Maternal anesthesia for EXIT procedure: A systematic review of literature

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Abstract

The ex utero intrapartum treatment (EXIT) procedure is performed in cases of fetal congenital malformation. The anesthetic management is much more challenging and involves providing profound uterine relaxation, maintenance of Uteroplacental blood flow and fetal anesthesia. The aim of the article is to review the literature and compare the efficacy of both the anesthetic techniques with respect to maternal and fetal outcomes. The literature source for this review was obtained via PubMed, Medline, Google scholar and Cochrane database of systematic reviews until January 2017. In our literature review we found that both GA and Regional anesthesia were successfully described for EXIT procedure but GA was performed in the majority of cases. Consideration for anesthetic technique should be done on a case-by-case basis.

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Most cited references 44

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The EXIT procedure: experience and outcome in 31 cases.

Timothy M. Crombleholme, M. Johnson, Damien S Bouchard … (2002)

The EXIT (ex utero intrapartum treatment) procedure, although initially designed for reversal of tracheal occlusion in fetuses with congenital diaphragmatic hernias (CDH), has been adapted to treat a variety of fetal conditions. A retrospective chart review of all consecutive EXIT procedures since 1996 was conducted. Thirty-one women underwent the EXIT procedure, with an average maternal age of 29 years (range, 20 to 38), and average gestational age of 34 weeks (range, 29 to 40). The indication was airway obstruction from fetal neck mass in 13, and reversal of tracheal occlusion from in utero clipping in 13. Singular indications included an EXIT-to-ECMO (extracorporeal membrane oxygenation) procedure for a fetus with CDH and a cardiac defect (n = 1), congenital high airway obstruction syndrome (CHAOS, n = 1), resection of a very large congenital cystic adenomatoid malformation of the lung (CCAM) on uteroplacental bypass (n = 1), unilateral pulmonary agenesis (n = 1), and thoracoomphalopagus conjoined twins. The mean duration on uteroplacental bypass (from uterine incision to umbilical cord clamping) was 30.3 plus minus 14.7 minutes (range, 8 to 66). No fetus experienced hemodynamic instability during uteroplacental bypass as recorded by fetal heart rate (FHR), pulse oximeter, and fetal echocardiography, except for one instance of reversible bradycardia from umbilical cord compression. The mean FHR and fetal saturation were 153.0 plus minus 38.5 beats per minute and 71.2% plus minus 19.9%, respectively. Five fetuses required a tracheostomy. Only 1 death occurred during an EXIT procedure because of inability to secure the airway secondary to extensive involvement by a lymphangioma. The average cord pH and pCO(2) were, respectively, 7.20 plus minus 0.11 and 63.2 plus minus 14.6. Two maternal complications occurred: bleeding from a hysterotomy site and dehiscence of an old hysterotomy scar noticed at a subsequent cesarean section. The average maternal blood loss was 848.3 plus minus 574.1 mL. The EXIT procedure was used successfully to ensure uteroplacental gas exchange and fetal hemodynamic stability during a variety of surgical procedures performed to secure the fetal airway or ensure successful transition to postnatal environment. Copyright 2002 by W.B. Saunders Company.

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Operating on placental support: the ex utero intrapartum treatment procedure.

G B Mychaliska, J F Bealer, J L Graf … (1997)

While treating eight fetuses with predictable airway obstruction, the authors developed a systematic approach, the ex utero intrapartum treatment procedure, to secure the airway during delivery. Six patients had their trachea plugged or clipped in utero for treatment of congenital diaphragmatic hernia, and two patients had prenatally diagnosed cystic hygroma of the neck and oropharynx. The ex utero intrapartum treatment procedure was performed by using high doses of inhaled halogenated agents to facilitate uterine relaxation during cesarean section, securing the fetal airway while feto-placental circulation remained intact, and then dividing the umbilical cord. A variety of procedures were performed during the ex utero intrapartum treatment procedure including bronchoscopy, orotracheal intubation, tracheostomy, tracheostomy with retrograde orotracheal intubation, tracheoplasty, removal of internal tracheal plug, removal of external tracheal clip, central line placement, and instillation of surfactant. There were minimal maternal or fetal complications during the procedure. This approach requires the coordinated efforts of pediatric surgeons, obstetricians, anesthesiologists, sonographers, and neonatologists. The combination of intensive maternal-fetal monitoring, cesarean section with maximal uterine relaxation, and maintenance of intact feto-placental circulation provides a controlled environment for securing the airway in babies with prenatally diagnosed airway obstruction.

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Ex-utero intrapartum treatment procedure for giant neck masses--fetal and maternal outcomes.

David Lazar, Oluyinka O. Olutoye, Kenneth Moise … (2011)

For fetuses with giant neck masses and tracheal obstruction, an ex-utero intrapartum treatment (EXIT) procedure allows for safe nonemergent airway management while on placental support. Our objective was to examine fetal and maternal outcomes after EXIT procedure specifically for giant neck masses.

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Journal

Journal ID (nlm-ta): J Anaesthesiol Clin Pharmacol

Journal ID (iso-abbrev): J Anaesthesiol Clin Pharmacol

Journal ID (publisher-id): JOACP

Title: Journal of Anaesthesiology, Clinical Pharmacology

Publisher: Wolters Kluwer - Medknow (India )

ISSN (Print): 0970-9185

ISSN (Electronic): 2231-2730

Publication date (Print): Jan-Mar 2019

Volume: 35

Issue: 1

Pages: 19-24

Affiliations

[1]Department of Anesthesia, Schulich School of Medicine, Western University, London, ON, Canada

Author notes

Address for correspondence: Dr. Kamal Kumar, Department of Anesthesia, Schulich School of Medicine, Western University, London, ON, Canada. E-mail: drkamalcmc@ 123456gmail.com

Article

Publisher ID: JOACP-35-19

DOI: 10.4103/joacp.JOACP_302_17

PMC ID: 6495613

PubMed ID: 31057234

SO-VID: f9d0b816-6ec0-47db-bc89-ad2f5b62fd55

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This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Maternal anesthesia for EXIT procedure: A systematic review of literature

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Irish Journal of Paramedicine

Most cited references 44

The EXIT procedure: experience and outcome in 31 cases.

Operating on placental support: the ex utero intrapartum treatment procedure.

Ex-utero intrapartum treatment procedure for giant neck masses--fetal and maternal outcomes.

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