Taking the Natural Exit: Opportunities for Treatment Rightsizing in Fetal Head and Neck Mass

Puricelli, Michael D.; Danielsen, Brodey Matthew; Beek-King, Jessica Van; Wraight, C. Lydia; Stewart, Katharina; Beninati, Michael; Lobeck, Inna N.; Iruretagoyena, J. Igor

doi:10.1177/87564793221100275

Cited by 3 publications

(1 citation statement)

References 25 publications

(60 reference statements)

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“…When considering a delivery for EXIT, having a range of standardized protocols to account for possible variations in patient presentation is vital to ensuring an optimal outcome for both mother and neonate. Such protocols should be dynamic to escalate or de-escalate treatment as clinical data dictate [24].…”

Section: Discussionmentioning

confidence: 99%

Indications, Resource Allocation, and Outcomes Associated with Ex-Utero Intrapartum Treatment Procedures: A North American Fetal Therapy Network Survey

Joshi¹,

Stellon²,

Antony³

et al. 2023

Fetal Diagn Ther

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Introduction: Neonates with cardiorespiratory compromise at delivery are at substantial risk of hypoxic neurologic injury and death. Though mitigation strategies such as ex-utero intrapartum treatment (EXIT) exist, the competing interests of neonatal beneficence, maternal non-maleficence, and just distribution of resources require consideration. Due to the rarity of these entities, there are few systematic data to guide evidence-based standards. This multi-institutional, interdisciplinary approach aims to elucidate the current scope of diagnoses that might be considered for such treatments and examine if treatment allocation and/or outcomes could be improved. Methods: After IRB approval, a survey investigating diagnoses appropriate for EXIT consultation and procedure, variables within each diagnosis, occurrence of maternal and neonatal adverse outcomes, and instances of suboptimal resource allocation in the last decade was sent to all North American Fetal Treatment Network center representatives. One response was recorded per center. Results: We received a 91% response rate and all but one center offer EXIT. Most centers (34/40, 85%) performed 1–5 EXIT consultations per year and 17/40 (42.5%) centers performed 1–5 EXIT procedures in the last 10 years. The diagnoses with the highest degree of agreement between centers surveyed to justify consultation for EXIT are head and neck mass (100%), congenital high airway obstruction (90%), and craniofacial skeletal conditions (82.5%). Maternal adverse outcomes were noted in 7.5% of centers while neonatal adverse outcomes in 27.5%. A large percentage of centers report cases of suboptimal selection for risk mitigation procedures and several centers experienced adverse neonatal and maternal outcomes. Conclusion: This study captures the scope of EXIT indications and is the first to demonstrate the mismatch in resource allocation for this population. Further, it reports on attributable adverse outcomes. Given suboptimal allocation and adverse outcomes, further examination of indications, outcomes, and resource use is justified to drive evidence-based protocols.

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Section: Discussionmentioning

confidence: 99%

Indications, Resource Allocation, and Outcomes Associated with Ex-Utero Intrapartum Treatment Procedures: A North American Fetal Therapy Network Survey

Joshi¹,

Stellon²,

Antony³

et al. 2023

Fetal Diagn Ther

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Perinatal Airway Management Mandibular Anomalies: A National Inpatient Cohort Analysis

Puricelli,

Barr,

Ellefson

et al. 2024

The Laryngoscope

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ObjectiveTo characterize incidence of mandibular anomalies (MAs) and compare gestational age, airway interventions, and complications among individuals with MA phenotypes (isolated retrognathia, isolated micrognathia, syndromic micrognathia, micrognathia plus cleft palate/cleft lip and palate, agnathia/micrognathia plus cervical auricle/otocephaly, and agnathia/micrognathia plus microstomia) and unaffected individuals.MethodsThe Healthcare Cost and Utilization Project Kids' Inpatient Database was used to collect data over a 20‐year period beginning in 2000. Interventions were classified as perinatal when performed on day of life (DOL) 0 or 1 and subsequent when performed during the birth hospitalization after DOL 1. Hypoxic complications included cardiac arrest, birth asphyxia, hypoxic–ischemic encephalopathy, anoxic brain damage, intraventricular hemorrhage or cerebral infarction. Descriptive statistics are reported, and the Rao‐Scott chi‐square test compared groups.ResultsMAs affected 119 per 100,000 birth visits. Preterm delivery was more frequent for all MA phenotypes. Individuals with MA phenotypes are more likely to require medical attention (airway intervention on DOL 0 or 1 OR no airway intervention received but patient sustained hypoxic complication/mortality): 16.2%–70.7% vs. 3.8%, p < 0.01. Despite receipt of airway interventions at a higher rate, collectively individuals with MAs who received an airway intervention on DOL 0 or 1 have a mildly elevated risk of hypoxic complication or mortality (32.4% vs. 26.4%, p < 0.01).ConclusionsPreterm birth is more common, however, does not account for the elevated rate of airway intervention. Individuals with MAs require higher rates of medical attention, and current airway management paradigms are insufficient to prevent complications and mortality.Level of EvidenceIII Laryngoscope, 2024

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Perinatal airway management in neonatal goiter: A healthcare cost and utilization project (HCUP) kids’ inpatient database analysis

Matabele,

Cheng,

Venkatesh

et al. 2023

International Journal of Pediatric Otorhinolaryngology

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Taking the Natural Exit: Opportunities for Treatment Rightsizing in Fetal Head and Neck Mass

Cited by 3 publications

References 25 publications

Indications, Resource Allocation, and Outcomes Associated with Ex-Utero Intrapartum Treatment Procedures: A North American Fetal Therapy Network Survey

Indications, Resource Allocation, and Outcomes Associated with Ex-Utero Intrapartum Treatment Procedures: A North American Fetal Therapy Network Survey

Perinatal Airway Management Mandibular Anomalies: A National Inpatient Cohort Analysis

Perinatal airway management in neonatal goiter: A healthcare cost and utilization project (HCUP) kids’ inpatient database analysis

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