Prenatal Imaging Findings Predict Obstructive Fetal Airways Requiring EXIT

Abstract

Objective: Detection of fetal airway compromise through imaging raises the possible need for ex utero intrapartum treatment (EXIT) procedures. Despite EXIT procedures involving massive resource utilization and posing increased risk to the mother, decisions for EXIT are usually based on anecdotal experience. Our objectives were to analyze prenatal consultations with potential fetal airway obstruction for imaging and obstetric findings used to determine management strategy. Methods: Retrospective chart review was performed for prenatal abnormal fetal airway consults between 2004-2019 at a quaternary pediatric facility. Data collected included demographics, imaging characteristics, delivery information, and airway management. Our primary outcome was EXIT performance and the secondary outcome was postnatal airway management. Fisher's exact test was used to compare management decisions, outcomes, and imaging findings. Results: Thirty-seven patients met inclusion criteria. The most common diagnoses observed were lymphatic malformation, teratoma, and micrognathia. Of the imaging findings collected, only midline neck mass location was associated with EXIT procedure performance. Factors associated with invasive airway support at birth were mass-induced in-utero neck extension and neck vessel compression, polyhydramnios, and micrognathia. Conclusions: Multidisciplinary input and interpretation of prenatal imaging can guide management of fetal airway-related pathology. EXIT is an overall safe procedure and can decrease risk due to airway obstruction at birth. We identified in-utero neck extension, neck vessel compression, micrognathia, and polyhydramnios as better indicators of a need for invasive airways measures at birth and suggest use of these criteria in combination with clinical judgement when recommending EXIT.

Prenatal Tanılı Servikal Kitleye Ekstrauterin İntrapartum Tedavi ((EXIT) Yöntemiyle Yaklaşım

“…), congenital diaphragmatic hernia, head-neckmediastinum teratomas, lymphangiomas, epulis, ranula cysts, branchial sinus cysts are associated with serious airway complications during delivery. In the past, mortality rates of up to 80-100 % have been reported in these type of malformations (1) . The primary goal is to provide a safe airway in the neck, face and mediastinum pathologies that cause full obstruction in the early postnatal period by damaging or compressing the airway structures.…”

“…In congenital mass lesions of the neck, face and mediastinum, it is vital to have an open airway and oxygenation immediately after birth. In these cases, in whom teratomas and lymphangiomas constitute the majority of the lesions, recognition during the antenatal period, revealing the relationship of the lesion with airway structures, making preparations for extrauterine intrapartum treatment (ex utero intrapartum treatment-EXIT) and performing a planned cesarean delivery reduces mortality and morbidity (1 ) . The aim of this report is to present the treatment process of a prenatally diagnosed cervical teratoma with the EXIT procedure and surgical excision to emphasize the importance of multidisciplinary approach in these cases.…”

Pediatric vascular anomalies with airway compromise

“…Progresses made in prenatal screening with ultrasound (US) and magnetic resonance imaging (MRI) allow in utero detection of fetal head and neck masses with potential airway compromise. 10,11 Even if the diagnosis can be inaccurate, 12 any suspicion should evoke a multidisciplinary evaluation to plan a safe perinatal airway management, sometimes with an ex-utero intrapartum treatment (EXIT) procedure.…”

Surgical management of complex neonatal airway abnormalities

“…Nearly 80% of the masses were lymphatic malformations and commonly underwent sclerotherapy with or without rapamycin, with only 33% requiring surgical excision [16]. A similar study reviewed all prenatal consultations for possible airway obstruction and found that only a midline mass was associated with EXIT procedure, whereas mass-induced in-utero neck extension and neck vessel compression, polyhydramnios, and micrognathia were associated with invasive airway support [17] [Fig. 4].…”