ARTICLE IN PRESS+ModelBJANE-180; No. of Pages 3

Rev Bras Anestesiol. 2014;xxx(xx):xxx---xxx

REVISTABRASILEIRA DEANESTESIOLOGIA Official Publication of the Brazilian Society of Anesthesiology

www.sba.com.br

CLINICAL INFORMATION

Anesthesia for ex utero intrapartum treatment: renewed insighton a rare procedure

Miguel Vieira Marquesa,∗, João Carneiroa, Marta Adrianob, Filipa Lancaa

a Servico de Anestesiologia, Hospital Universitário de Santa Maria, Centro Hospitalar de Lisboa Norte, E.P.E., Lisboa, Portugalb Servico de Anestesiologia, Hospital Curry Cabral, Centro Hospitalar de Lisboa Central, Lisboa, Portugal

Received 29 October 2013; accepted 4 December 2013

KEYWORDSAirway --- obstruction;Anesthesia --- fetal;Anesthesia ---obstetric;Cervicallymphangioma;EXIT

Abstract The ex utero intrapartum treatment is a rare surgical procedure performed in casesof expected postpartum fetal airway obstruction. The technique lies on a safe establishment ofa patent airway during labor in anticipation of a critical respiratory event, without interruptingmaternal---fetal circulation.

Anesthetic management is substantially different from that regarding standard cesareandelivery and its main goals include uterine relaxation, fetal anesthesia and preservation ofplacental blood flow.

We present the case of an ex utero intrapartum treatment procedure performed on a fetuswith a large cervical lymphangioma and prenatal evidence of airway compromise. Modificationsto the classic ex utero intrapartum treatment management strategies were successfully adopted

and will be discussed in the following report.© 2013 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rightsreserved.

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Introduction

The ex utero intrapartum treatment (EXIT) is a rare sur-gical procedure performed to ensure fetal airway patencyduring labor in situations of expected severe, potentiallylife-threatening respiratory failure secondary to airway

Please cite this article in press as: Marques MV, et al. Anesthesia rare procedure. Rev Bras Anestesiol. 2014. http://dx.doi.org

obstruction.Also known as operation on placental support1 (OOPS)

and airway management on placental support2 (AMPS), EXIT

∗ Corresponding author.E-mail: miguelvieiramarques@hotmail.com, clqui@hotmail.com

(M.V. Marques).

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0104-0014/$ – see front matter © 2013 Sociedade Brasileira de Anestesiohttp://dx.doi.org/10.1016/j.bjane.2013.12.002

urgery was first described in the late 1980s by Norrisnd colleagues3 and was initially performed in trachealcclusion reversion protocols for fetuses with congenitaliaphragmatic hernia.4,5 The indisputable usefulness of thisechnique later extended its applicability to a variety ofbstetric clinical scenarios,6---8 including fetal head and neckumor surgical approaches.9

The procedure consists of a partial cesarean section withimultaneous maintenance of placental circulation as a wayo preserve fetal gas exchanges during the establishment

a for ex utero intrapartum treatment: renewed insight on/10.1016/j.bjane.2013.12.002

f a definitive airway through direct laryngoscopy, bron-hoscopy, or tracheostomy.

The anesthetic approach is significantly different from aonventional cesarean section and involves a deep volatile

logia. Published by Elsevier Editora Ltda. All rights reserved.

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ARTICLEJANE-180; No. of Pages 3

nesthesia with maximum uterine relaxation, preservationf uteroplacental blood flow and fetal anesthesia.

The success of an EXIT depends on a rigorous strate-ic planning with involvement of a multidisciplinary teamhere the anesthesiologist often takes the leadership

ole.In our report we describe the anesthetic management of a

arturient scheduled for EXIT surgery after prenatal diagno-is of cervical lymphangioma with mediastinal involvement,ighlighting both fetal and maternal singularities in the lightf current clinical practice.

ase report

healthy 25-year-old woman, gravida 1, para 0, was sched-led for elective EXIT at 38 weeks of gestation due to

prenatal ultrasound diagnosis of fetal cervical lymphan-ioma with tracheal deviation and risk of postdelivery airwayompromise.

Preparation for the procedure involved a multidisci-linary team of anesthesiologists, obstetricians, neonatol-gists, pediatric surgeons, otolaryngologists and pulmonolo-ists. Several preliminary meetings were held and everytakeholder’s role and positioning in the operatory roomere clearly defined.

Anesthesia material, room temperature, blood group-ng, hemoderivatives availability and both neonatology andostanesthetic care unit vacancies were all preoperativelyonfirmed.

