GA4-87
Modified EXIT procedure for fetal macroglossia: a challenging case of maintaining uteroplacental perfusion without the use of maternal uterine hypotonic agents.
Hendrickson M, Hendrickson M, Saab A
University of Miami, Coconut Grove, FL, USA
Introduction:
Ex-utero intrapartum treatment, the EXIT procedure, is a technique that allows for life-saving fetal interventions while maintaining utero-placental perfusion. It often involves cases of fetal airway obstruction that are detected on pre-natal imaging. Historically, many of these infants would not survive birth, or would incur a high degree of morbidity following delivery. By maintaining utero-placental perfusion, these infants can obtain life-saving interventions while avoiding hypoxia.
The technique involves partial delivery of the fetus in order to perform an intervention while remaining on placental support. In order to obtain access to the fetus without interrupting utero-placental perfusion, a high degree of maternal uterine relaxation is required. This can be achieved with titration of inhalational anesthetics to 2-3 MAC, while supplementing with uterine relaxants such as nitroglycerin. While optimal for the fetus, decreased uterine tone is not without risk to the mother. The EXIT procedure confers the possibility of large volume blood loss for the parturient.
Case description:
In our case we describe successful fetal airway intervention while maintaining utero-placental perfusion without the use of maternal hypotonic agents, due to maternal refusal of blood products. The patient’s mother is a Jehova’s witness who did not wish to accept increased risk of morbidity and mortality from potential blood loss, even if this increased the risk of morbidity and mortality in our patient. Through careful multidisciplinary preoperative preparation, we were able to coordinate a plan to allow for operation on placental support, with minimal increase in risk to the parturient.
With the support of Nursing, and Neonatology, our Anesthesia team together with our Obstetric colleagues were able to partially deliver the fetus to her shoulders while maintaining placental support without uterine relaxation. After scrubbing in to the surgical field, our ENT surgeon was able to safely secure the patient’s airway through intubation utilizing a rigid bronchoscope in under 2 minutes. Our patient maintained appropriate physiological oxygenation, while her mother avoided increased risk.
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