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Caldeira A, Pacheco J, Fernandes S, Lança F. [The multidisciplinary challenge of anesthesia for ex utero intrapartum treatment: a case report]. Rev Bras Anestesiol 2020; 70:59-62. [PMID: 32171498 DOI: 10.1016/j.bjan.2019.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 11/26/2019] [Accepted: 12/01/2019] [Indexed: 10/25/2022] Open
Abstract
The Ex- Utero Intrapartum Treatment (EXIT) is a surgical procedure performed in cases of expected postpartum fetal airway obstruction, allowing the establishment of patent airway while maintaining placental circulation. Anesthesia for EXIT procedure has several specific features such as adequate uterine relaxation, maintenance of maternal blood pressure fetal anesthesia and fetal airway establishment. The anesthesiologist should be aware of these particularities in order to contribute to a favorable outcome. This is a case report of an EXIT procedure performed on a fetus with a cervical lymphangioma with prenatal evidence of partial obstruction of the trachea and risk of post-delivery airway compromise.
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Affiliation(s)
- Alexandre Caldeira
- Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Serviço de Anestesiologia, Lisboa, Portugal.
| | - Jânia Pacheco
- Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Serviço de Anestesiologia, Lisboa, Portugal
| | - Sofia Fernandes
- Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Serviço de Anestesiologia, Lisboa, Portugal
| | - Filipa Lança
- Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Serviço de Anestesiologia, Lisboa, Portugal
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The multidisciplinary challenge of anesthesia for ex utero intrapartum treatment: a case report. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 32171498 PMCID: PMC9373562 DOI: 10.1016/j.bjane.2020.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The Ex Utero Intrapartum Treatment (EXIT) is a surgical procedure performed in cases of expected postpartum fetal airway obstruction, allowing the establishment of patent airway while maintaining placental circulation. Anesthesia for EXIT procedure has several specific features such as adequate uterine relaxation, maintenance of maternal blood pressure fetal anesthesia and fetal airway establishment. The anesthesiologist should be aware of these particularities in order to contribute to a favorable outcome. This is a case report of an EXIT procedure performed on a fetus with a cervical lymphangioma with prenatal evidence of partial obstruction of the trachea and risk of post-delivery airway compromise.
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Sasano T, Tomimatsu T, Kanagawa T, Kimura T. Neglected shoulder presentation with foetal death managed by internal podalic version with nitroglycerine and sevoflurane. J OBSTET GYNAECOL 2016; 37:111-112. [PMID: 27923287 DOI: 10.1080/01443615.2016.1239068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Tomoyuki Sasano
- a Department of Obstetrics and Gynaecology , Osaka University Graduate School of Medicine , Suita City , Osaka , Japan
| | - Takuji Tomimatsu
- a Department of Obstetrics and Gynaecology , Osaka University Graduate School of Medicine , Suita City , Osaka , Japan
| | - Takeshi Kanagawa
- a Department of Obstetrics and Gynaecology , Osaka University Graduate School of Medicine , Suita City , Osaka , Japan
| | - Tadashi Kimura
- a Department of Obstetrics and Gynaecology , Osaka University Graduate School of Medicine , Suita City , Osaka , Japan
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Byun SH, Lee SY, Hong SY, Ryu T, Kim BJ, Jung JY. Use of the GlideScope video laryngoscope for intubation during ex utero intrapartum treatment in a fetus with a giant cyst of the 4th branchial cleft: A case report. Medicine (Baltimore) 2016; 95:e4931. [PMID: 27684833 PMCID: PMC5265926 DOI: 10.1097/md.0000000000004931] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION In fetuses who are predicted to be at risk of catastrophic airway obstruction at delivery, the ex utero intrapartum treatment (EXIT) procedure is useful for securing the fetal airway while maintaining fetal oxygenation via placental circulation. Factors, including poor posture of the fetus and physician, narrow visual field, and issues of contamination in the aseptic surgical field, make fetal intubation during the EXIT procedure difficult. Herein, we report our experience of the usefulness of the GlideScope video laryngoscope (GVL) for intubation during the EXIT procedure. SYMPTOMS AND CLINICAL FINDINGS A 28-year-old woman presented with a fetus having a cystic neck mass diagnosed on prenatal ultrasound at 25 weeks of gestation. We planned the EXIT procedure in conjunction with cesarean delivery at 38 weeks of gestation, as the mass enlarged to 4.9 cm × 3.2 cm, protruded externally at the neck, and subsequently resulted in polyhydramnios. THERAPEUTIC INTERVENTION AND OUTCOMES After