A review of the EXIT (<i>Ex utero</i>Intrapartum Treatment) procedure

Abraham, Reena; Sau, Ashis; Maxwell, D.

doi:10.3109/01443610903281656

Cited by 64 publications

(46 citation statements)

References 17 publications

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“…[1–6,12] Recent technological advancements in prenatal diagnosis have allowed the early detection of fetal malformations before delivery, thereby facilitating planning of appropriate treatment for such cases and improving the perinatal outcome. [7] In fetuses who are expected to have airway difficulty and subsequent airway crisis related to airway obstruction at delivery, the EXIT procedure has been reported to be appropriate for securing the fetal airway.…”

Section: Discussionmentioning

confidence: 99%

“…[1–3] With maintenance of fetal oxygenation via uteroplacental circulation, sufficient time is provided to achieve airway access in a fetus through direct laryngoscopy, fiberoptic bronchoscopy, or tracheostomy. [4–7] However, it is very challenging to establish airway access during the EXIT procedure, even for anesthesiologists who are very skilled at airway management, because such a fetus has severe airway difficulty that necessitates the EXIT procedure and there is insufficient room for airway management within the surgical field.…”

Section: Introductionmentioning

confidence: 99%

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Use of the GlideScope video laryngoscope for intubation during ex utero intrapartum treatment in a fetus with a giant cyst of the 4th branchial cleft

Byun

Lee²,

Hong³

et al. 2016

Medicine

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Introduction:In fetuses who are predicted to be at risk of catastrophic airway obstruction at delivery, the ex utero intrapartum treatment (EXIT) procedure is useful for securing the fetal airway while maintaining fetal oxygenation via placental circulation. Factors, including poor posture of the fetus and physician, narrow visual field, and issues of contamination in the aseptic surgical field, make fetal intubation during the EXIT procedure difficult. Herein, we report our experience of the usefulness of the GlideScope video laryngoscope (GVL) for intubation during the EXIT procedure.Symptoms and clinical findings:A 28-year-old woman presented with a fetus having a cystic neck mass diagnosed on prenatal ultrasound at 25 weeks of gestation. We planned the EXIT procedure in conjunction with cesarean delivery at 38 weeks of gestation, as the mass enlarged to 4.9 cm × 3.2 cm, protruded externally at the neck, and subsequently resulted in polyhydramnios.Therapeutic intervention and outcomes:After induction of anesthesia using intravenous thiopental (300 mg), adequate uterine relaxation was achieved with sevoflurane (2.0–3.0 vol%) combined with continuous intravenous infusion of nitroglycerin (0.5–1.0 μg/kg/min) for maintaining uteroplacental circulation. After hysterotomy, the head and right upper limb of the fetus were partially delivered, and fetal heart tones were monitored with a sterile Doppler probe. After oropharyngeal suctioning to improve the visual field, the fetus was intubated successfully using a sterile GVL by an anesthesiologist, and the passage of the endotracheal tube beyond the vocal cords was confirmed on the screen of the GVL system. Immediately after the fetal airway was definitely secured, the fetus was fully delivered with umbilical cord clamping. After delivery, nitroglycerine administration was ceased and sevoflurane administration was reduced to 0.5 minimum alveolar concentration. Additionally, oxytocin (10 units) and carbetocin (100 μg) were administered for recovery of uterine contraction. Cesarean delivery was successfully performed without any problems, and the neonate successfully underwent surgery for removal of the neck mass under general anesthesia on the 7th day after delivery. The neonate is developing normally.Conclusion:The GVL approach may be a useful noninvasive approach for establishing a clear fetal airway during the EXIT procedure.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Use of the GlideScope video laryngoscope for intubation during ex utero intrapartum treatment in a fetus with a giant cyst of the 4th branchial cleft

Byun

Lee²,

Hong³

et al. 2016

Medicine

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“…The presence of polyhydramnios and hydrops in these cases can negatively affect prognosis. Long-term follow-up has not been sufficiently reported (3,10). Parents should be informed about the difficulties and outcomes of the EXIT procedure in further detail.…”

Section: Discussionmentioning

confidence: 99%

Fetal Oropharyngeal and Neck Tumors: Determination of the Need for Ex-Utero Intrapartum Treatment Procedure

