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Eshiba SM, Zahran MH, Elnekeidy AM, Abdeldayem TM, Hassan HHM. Added value of fetal MRI as a complementary method to antenatal ultrasound in the assessment of non-CNS fetal congenital anomalies. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2022. [DOI: 10.1186/s43055-022-00708-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Birth defects and congenital anomalies are different words used to describe developmental abnormalities that occur at birth. Congenital anomalies diagnosis during pregnancy is a difficult topic to which ultrasonography has made significant contributions. The availability of a generally safe, independent technique in the evaluation of prenatal anomalies would be a welcomed clinical and scientific alternative. Ultrasound (US) is the predominant modality for evaluating disorders related to fetus and pregnancy. In most situations, this examination by a professional operator offers sufficient information about fetal morphology, surroundings, and well-being. The abnormalities revealed by ultrasound can be subtle or inconclusive at times. MRI has been demonstrated to be useful in such circumstances in various studies. So the effective use of fetal MRI in the evaluation of non-CNS abnormalities of the body is a reason for adopting fetal MRI as an adjunct to US in obstetric imaging. This study aimed to examine the role of fetal MRI as a complementary method to the antenatal US in assessing non-CNS anomalies and how it changed or modified the diagnosis of anomalies.
Results
By analyzing the data of 30 pregnant females with fetal non-CNS congenital anomalies, the diagnostic accuracy of prenatal ultrasound alone in the detection of congenital anomalies was 76%, with a sensitivity of about 76%. And diagnostic accuracy of MRI alone was 96.6%, with a sensitivity of approximately 96.6%. Moreover, the diagnostic accuracy of combined prenatal US and prenatal MRI in the detection of congenital anomalies was 100%, with sensitivity about 100% and PPV about 100%.
Conclusion
Fetal MRI raises confidence in non-CNS malformation assessment. Compared to US, MRI overcomes many of the obstacles faced by the antenatal US. MRI is superior to the US in refining, changing, or adding more diagnostic information about the disease.
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Ex utero intrapartum technique (EXIT): Indications, procedure methods and materno-fetal complications - A literature review. J Gynecol Obstet Hum Reprod 2021; 51:102252. [PMID: 34638008 DOI: 10.1016/j.jogoh.2021.102252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/24/2021] [Accepted: 10/06/2021] [Indexed: 12/23/2022]
Abstract
A congenital malformation of the head, neck or thorax can lead to upper airway compression with a risk of asphyxia or neonatal death. To secure and protect the upper airway, the Ex Utero Intrapartum Therapy (EXIT) procedure has been developed. The procedure allows delivery of the fetus via a hysterotomy while relying on the placenta as the organ of respiration for the fetus prior to clamping of the umbilical cord. A high level of expertise is necessary for successful completion of the EXIT procedure, which is not void of maternal and fetal risks. In this literature review, we present the indications, procedure methods and materno-fetal complications associated with the EXIT procedure.
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Barrette LX, Morales CZ, Oliver ER, Gebb JS, Feygin T, Lioy J, Howell LJ, Hedrick HL, Jackson OA, Adzick NS, Javia LR. Risk factor analysis and outcomes of airway management in antenatally diagnosed cervical masses. Int J Pediatr Otorhinolaryngol 2021; 149:110851. [PMID: 34311168 DOI: 10.1016/j.ijporl.2021.110851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/01/2021] [Accepted: 07/20/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE To investigate antenatally-determined imaging characteristics associated with invasive airway management at birth in patients with cervical masses, as well as to describe postnatal management and outcomes. STUDY DESIGN A retrospective analysis of 52 patients with antenatally diagnosed neck masses was performed using single-center data from January 2008 to January 2019. Antenatal imaging, method of delivery, management, and outcomes data were abstracted from the medical record and analyzed. RESULTS Antenatal diagnosis of neck masses in this cohort consisted of 41 lymphatic malformations (78.8%), 6 teratomas (11.5%), 3 hemangiomas (5.8%), 1 hemangioendothelioma (1.9%), and 1 giant foregut duplication cyst (1.9%). Mean gestational age at time of diagnostic imaging was 29 weeks 3 days (range: 19w4d - 37w). Overall, 22 patients (42.3%) required invasive airway management at birth, specifically 18 patients (34.6%) required endotracheal intubation and 4 (7.7%) required tracheostomy. 15 patients (28.8%) underwent ex-utero intrapartum treatment (EXIT) for the purposes of securing an airway. Polyhydramnios, tracheal deviation and compression, and anterior mass location on antenatal imaging were significantly associated with incidence of invasive airway intervention at birth, EXIT procedure, and tracheostomy during the neonatal hospitalization (p < 0.025; Fisher's exact test). Logistic regression analysis demonstrated statistically significant association between increasing antenatally-estimated mass volume and incidence of invasive airway management at birth (p = 0.02). Post-natal cervical mass management involved surgical excision (32.7%), sclerotherapy (50%), and adjuvant therapy with rapamycin (17.3%). Demise in the neonatal period occurred in 4 (7.7%) patients. CONCLUSION This series documents the largest single-center experience of airway management in antenatally diagnosed cervical masses. Fetal imaging characteristics may help inform the appropriate method of delivery, airway management strategy at birth, and prenatal counseling.
