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Anesthetic Management During Ex Utero Intrapartum Treatment In A Parturient With A Monochorionic Diamniotic Twin Pregnancy
Abstract Number: T2C-3
Abstract Type: Case Report/Case Series
The ex utero intrapartum treatment (EXIT) procedure is a rare technique that can be used in cases involving prenatally-identified fetal airway anomalies. EXIT is performed in concurrence with an elective Cesarean section after the fetus is partially-delivered, allowing for securement of the compromised fetal airway using direct laryngoscopy, fiberoptic bronchoscopy, or surgery while oxygenation is maintained through utero-placental bypass. This obviates the need for emergent fetal airway intervention and instead permits airway evaluation and management in a more controlled environment for the anatomically-compromised fetus, which would likely otherwise experience a poor outcome. EXIT procedure in twin pregnancy has been rarely reported and, to our knowledge, has never been reported in monochorionic diamniotic twins.2
Our case involved a 25-yr-old female, gravida 3 para 2, who at 18 weeks gestation had an ultrasound revealing a large fetal neck mass (3.5 cm (anterior-posterior) x 2.4 cm (transverse) x 2.7 cm (craniocaudal)) with mass effect on the trachea in twin B with MRI findings consistent with cystic hygroma. Prior to the scheduled multi-disciplinary delivery planning meeting, she presented in preterm labor at 31 weeks gestation and due to failed tocolysis, delivery proceeded urgently by Cesarean delivery with EXIT. Surgery was performed in the main operating room with ENT and neonatology teams present for neonatal airway management and stabilization. A combined spinal-epidural (CSE; bupivacaine 12mg, fentanyl 15mcg, morphine 150mcg) was the selected anesthetic technique followed by initiation of a phenylephrine infusion (50 mcg/min IV) and co-loading of lactated ringers. Maternal administration of remifentanil (0.15 mcg/kg/min IV) was initiated 15 minutes before skin incision for fetal immobilization and analgesia to optimize airway management at EXIT, as well as nitroglycerin (50mcg bolus, 50mcg/minute infusion IV) for uterine relaxation. The unaffected twin was delivered first followed by delivery of the fetal head of the affected twin who was intubated by the neonatologist via direct laryngoscopy. Baby A apgars 3, 7, and 8; Baby B apgars 3 and 7. The babies’ father was present for delivery. No maternal complications.
We have identified five previous case reports involving EXIT procedures in Di-Di twin gestations. Although general anesthesia is most commonly used for EXIT, CSE with concomitant IV administration of remifentanil and nitroglycerin has been previously described1,3. To our knowledge, this is the first documented EXIT procedure in a monochorionic diamniotic twin pregnancy where placental circulation is shared by the fetuses, and thus the first documented EXIT in a twin pregnancy using neuraxial anesthesia.
1) Fink, R. et al. (2011) British Journal of Anaesthesia 106 (6): 851-855
2) Garcia-Diaz. et al. (2014) BMC Pregnancy and Childbirth 14: 252
3) Whited, C. et al. (2013) Open Journal of Pediatrics 3: 366-369