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BACKGROUND

Ex utero intrapartum treatment (EXIT) is a set of clinical procedures where a fetus with life-threatening airway or pulmonary abnormalities is partially delivered during cesarean section and is kept oxygenated through an attached placenta until treatment is completed. Fetal head and one or both shoulders are delivered for access during treatment; uterine relaxation during the treatment phase is paramount, as is preservation of uterine perfusion also is essential.

Principles of management of EXIT procedures are similar to that of nonobstetric surgeries in pregnancy, but with two surgical patients, mother and fetus. Fetal analgesia can be partially provided by maternal transfer of agents but also frequently requires intramuscular (IM) and intravenous (IV) administration of drugs.

Preparation for fetal resuscitation and maternal hemorrhage is important. With the ongoing controversy regarding the fetal neurotoxicity of anesthetic agents, minimizing the duration of exposure of the fetus to anesthetic agents is extremely important. The common indications and fetal physiologic consideration for EXIT procedures are listed in Table 25-1.

TABLE 25-1Fetal Considerations for EXIT Procedures

PHASES OF EXIT PROCEDURE (FIG. 25-1)

FIGURE 25-1

Phases of EXIT procedure.

PREOPERATIVE PREPARATION (TABLE 25-2)

Preoperative Preparation2,3

  • Assessment of maternal comorbidities

  • Imaging studies for placental location, location of lesion, and fetal weight

  • Ideal timing: Close to term, often 34 to 35 weeks of gestational age

  • Multidisciplinary meeting (anesthesiologists, obstetricians, pediatric surgeons, pediatric cardiologists, neonatologists, radiologists, nurse, blood bank).

  • Maternal aspiration prophylaxis.

  • IV lines for hemorrhage preparedness.

  • Arterial line to assess fetal perfusion.

  • General anesthesia with intubation is most often used.

TABLE 25-2Anesthetic Considerations for EXIT Procedure

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