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Affiliation(s)
- Louis-Xavier Barrette
- Division of Otolaryngology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Carrie Z Morales
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Leonard and Madlyn Abramson Pediatric Research Center, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Edward R Oliver
- Department of Radiology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Juliana S Gebb
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Tamara Feygin
- Department of Radiology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Janet Lioy
- Division of Neonatology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Lori J Howell
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Holly L Hedrick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Oksana A Jackson
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Leonard and Madlyn Abramson Pediatric Research Center, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - N Scott Adzick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Luv R Javia
- Division of Otolaryngology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
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Novoa RH, Quintana W, Castillo-Urquiaga W, Ventura W. EXIT (ex utero intrapartum treatment) surgery for the management of fetal airway obstruction: A systematic review of the literature. J Pediatr Surg 2020; 55:1188-1195. [PMID: 32151401 DOI: 10.1016/j.jpedsurg.2020.02.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 11/24/2019] [Accepted: 02/11/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE To provide a comprehensive overview of the perinatal and maternal outcomes of fetuses undergoing EXIT surgery for the management of fetal airway obstruction secondary to cervical or oral tumors. METHODS A comprehensive search from inception to September 2018 was conducted on databases including MEDLINE, EMBASE, Cochrane Library and LILACS. All studies that reported an EXIT surgery in singleton were considered eligible. A descriptive analysis was performed. RESULTS Out of the 250 full-text study reports, 120 articles reporting 235 cases of EXIT surgery were included. EXIT surgery was performed at 35.1 weeks of gestation on average. The most frequent diagnosis was teratoma (46.4%, n = 109/235). There were 13 adverse maternal events, and the most frequent one was postpartum hemorrhage (4.7%, n = 11/235). No maternal death was reported. Fetal and neonatal death occurred in 17% (40/235) of the cases. There were 29 adverse fetal events (12.2%), and the most frequent one was the failure of intubation or tracheostomy (3.4%, n = 8/235). CONCLUSION EXIT surgery could be considered for the management of an oral or cervical tumor that's highly suspicious of blocking the fetal airway. This systematic review reports that EXIT surgery poses substantial risks of maternal and fetal adverse events, including neonatal death. LEVEL OF EVIDENCE IV case series with no comparison group.
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Affiliation(s)
- Rommy H Novoa
- Resident trainee in Ob/Gyn Department of Obstetrics and Gynecology, InstitutoNacional Materno Perinatal, Lima, Peru; Faculty of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Willy Quintana
- Resident trainee in Ob/Gyn Department of Obstetrics and Gynecology, InstitutoNacional Materno Perinatal, Lima, Peru; Faculty of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | | | - Walter Ventura
- Fetal Medicine Unit, Instituto Nacional Materno Perinatal, Lima, Peru; Fetal Medicine Unit, Clinica Delgado, Grupo AUNA, Lima, Peru.
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Jiang S, Yang C, Bent J, Yang CJ, Gangar M, Nassar M, Suskin B, Dar P. Ex utero intrapartum treatment (EXIT) for fetal neck masses: A tertiary center experience and literature review. Int J Pediatr Otorhinolaryngol 2019; 127:109642. [PMID: 31479918 DOI: 10.1016/j.ijporl.2019.109642] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 07/17/2019] [Accepted: 08/09/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Currently no established criteria exist to guide use of ex utero intrapartum treatment (EXIT) for fetal neck mass management. This study aims to correlate prenatal radiographic findings with incidence of ex utero intrapartum treatment and necessity of airway intervention at delivery. METHODS We reviewed our EXIT experience between 2012 and 17. Furthermore, we performed a literature review of articles reporting incidences of fetal neck masses considered for EXIT. Articles that were included (1) discussed prenatal radiographic findings such as size, features, and evidence of compression and (2) reported extractable data on delivery outcomes and airway status. RESULTS Ten cases at our institution were reviewed. Another 137 cases across 81 studies met inclusion criteria. These studies showed aerodigestive tract compression to be significantly associated with neck masses undergoing EXIT. Additionally, there was significantly higher incidence of airway intervention in cases where polyhydramnios, anatomic compression, and solid masses were seen on prenatal diagnostic imaging, while mass location and size did not correlate with airway intervention. CONCLUSION With this data, we propose that any neck mass with anatomic compression on fetal imaging in the 3rd trimester should be considered for EXIT. When radiographic findings do not show compression but do display polyhydramnios or a solid neck mass (regardless of polyhydramnios), an airway surgeon should be available for perinatal airway assistance.