induction of anesthesia using intravenous thiopental (300 mg), adequate uterine relaxation was achieved with sevoflurane (2.0-3.0 vol%) combined with continuous intravenous infusion of nitroglycerin (0.5-1.0 μg/kg/min) for maintaining uteroplacental circulation. After hysterotomy, the head and right upper limb of the fetus were partially delivered, and fetal heart tones were monitored with a sterile Doppler probe. After oropharyngeal suctioning to improve the visual field, the fetus was intubated successfully using a sterile GVL by an anesthesiologist, and the passage of the endotracheal tube beyond the vocal cords was confirmed on the screen of the GVL system. Immediately after the fetal airway was definitely secured, the fetus was fully delivered with umbilical cord clamping. After delivery, nitroglycerine administration was ceased and sevoflurane administration was reduced to 0.5 minimum alveolar concentration. Additionally, oxytocin (10 units) and carbetocin (100 μg) were administered for recovery of uterine contraction. Cesarean delivery was successfully performed without any problems, and the neonate successfully underwent surgery for removal of the neck mass under general anesthesia on the 7th day after delivery. The neonate is developing normally. CONCLUSION The GVL approach may be a useful noninvasive approach for establishing a clear fetal airway during the EXIT procedure.
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Affiliation(s)
| | | | - Seong Yeon Hong
- Department of Obstetrics and Gynecology, School of Medicine, Catholic University of Daegu, Daegu, Republic of Korea
| | - Taeha Ryu
- Department of Anesthesiology and Pain Medicine
| | | | - Jin Yong Jung
- Department of Anesthesiology and Pain Medicine
- Correspondence: Jin Yong Jung, Department of Anesthesiology and Pain Medicine, School of Medicine, Catholic University of Daegu, 33, Duryugongwon-ro 17-gil, Nam-gu, Daegu 42472, Republic of Korea (e-mail: )
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Oliveira E, Pereira P, Retroz C, Mártires E. Anestesia para procedimento EXIT (tratamento extraútero intraparto) em malformação congênita cervical – um desafio para o anestesiologista. Braz J Anesthesiol 2015; 65:529-33. [DOI: 10.1016/j.bjan.2015.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Accepted: 07/22/2013] [Indexed: 12/20/2022] Open
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Oliveira E, Pereira P, Retroz C, Mártires E. Anesthesia for EXIT procedure (ex utero intrapartum treatment) in congenital cervical malformation--a challenge to the anesthesiologist. Braz J Anesthesiol 2015; 65:529-33. [PMID: 26614154 DOI: 10.1016/j.bjane.2013.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Accepted: 07/22/2013] [Indexed: 12/20/2022] Open
Abstract
The ex utero intrapartum treatment (EXIT) procedure consists of partial externalization of the fetus from the uterine cavity during delivery, allowing the maintenance of placental circulation. It is indicated in the presence of congenital malformation when difficulty in fetal airway access is anticipated, allowing it to be ensured by direct laryngoscopy, bronchoscopy, tracheostomy, or surgical intervention. Anesthesia for EXIT procedure has several special features, such as the appropriate uterine relaxation, maintenance of maternal blood pressure, fetal airway establishment, and maintenance of postpartum uterine contraction. The anesthesiologist should be prepared for the anesthetic particularities of this procedure in order to contribute to a favorable outcome for the mother and particularly the fetus.
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Affiliation(s)
- Elsa Oliveira
- Department of Anesthesiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Paula Pereira
- Department of Anesthesiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Carla Retroz
- Department of Anesthesiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Emília Mártires
- Department of Anesthesiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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Abstract
The diagnosis of a gynecological malignancy during pregnancy is rare but not uncommon. Cancer treatment during pregnancy is possible, but both maternal and fetal interests need to be respected. Different treatment plans may be justifiable and multidisciplinary treatment is advised. Clinical trials are virtually impossible, and current evidence is mainly based on small case series and expert opinion. Individualization of treatment is necessary and based on tumor type, stage, and gestational age at time of diagnosis. Termination of pregnancy is not necessary in most cases. Surgery and chemotherapy (second trimester and onwards) are possible types of treatment during pregnancy. Radiotherapy of the pelvic area is not compatible with an ongoing pregnancy. This article discusses the current recommendations for the management of gynecological malignancies (cervical, ovarian, and vulvar cancers) during pregnancy.
