INTRODUCTION

CASE

DISCUSSION

REFERENCES

1. Maternal Fetal Medicine Consultant e-mail: guillermoireyes@gmail.com. 2. Obstetrics and gynaecology Consultant. 3. Neonatology Consultant. 4. Anaesthesiology Consultant. 5. Paediatric Surgery Consultant. 6. Scientific Director of CPO

Centro Policlinico del Olaya (CPO)-Bogotá, ColombiaG. Reyes1, R. Duque2, C. Rojas3, A. Romero4, B. Narvaez5, R. Herrera6

Safe surgery checklist in an EXIT procedure for a foetus with a giant neck mass.

The ex utero intrapartum treatment (EXIT) is procedure for maintaining utero-placental circulation during caesarean section to guaranty new-born air way in a potentially obstructed fetal airway1,2.  The EXIT procedure is an elective caesarean section, which the foetus is only partially delivered from the uterus with maintenance of the utero-placental circulation allowing for diagnostic and/or therapeutic procedures to the fetal airway. The foetus has been anesthetized and when the airway is secured the foetus is delivered and the umbilical cord clamped. . A complete uterine relaxation by deep volatile anaesthesia in needed and uterine volume must be preserved by the foetus and warmed Ringer’s lactate solution infused into the uterine cavity1,3,4,5 . In order to maintain the uteroplacental blood flow, maternal cardiac output and blood pressure have to be kept at acceptable levels6,7.  Main prerequisites during the EXIT procedure include a multidisciplinary coordinated team so we applied the WHO criteria and a check list was performed8,9. We organized a preliminary drill to prepare the final EXIT. Finally, the EXIT was performed including a team of 20 people inside the operating theater.

A 25-year-old primigravida patient, at 22 weeks during the anomaly scan has been detected a 60 mm foetal neck cystic mass in the left side. Its extension inside the fetal face was not clear, no other fetal malformations were detected. A fetal cervical cystic teratoma or cystic lymphangioma was diagnosed and we continued other diagnostic procedures. Fetal echocardiogram and neurosonography showed no other malformations. Fetal karyotype in amniotic fluid was normal 47 xy. Fetal growth was followed at 28, 32 and 36 weeks and the foetus was growing in a normal range, polihydramnios was not showed. At 34 week a fetal MRI was performed and the neck mass was extended to the fetal pharynx in the midline. Because there was risk of congenital high airway obstruction syndrome (CHAOS) an elective EXIT procedure was performed at 38 weeks. A successful EXIT procedure was performed and a male new-born 3630 gr., 52 cm, Ballard 38 weeks was born. The intubated new-born was moved to the NICU. MRI was very consistent with the prenatal MRI and the neonate was carried to the operating theater and the paediatric surgery consultant performed a sclerotherapy procedure with intralesional bleomycin injection. Postoperative evolution was successful and the neonate left the hospital 5 days later.

Prenatal diagnosis of neck masses with upper airway obstruction risk should alert the perinatal team for closed and coordinated management1,2,10. The EXIT procedure provides time for placental bypass and includes procedures such as laryngoscopy, bronchoscopy, endotracheal intubation, tracheostomy and/ or the resection of neck masses1.2.11.

The team approach is really important in providing organized and coordinated surgery plan. An obstetrician and/or perinatologist, neonatologist, paediatric surgeon and anaesthesiologist should all be available in the operating theater for the birth, resuscitation and possible surgical intervention to the neonate1,2,4. Operating Theatres with the implementation of surgical checklist have great decrease in both mortality and morbidity according the WHO criterias8,9.

So, an early prenatal diagnoses alerts about the fetal risk of CHAOS and them a multidisciplinary and coordinated medical team must organized a very precised EXIT proceure4,12,13. An EXIT check list was an important instrument in our team and we planned every detail before the procedure because during it has interacting different medical teams with special non day to day situations, therefore it is a challenging surgery.

1. Dahlgren G., Four cases of the ex utero intrapartum treatment (EXIT) procedure: anesthetic implications. International Journal of Obstetric Anesthesia. 2004; 13, 178–182.2.Cansaran S., The EXIT for Prenatally Diagnosed Cervical Cystic Teratoma. Journal of Neonatal Surgery 2015; 4(2):18.3. Agarwal P., Ex-utero Intrapartum Treatment (EXIT) Procedure for Giant Fetal Epignathus.Indian paediatrics. Volume 52-October 15, 2015;893-5.4. Tuncay F., Fetal Oropharyngeal and Neck Tumors: Determination of the Need for Ex-Utero Intrapartum Treatment Procedure. Balkan Med J, Vol. 32, No. 2, 2015.5. Thawani J., Management of Giant Cervical Teratoma with Intracranial Extension Diagnosed in Utero. J Neurol Surg Rep 2016;77:e118–e1206.Vieira M., Anestesia para tratamento ex-útero intraparto: visão renovadasobre um procedimento raro. Rev Bras Anestesiol. 2015;65(6):525-528.7. Torossian A. , Geburtshilfe: Anästhesie bei EXIT-Prozedur. Anästhesiol Intensivmed Notfallmed Schmerzther 2017; 52: 214–219.8. WHO. Safe surgery saves lives Newsletter Nov., 20119. WHO: Surgical Safety Checklist 1/2009.10. Chu GM et al. Ex-utero intrapartum treatment: a controlled approach to the management of anticipated airway problems in the new born. Hong Kong Med J 2006; 12:381-411. Matte G., A Modified EXIT-to-ECMO with Optional Reservoir Circuit for Use during an EXIT Procedure Requiring Thoracic Surgery. JECT. 2016;48:35–38.12. Gupta A., CHAOS. The Journal of Obstetrics and Gynecology of India (May–June 2016) 66(3):202–208.13. Gupta A., CHAOS: Prenatal imaging findings with post mortem contrast radiographic correlation. Radiology Case. 2016 Aug; 10(8):39-49

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