an emergent crisis into a controlled situation.