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Abstract
The scope of obstetric anesthesia practice ranges far beyond the delivery of care to women for vaginal and cesarean deliveries. Increasingly, obstetric anesthesiologists are involved in the management of anesthetics for new procedures and for new indications. Anesthesia is frequently needed for maternal procedures, as well as fetal procedures, and at varying times in the intrapartum period. Maternal-specific procedures include cerclage, external cephalic version (ECV), postpartum bilateral tubal ligation (BTL), and dilation and evacuation (D and E). Fetus-specific procedures include fetoscopic laser photocoagulation and ex-utero intrapartum treatment (EXIT). This review will not include discussion of the anesthetic management of non-obstetric surgery during pregnancy, such as appendectomy or cholecystectomy.
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Affiliation(s)
- Jaime Aaronson
- Division of Obstetric Anesthesiology, Department of Anesthesiology, Columbia University, 630 W 168th St, P & S Box 46, New York, NY, 10032
| | - Stephanie Goodman
- Division of Obstetric Anesthesiology, Department of Anesthesiology, Columbia University, 630 W 168th St, P & S Box 46, New York, NY, 10032.
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Ex utero intrapartum treatment procedure for management of congenital high airway obstruction syndrome in a vertex/breech twin gestation. Int J Pediatr Otorhinolaryngol 2013; 77:439-42. [PMID: 23260572 DOI: 10.1016/j.ijporl.2012.11.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Revised: 11/10/2012] [Accepted: 11/17/2012] [Indexed: 11/20/2022]
Abstract
Congenital high airway obstruction syndrome (CHAOS) is one indication for the ex utero intrapartum treatment (EXIT), which is used to secure the fetal airway, while fetal oxygenation is maintained by uteroplacental circulation. We report a successful EXIT procedure in a twin gestation in which one child had CHAOS while the other was a healthy child without any congenital abnormalities. After version of Twin B to allow for delivery of Twin A, Twin B underwent airway evaluation and tracheostomy for laryngeal atresia prior to delivery.
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Kuczkowski KM. Towards state-of-the-art anesthesia for fetal surgery: obstacles and opportunities. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2013; 60:3-6. [PMID: 22935762 DOI: 10.1016/j.redar.2012.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 07/10/2012] [Indexed: 06/01/2023]
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Bellieni CV, Tei M, Stazzoni G, Bertrando S, Cornacchione S, Buonocore G. Use of fetal analgesia during prenatal surgery. J Matern Fetal Neonatal Med 2012; 26:90-5. [PMID: 22881840 DOI: 10.3109/14767058.2012.718392] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Recent progresses in fetal surgery have raised concern on fetal pain, its long-term consequences and the risks of sudden fetal movements induced by pain. In several studies, surgeons have directly administered opioids to the fetus, while others have considered sufficient the maternally administered analgesics. We performed a review of the literature to assess the state of the art. METHODS We performed a PubMed search to retrieve the papers that in the last 10 years reported studies of human fetal surgery and that described whether any fetal analgesia was administered. RESULTS We retrieved 34 papers. In three papers, the procedure did not hurt the fetus, being performed on fetal annexes, in two papers, it was performed in the first half of pregnancy, when pain perception is unlikely. In 10 of the 29 remaining papers, fetal surgery was performed using direct fetal analgesia, while in 19, analgesia was administered only to the mother. In most cases, fetal direct analgesia was obtained using i.m. opioids, and muscle relaxant. Rare drawbacks on either fetuses or mothers due to fetal analgesia were reported. CONCLUSION Fetal direct analgesia is performed only in a minority of cases and no study gives details about fetal reactions to pain. More research is needed to assess or exclude its possible long-term drawbacks, as well as the actual consequences of pain during surgery.
