The EXIT (Ex utero Intrapartum Treatment) procedure is done in cases where difficulty is anticipated in neonatal airway establishment at delivery and is done at the time of caesarean section. The partially delivered fetus is maintained on placental circulation while airway is established and this is carried out by a multidisciplinary team. In this paper, we review the indications, the maternal and fetal considerations of the procedure and the results and outcomes. The review highlights the fact that the benefits far outweigh the risks and that the risk of postpartum haemorrhage is more theoretical than real. As technology improves and more anomalies are diagnosed during the antenatal period, the EXIT procedure can be performed with good results after carefully considering the ethical issues. We have performed a MEDLINE search by using the keywords EXIT, CHAOS, fetal surgery, fetal neck masses and ex utero intrapartum treatment. As there are not many large studies, we have also reviewed smaller case series and case reports.
INTRODUCTIONEvery year over five lac women die worldwide due to causes related to pregnancy and delivery. Postpartum Haemorrhage (PPH) accounts for the major part of the mortality as well as morbidity like severe anaemia, need for blood transfusion, hospital stay and infection. Millennium Development Goal 5 targets for reduction of maternal mortality rate by 75% by 2015, which means 5.5% reduction per year is required. People at high risk of PPH account for only small percent of all maternal deaths. Majority of morbidity and mortality happen in those with no risk factors and cannot be predicted. In an analysis of 1620 women in rural India, it was found that 9.2% experienced PPH. No maternal or socio-demographic factors differed between women with PPH and those without [1]. Though the incidence of early PPH (occurring within 24 hours of delivery) is lower in caesarean section than vaginal delivery, the former is a major surgery and causes greater blood loss. Hence, it is essential to prevent the blood loss effectively in a feasible way, thus, explaining the need for this study.Apart from obstetric, surgical and radiological interventions, pharmacologic management also plays an important role in this aspect. Uterine atony is the most common cause for PPH. First line of therapeutic management for PPH is oxytocin [2] Other modalities include intravenous ergometrine, intra-muscular carboprost and misoprostol. Prohaemostatic drugs such as TXA provide a complementary biochemical haemostatic effect to the well proven uterotonics, especially oxytocin. Systemic anti-fibrinolytic agents are widely used in surgery. A systematic review of randomised controlled trials of anti-fibrinolytic agents in elective surgical patients identified 211 randomised controlled trials [3]. The results showed that aprotinin reduced the risk of blood transfusion by 34% and TXA by 39%. TXA is an analogue of lysine that inhibits fibrinolysis by competitively binding to plasminogen. It prevents the lysis of formed clot by inhibiting activation of plasminogen and plasmin. It is ten times more potent than Amino-caproic acid [4,5]. TXA has been shown to reduce uterine blood loss in non-surgical aspect. A study done on women with menorrhagia has showed significant reduction in mean menstrual blood loss in those treated with TXA [6]. A randomized controlled trial assessed TXA for the treatment of PPH and it showed that a high dose of TXA reduces blood loss in women with PPH [7]. Several RCTs have analysed the prophylactic role of TXA (described in discussion) and have shown significant results in reducing blood loss [8][9][10][11][12][13][14][15][16]. TXA might reduce the need for hysterectomy, reduce the risk of severe anaemia and avoid the need for blood transfusion; hence, this could contribute significantly to the goal of reducing maternal mortality.
MATERIALS AND METHODS
ABSTRACTIntroduction: Obstetric haemorrhage accounts for 20-25% of maternal mortality and morbidity. Anti-fibrinolytics are being widely used in field of surgery. It is also used...
Anaesthesia mumps is an uncommon postoperative complication resulting in unilateral or bilateral swelling of the parotid glands following surgical and endoscopic procedures. Our case illustrates the benign course of anaesthesia mumps in a postoperative vaginal hysterectomy patient with no underlying illness and also discusses previous cases in the literature and management strategies.
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