Özgünen¹,

Güleç²,

Evrüke³

et al. 2015

Balkan Med J

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Oropharyngeal and neck tumors are rarely seen in fetal life. The lesions located in the area involve cystic hygroma, teratoma, ranula, epulis, hemangioma, congenital goiter, solid thyroid tumor, thyroid cyst or thyroglossal duct cyst, branchial cleft cyst, neuroblastoma and hamartoma. The most common types are cervical teratoma and cystic hygroma (1). These tumors have the potential to obstruct the airway, which can be life threatening, and endotracheal intubation can be difficult or impossible due to anatomic distortion.The aim of the ex-utero intrapartum therapy (EXIT) procedure is to maintain the newborn's airway open during placental circulation after the partial delivery of a fetus, and, in this way, to protect the fetus from hypoxia until providing an open airway (2). As fetoplacental circulation continues, endotracheal intubation is implemented for opening the airway of the fetus. If this is not possible, other interventions such as bronchoscopy or tracheostomy and excision of the mass can be applied (1-3). However, the EXIT procedure is not a treat- Background:The aim of this study was to assess the ex-utero intrapartum therapy (EXIT) applied to 3 of the 7 cases with oropharyngeal or neck masses and review the indicators of the need for an EXIT procedure. Case Report: Prenatal presentation, size and localization of the masses, existence of fetal hydrops and associated findings such as polyhydramnios, intraoperative managements, complications, and maternal and neonatal outcomes were evaluated through a retrospective analysis. Four cases had neck masses and three cases had oropharyngeal masses. Prenatal sonography was used as the main diagnostic tool for all patients. The median gestational age was 34.5 weeks at the time of diagnosis and 36 weeks at delivery. Polyhydramnios was observed in three of the seven cases and they were delivered prematurely. Interventions such as endotracheal intubation or tracheostomy were performed to provide patency of the airway during delivery by the EXIT procedure in three cases. Hemangioma was found in two cases, teratoma in two cases, lymphangioma in two cases and hamartoma in one case following pathological examination of the masses. Conclusion: The localization of mass, its characteristics, invasion (if it exists), and relation to the airway are the main factors used to determine the need for EXIT. The presence of polyhydramnios may be an important indicator to predict both the need for EXIT and fetal outcomes.

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“…Fetal well being plays an important role in the early diagnose of impaired placental perfusion and can be monitored by different methods 4,2,26,27 . Fetal heart rate can be monitored through the umbilical cord pulse, just as it was performed in our cases, or through echocardiography, which also gives information on end-systolic volume, contraction and the filling of the heart chambers 27 . Oxygenation may be assessed by using pulse oximetry (saturation should be higher than 50%) and through the analysis of fetal blood gas.…”

Section: Discussionmentioning

confidence: 99%

Anestesia para tratamento intraparto extraútero (EXIT) em fetos com diagnóstico pré-natal de malformações cervical e oral: relato de casos

Helfer¹,

Clivatti

Yamashita³

et al. 2012

Rev. Bras. Anestesiol.

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Helfer DC, Clivatti J, Yamashita AM, Moron AF -Anesthesia for Ex Utero Intrapartum Treatment (EXIT procedure) in Fetus with Prenatal Diagnosis of Oral and Cervical Malformations: Case Reports. Background and objectives:Fetus prenatally diagnosed with neck tumors, or with any other disease that obstructs the airways, should not be treated conventionally, as the assistant physician has to face two challenges right after the infant's delivery: the limited time to establish the access to the potentially difficult airways and the lack of anesthesia of the neonate in case of instrumentation of the airways. The ex utero intrapartum treatment, i.e., the EXIT procedure consists of maintaining the fetoplacental circulation during the cesarean section, until the airways of the fetus be secured.

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A review of the EXIT (Ex uteroIntrapartum Treatment) procedure

Cited by 64 publications

References 17 publications

Use of the GlideScope video laryngoscope for intubation during ex utero intrapartum treatment in a fetus with a giant cyst of the 4th branchial cleft

Use of the GlideScope video laryngoscope for intubation during ex utero intrapartum treatment in a fetus with a giant cyst of the 4th branchial cleft

Fetal Oropharyngeal and Neck Tumors: Determination of the Need for Ex-Utero Intrapartum Treatment Procedure

Anestesia para tratamento intraparto extraútero (EXIT) em fetos com diagnóstico pré-natal de malformações cervical e oral: relato de casos

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