Ex Utero Intrapartum Treatment Procedure (EXIT)

Bhavani Shankar Kodali MDAnesthesiologist-in-Chief, Interim Chairman

Brigham and Women’s Hospital

Associate ProfessorHarvard Medical School

Why this session?

• Full term • Fetal anomaly• No time to referral• Your facility can undertake corrective

surgery

Fetal Surgery

• Open Fetal Surgery

• Minimally Invasive Fetal Surgery

• EXIT

Goals

• Correct and improve fetal anomaly

• Minimize the risk to the mother

Open Fetal Surgery

Minimally Invasive Fetal Surgery

Minimally Invasive Fetal Surgery• Twin-Twin Transfusion syndrome• Obstructive uropathy: shunt insertion and

valve ablation• Aortic or pulmonary stenosis: Valvoplasty• Cyanotic heart disease: atrial septostomy• Congenial diaphragm hernia: tracheal

balloon occlusion• Spina bifida: fetoscopic closure of the defect

Anesthesia

• General anesthesia

• Epidural analgesia

• Combined spinal anesthesia

• Fetal analgesia and relaxation

EXIT

• A modification of cesarean delivery.

• Baby is partially (head and upper torso) or, less often, completely delivered.

• Placental support is maintained and the baby oxygenated via placental blood flow

What should you know?

• Not an intra-partum procedure

• You may have a baby that may require EXIT until pediatric surgeons secure the oxygenation via other means

• Most procedures last a matter of minutes (eg, tracheal intubation)

When Do You Perform

• Not at preterm

• At, or close to term

• Ideally should not be in labor

What is the requirement?

• Uterine relaxation is important not only to facilitate delivery of fetal head but also to prevent placental separation and to preserve utero-placental flow during the procedure

Management

• Usual Cesarean Delivery

• Uterine relaxation

Procedure

• Arterial line

• Spinal with Duramorph (Hydromorphone)

• General anesthesia

ECMO – 32 weeks - CHD• Arterial Line• Spinal in the labor room with Duramorph• General Anesthesia• Isoflurane, Sevoflurane, Desflurane• Phenylephrine boluses• Decreased inhalational agent to 0.5 mac• BIS is a good idea• Uterotonics may be necessary• Hemorrhage• Reversal and extubation

Regional Anesthesia

• Uterine relaxation – Nitroglycerine