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Affiliation(s)
- Sydney Jiang
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA; Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA.
| | - Catherina Yang
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - John Bent
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Christina J Yang
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Mona Gangar
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Michel Nassar
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Barrie Suskin
- Department of Obstetrics and Gynecology, Stamford Hospital, One Hospital Plaza, Whittingham Pavilion, Stamford, CT, 06902, USA
| | - Peer Dar
- Division of Fetal Medicine and OB-Gyn Ultrasound, Albert Einstein College of Medicine / Montefiore Medical Center, 1695 Eastchester Road Room L4, Bronx, NY, 10461, USA
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Gonzales SK, Goudy S, Prickett K, Ellis J. EXIT (ex utero intrapartum treatment) in a growth restricted fetus with tracheal atresia. Int J Pediatr Otorhinolaryngol 2018; 105:72-74. [PMID: 29447823 DOI: 10.1016/j.ijporl.2017.12.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 12/04/2017] [Accepted: 12/06/2017] [Indexed: 10/18/2022]
Abstract
Congenital high airway obstruction syndrome (CHAOS) encompasses a heterogeneous group of pathologies leading to poor lung development and difficulty oxygenating the newborn after delivery. While previously uniformly fatal, the ex utero intrapartum therapy (EXIT) procedure has provided a method to treat these patients and provide an airway to potentiate survival. We present a patient diagnosed prenatally with CHAOS secondary to tracheal atresia complicated by severe intra-uterine growth restriction (IUGR) who was successfully delivered via an EXIT procedure at 33-weeks. Multidisciplinary care and planning is paramount.
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Affiliation(s)
- S Kyle Gonzales
- Division of Maternal Fetal Medicine, Emory University, Atlanta, GA, USA.
| | - Steven Goudy
- Division of Otolaryngology, Head & Neck Surgery, Emory University, Atlanta, GA, USA
| | - Kara Prickett
- Division of Otolaryngology, Head & Neck Surgery, Emory University, Atlanta, GA, USA
| | - Jane Ellis
- Division of Maternal Fetal Medicine, Emory University, Atlanta, GA, USA
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Abstract
Fetal MRI is a level III diagnostic tool performed subsequently a level II prenatal ultrasound (US), in cases of inconclusive ultrasonographic diagnosis or when a further investigation is required to confirm or improve the diagnosis, to plan an appropriate pregnancy management. Fetal MRI plays an increasingly important role in the prenatal diagnosis of fetal neck, chest and abdominal malformations, even if its role has been amply demonstrated, especially, in the field of fetal CNS anomalies. Due to its multiparametricity and multiplanarity, MRI provides a detailed evaluation of the whole fetal respiratory, gastrointestinal and genitourinary systems, especially on T2-weighted (W) images, with a good tissue contrast resolution. In the evaluation of the digestive tract, T1-W sequences are very important in relation to the typical hyperintensity of the large intestine, due to the presence of meconium. The objective of this review is to focus on the application of fetal MRI in neck, chest and abdominal diseases.
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Zhao C, Anicete R, Tan H. Management of airway obstruction in two cases of head and neck teratoma. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.pedex.2016.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Cervical teratomas are rare germ cell tumors affecting the fetus that are associated with significant morbidity and mortality due to an increased risk of airway obstruction at delivery. These tumors can commonly produce polyhydramnios that results from the fetus' impaired ability to swallow amniotic fluid. Improved rates of prenatal diagnosis through comprehensive evaluations and imaging have dramatically impacted the perinatal management of infants with this condition. Here, we report a patient diagnosed with polyhydramnios whose fetus was discovered to have a giant cervical teratoma on imaging studies. The child underwent surgical resection after having the airway secured under the uteroplacental support as part of an ex utero intrapartum treatment procedure performed at 37 weeks. The following gross pathological and magnetic resonance images demonstrate this condition and its currently accepted treatment.
