Outcomes of Airway Management in Micrognathia and Retrognathia Patients Born at Fetal versus Nonfetal Centers

Abstract

<b><i>Objectives:</i></b> There is a paucity of evidence to guide the perinatal management of difficult airways in fetuses with micrognathia. We aimed to (1) develop a postnatal grading system based on the extent of airway intervention required at birth to assess the severity of micrognathic airways and (2) compare trends in airway management and outcomes by location of birth [nonfetal center (NFC), defined as a hospital with or without an NICU and no fetal team, versus fetal center (FC), defined as a hospital with an NICU and fetal team]. <b><i>Methods:</i></b> We retrospectively reviewed the prenatal and postnatal records of all neonates diagnosed with micrognathia from January 2010 to April 2018 at a quaternary children’s hospital. We developed a novel grading scale, the Micrognathia Grading Scale (MGS), to grade the extent of airway intervention at birth from 0 (no airway intervention) to 4 (requirement of EXIT or advanced airway instrumentation for airway securement). <b><i>Results:</i></b> We identified 118 patients with micrognathia. Eighty-nine percent (105/118) were eligible for grading using the MGS. When the MGS was applied, the airway grades were as follows: grade 0 (30%), grade 1 (10%), grade 2 (9%), grade 3 (48%), and grade 4 (4%). A quarter of micrognathic patients with grade 0–2 airways had postnatal hospital readmissions for airway obstruction after birth, of which all were born at NFC. Over 40% of patients with grade 3–4 micrognathic airways required airway intervention within 24 h of birth. Overall, NFC patients had a readmission rate of (27%) for airway obstruction after birth compared to FC patients (17%). <b><i>Conclusions:</i></b> Due to the high incidence of grade 3–4 airways on the MGS in micrognathic patients, fetuses with prenatal findings suggestive of micrognathia should be referred to a comprehensive fetal care center capable of handling complex neonatal airways. For grade 0–2 airways, infants frequently had postnatal complications necessitating airway intervention; early referral to a multidisciplinary team for both prenatal and postnatal airway management is recommended.

Mandibular Measurements at the 20-Week Anatomy Ultrasound as a Prenatal Diagnostic Predictor of Pierre Robin Sequence

“…Diagnosis currently relies on clinical exam after birth. While there may be suspicion for PRS with micrognathia subjectively noted on ultrasound or polyhydramnios (Pilu et al, 1986), many of these infants present after uncomplicated pregnancies in the delivery room with respiratory distress and/or airway compromise necessitating emergent respiratory support (Shahi et al, 2020). Without swift intervention, prolonged hypoxia can lead to multiorgan failure, hypoxic ischemic encephalopathy and permanent neurologic disability (Douglas-Escobar and Weiss, 2015).…”

Immediate postdelivery airway management of neonates with prenatally diagnosed micrognathia: A retrospective observational study

“…[3][4][5][7][8][9] When severe micrognathia is observed on prenatal imaging, expectant mothers may be referred for delivery at a center with physicians capable of managing severe upper airway obstruction. 10,11 One approach is the ex-utero intrapartum treatment (EXIT) procedure, which involves partial delivery for access and management of the airway while fetal gas exchange is maintained through the uteroplacental circulation. 3,7,10,12,13 General anesthesia for the mother and profound uterine relaxation are commonly required to facilitate partial delivery, vascular access, and airway management of the neonate.…”