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Remifentanil for fetal immobilization and analgesia during the ex utero intrapartum treatment procedure under combined spinal–epidural anaesthesia †. Br J Anaesth 2011; 106:851-5. [DOI: 10.1093/bja/aer097] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Lee H, Ryu JW, Kim DY, Lee GY. Anesthetic management of the ex utero intrapartum treatment (EXIT) procedure -A case report-. Korean J Anesthesiol 2010; 59 Suppl:S154-7. [PMID: 21286428 PMCID: PMC3030024 DOI: 10.4097/kjae.2010.59.s.s154] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 05/24/2010] [Accepted: 06/05/2010] [Indexed: 11/10/2022] Open
Abstract
The ex utero intrapartum treatment (EXIT) procedure is a very rare technique performed in cases of fetal congenital malformations. The EXIT procedure increases the rate of survival at delivery by maintaining the uteroplacental circulation until the airway of the fetus is secured. To maintain the uteroplacental circulation, a higher dose of inhalational anesthetics and/or intravenous nitroglycerin can be used as compared to conventional Cesarean section. The aim of this report is to share our anesthetic experience during the EXIT procedure with members of the Korean society of anesthesiology for the first time, and to highlight the maternal implications of the use of inhalational anesthetics and nitroglycerin during Cesarean section for the EXIT procedure.
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Affiliation(s)
- Heeseung Lee
- Department of Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
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Butwick A, Aleshi P, Yamout I. Obstetric hemorrhage during an EXIT procedure for severe fetal airway obstruction. Can J Anaesth 2009; 56:437-42. [PMID: 19396506 DOI: 10.1007/s12630-009-9092-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Revised: 03/03/2009] [Accepted: 03/05/2009] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To report a case of massive obstetric hemorrhage occurring during Cesarean delivery for an ex utero intrapartum treatment (EXIT) procedure. Methods to optimize the anesthetic, obstetric, and perinatal management are discussed. CLINICAL FEATURES A healthy parturient underwent an urgent EXIT procedure at 32 weeks gestation for a giant fetal neck mass. During the intraoperative period, severe intraoperative hemorrhage occurred from the site of the uterine incision. No evidence of placental bleeding, premature placental separation, or inadequate uterine relaxation was observed during the perioperative period. Placement of a uterine stapling device was unsuccessful in achieving adequate surgical hemostasis. Initial attempts with laryngoscopy and rigid bronchoscopy to secure the fetal airway on placental support were unsuccessful, and early termination of placental support was deemed necessary due to the severity of maternal blood loss. After full delivery of the neonate and termination of placental support, neonatal ventilation with bag-mask ventilation was achieved and successful endotracheal intubation occurred during repeat bronchoscopy. CONCLUSIONS The risk of obstetric hemorrhage due to uterine relaxation and inadequate surgical hemostasis in patients undergoing EXIT procedures is poorly reported. To reduce adverse maternal and neonatal outcomes, the premature termination of placental support during EXIT procedures may be required in the setting of severe obstetric hemorrhage.
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Affiliation(s)
- Alexander Butwick
- Department of Anesthesia (MC:5640), Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.
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Eivazi B, Ardelean M, Bäumler W, Berlien HP, Cremer H, Elluru R, Koltai P, Olofsson J, Richter G, Schick B, Werner JA. Update on hemangiomas and vascular malformations of the head and neck. Eur Arch Otorhinolaryngol 2008; 266:187-97. [PMID: 19052764 DOI: 10.1007/s00405-008-0875-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2008] [Accepted: 11/10/2008] [Indexed: 12/19/2022]
Abstract
Although the current classification systems of vascular malformations and hemangiomas are increasingly accepted, there are nonetheless several aspects that show us how special and at the same time difficult it is to diagnose, evaluate, and treat some of those diseases. Close interdisciplinary cooperation of all involved disciplines is essential; the discussion of the adequate individual procedure must be performed in angioma boards, as it is already well established in the context of tumor boards. The interface of angioma therapy and tumor therapy seems to be very close, which is certainly true for the aspect of angiogenesis and of course for the inhibited proliferation as promising therapeutic approach of complex vascular malformations. This leads to another obvious necessity of intensifying experimental scientific research on vascular malformations and hemangiomas, which is a precondition for optimizing or elimination of different current problems and deficits in the mentioned field.
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Affiliation(s)
- Behfar Eivazi
- Department of Otolaryngology, Head and Neck Surgery, Philipps University of Marburg, Deutschhausstr. 3, 35037 Marburg, Germany
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Ahn J, Kim JK, Yang M. Ex utero intrapartum treatment (EXIT) for fetal intubation with giant neck mass - A case report -. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2008.55.4.519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jihyun Ahn
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Kyoung Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mikyung Yang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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