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Moreddu E, Pereira J, Vaz R, Lena G, Triglia JM, Nicollas R. Combined endonasal and neurosurgical resection of a congenital teratoma with pharyngeal, intracranial and orbital extension: Case report, surgical technique and review of the literature. Int J Pediatr Otorhinolaryngol 2015; 79:1991-4. [PMID: 26590006 DOI: 10.1016/j.ijporl.2015.10.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 10/28/2015] [Accepted: 10/29/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study reports a patient with a large teratoma involving the oropharynx, the nasopharynx and the left orbit, with intracranial extension. This case represents one of the first reported instances of such an association. A literature review reporting head and neck teratomas with intracranial involvement is also presented. CASE REPORT The authors describe a case of a neonate presenting with a huge teratoma causing respiratory distress due to upper airway obstruction. The child was operated on at 3 months of age with a combined neurosurgical and endonasal endoscopic-assisted approach. After more than 1-year follow-up, the child has no recurrence and no complications of surgery. DISCUSSION This type of teratoma is very rare and surgical morbidity is common. The diagnosis may be apparent before birth, which will facilitate the planning of respiratory management. The combined neurosurgical and otolaryngologic approach for a neonatal teratoma has not previously been described. Using an endoscopic-assisted approach for intranasal tumors removal in neonates and infants is a very rare surgical challenge. CONCLUSION Large nasopharyngeal teratomas of infancy with sinonasal and intracranial extension may be managed using a combined endoscopic-assisted endonasal and neurosurgical procedure.
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Affiliation(s)
- Eric Moreddu
- Department of Pediatric Otolaryngology, Head and Neck Surgery, La Timone Children's Hospital, Aix-Marseille University, 264 rue Saint Pierre, F-13385 Marseille Cedex 5, France.
| | - Josue Pereira
- Department of Neurosurgery, Hospital S João, Porto, Portugal.
| | - Rui Vaz
- Department of Neurosurgery, Hospital S João, Porto, Portugal.
| | - Gabriel Lena
- Department of Pediatric Neurosurgery, La Timone Children's Hospital, Aix-Marseille University, 264 rue Saint Pierre, F-13385 Marseille Cedex 5, France.
| | - Jean-Michel Triglia
- Department of Pediatric Otolaryngology, Head and Neck Surgery, La Timone Children's Hospital, Aix-Marseille University, 264 rue Saint Pierre, F-13385 Marseille Cedex 5, France.
| | - Richard Nicollas
- Department of Pediatric Otolaryngology, Head and Neck Surgery, La Timone Children's Hospital, Aix-Marseille University, 264 rue Saint Pierre, F-13385 Marseille Cedex 5, France.
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Walz PC, Schroeder JW. Prenatal diagnosis of obstructive head and neck masses and perinatal airway management: the ex utero intrapartum treatment procedure. Otolaryngol Clin North Am 2014; 48:191-207. [PMID: 25442130 DOI: 10.1016/j.otc.2014.09.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Advances in prenatal imaging in the last 20 years have enabled prenatal diagnosis of obstructive head and neck masses. These advances, coupled with improvements in maternal-fetal anesthesia, have made possible the development of the ex utero intrapartum treatment (EXIT) procedure for management of obstructive head and neck masses, during which the airway is managed in a controlled fashion while maintaining fetal circulation for oxygenation. This review addresses the preoperative and perioperative assessment and management of patients with prenatally diagnosed airway obstruction, indications and contraindications for the EXIT procedure, technical details of the procedure, and outcomes.
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Affiliation(s)
- Patrick C Walz
- Department of Pediatric Otolaryngology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL 60611-2991, USA
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Taghavi K, Beasley S. The ex utero intrapartum treatment (EXIT) procedure: application of a new therapeutic paradigm. J Paediatr Child Health 2013; 49:E420-7. [PMID: 23662685 DOI: 10.1111/jpc.12223] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2012] [Indexed: 12/15/2022]
Abstract
The ex utero intrapartum treatment (EXIT) procedure is a term given to a technique that can transform a potentially fatal neonatal emergency to a controlled intervention with an improved outcome. It has revolutionised the care of prenatally diagnosed congenital malformations in which severe upper airway obstruction is anticipated. An extended period of utero-placental circulation can be utilised to avoid profound cardiopulmonary compromise. Its therapeutic applications have been broadened to include fetuses with congenital diaphragmatic hernia after tracheal plugging, high-risk intrathoracic masses, severe cardiac malformations and conjoined twins. It requires the co-ordination of a highly skilled and experienced multidisciplinary team. The recent enthusiasm for the EXIT procedure needs to be balanced against maternal morbidity. Specific indications and guidelines are likely to be refined as a consequence of ongoing advances in fetal intervention and antenatal imaging.
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