The EXIT Procedure: A Case Series and Literature Review
Abstract Type: Case Report/Case Series
We describe a case series of two caesarean deliveries of fetuses with known congenital anomalies necessitating intubation at Birth. The Ex-utero Intrapartum Treatment (EXIT) procedure was utilized to allow controlled intubation of the fetuses while maintaining maternal-fetal circulation to facilitate potentially difficult airway intervention. We also perform a thorough literature review of the most recent data and case reports available pertaining to anesthetic considerations associated with the EXIT procedure.
Our first case involves a healthy 28 year old parturient, G2P0, with an unremarkable prenatal course. On routine ultrasonography and prenatal fetal MRI, a 10.5cm x 9.6cm x 9.6 cm fetal neck mass was found. Due to the likelihood for difficult intubation, the EXIT procedure was utilized. The fetus was delivered via caesarean section under General Anesthesia. Arterial and central venous access was obtained, anesthesia was induced via rapid sequence and maintained with high concentration desflourane. Uterine relaxation was maintained with a nitroglycerine infusion, and maternal MAP was maintained using a dopamine infusion. After successful fetal intubation, maternal-fetal circulation was discontinued, and adequate Uterine tone was successfully attained using IV oxytocin, IM methylergonovine and IM carboprost.
The second case involves a 29 year old G3P2 parturient with BMI of 35.8 and no other medical problems, with 2 previous vaginal deliveries. Prenatal imaging showed the fetus to have a large Congenital Cyst Adenomatoid Malformation (CCAM) of the left chest. The CCAM necessitated immediate neonatal intubation and posed possible airway distortion. A planned caesarean delivery took place at 36 weeks estimated gestational age, utilizing the EXIT Procedure to facilitate neonatal intubation and stabilization for transport for immediate surgical removal of the CCAM. An arterial line and central line were placed. General anesthesia was induced by RSI and maintained with 1-1.5 MAC sevoflurane and a remifentanil infusion. Uterine relaxation was maintained using a nitroglycerine infusion, and MAP was maintained using a phenylephrine infusion. After the procedure was successfully completed, adequate uterine tone was attained using IV oxytocin.
As no standard protocol exists for Anesthetic management for the EXIT procedure, we perform a comprehensive literature review that includes the latest findings pertaining to the following considerations: General vs. Neuraxial anesthesia; maintenance of uterine relaxation; ensuring adequate post partum uterine tone; maternal hemodynamic goals and choice of pressors; maintenance of uteroplacental perfusion; peri- and post-operative pain control.
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