Additional pharmacological preparation includedocolytic support with intravenous nitroglycerin solution at

concentration of 50 mg mL−1 and drugs for supplementaryntramuscular fetal anesthesia: fentanyl 10 �g kg−1, vecuro-ium 0.2 mg kg−1 and atropine 100 �g, with a total volumef 2 mL.

Standard monitoring was applied with the parturient inupine and left lateral tilt position under manual uterineisplacement. Two intravenous 16G lines were placed andrinary catheterization was performed.

Balanced general anesthesia was initiated after preme-ication with fentanyl 2 �g kg−1. Rapid sequence inductionas performed with propofol 2 mg kg−1 and rocuronium.2 mg kg−1, followed by endotracheal intubation andechanical ventilation in volume-controlled mode. A radial

rtery catheter was placed for invasive blood pressure moni-oring. Anesthesia was maintained with low-dose desfluranend nitrous oxide in oxygen mixture. Goal-directed fluidherapy was managed with crystalloids.

Surgery began with a low segmental abdominal inci-ion and hysterotomy followed by fetal cephalic extractionp to the nipple line. Warm Hartmann’s solution amnioin-usion was further initiated. The fetus’ airway wasxposed and evaluated by the neonatologist and tra-heal intubation successfully achieved after a singlettempt.

After full extraction the newborn was stabilized andransported in a neonatal incubator under mechanical ven-

Please cite this article in press as: Marques MV, et al. Anesthesa rare procedure. Rev Bras Anestesiol. 2014. http://dx.doi.org

ilation to the neonatology unit. Total placental bypass timeas 4 min and 46 s. Amnioinfusion was discontinued andterine hypotonicity effectively reversed with oxytocin andolatile concentration reduction.

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The parturient remained hemodynamically stablehroughout the procedure with MAP > 70 mm Hg, equivalento preoperative records. Anesthesia emergence progressedneventfully. Intravenous analgesia was performed witharacetamol, ketorolac and tramadol and nausea andomiting prophylaxis with droperidol.

iscussion

he ideal constitution of a multidisciplinary team interven-ng in an EXIT surgery is not consensual6,10,11 and dependsn the nature and purpose of the surgery: EXIT-to-airway,XIT-to-ECMO or EXIT-to-ressection.11

In this case six medical teams were involved. Anesthe-iology, obstetrics and neonatology were directly involvedn the procedure. Additional participation of pulmonology,tolaryngology and pediatric surgery teams was justifiedy their assistance in the event of a difficult laryngo-copic approach to execute a bronchoscopic intubation,stablish a surgical airway or perform a partial tumor resec-ion.

The two main physiological goals during EXIT are uterineipotonicity preservation --- which facilitates partial extrac-ion of the fetus and prevents placental dissociation --- andlacental perfusion pressure conservation that ensures fetalxygenation.1---15

Although associated with higher rates of morbidity andortality among global obstetric population,12 general anes-

hesia is usually favored over regional techniques in thisrocedure. Although not contraindicated, regional anesthe-ia presents important disadvantages regarding the citedrecepts, particularly the risk of severe hypotension andlacental hypoperfusion.8 Aside from its contribution ton adequate uterine relaxation, general anesthesia allowsimultaneous induction of both mother and fetus throughlacental penetration of anesthetic agents.

Maternal blood pressure must be kept within the limit of0% of baseline.7,11 As a result, anesthesia induction shoulde performed with the lowest possible hemodynamic reper-ussion, ideally under continuous blood pressure monitoring.nduction without consideration for fetal respiratory depres-ion or time restriction to the expulsion helps to moderatehe hypotensive effect of general anesthetics.

Contrary to the classic recommendation of deep inhala-ional anesthetic maintenance,6,13 the use of 0.5---1.0alogenated minimum anesthetic concentration (MAC), sup-lemented if necessary by a tocolytic, is becoming accepteds an effective strategy for uterine tone control14 with min-mal cardiovascular impact and lower risk of postoperativeterine atony.6

In this particular case, pre-induction opiate administra-ion, rapid sequence induction with low dose propofol andaintenance with 0.5 MAC desflurane provided an adequateepth of anesthesia (BIS 35---45) and a stable hemodynamicrofile (�MAP < 10%).

The obtained uterine relaxation was in this case con-idered sufficient and intravenous nitroglycerin, previously

ia for ex utero intrapartum treatment: renewed insight on/10.1016/j.bjane.2013.12.002

repared as a first-line tocolytic alternative, was not admin-stered. Without uteroplacental circulation impairment,etal anesthesia was enabled and adequately demonstratedhrough complete akinesia at the time of airway approach,

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ARTICLEBJANE-180; No. of Pages 3

EXIT----renewed insight on a rare procedure

also eliminating the need for supplemental ex utero anes-thesia.

After complete fetal extraction and umbilical cordclamping, priority focused on pharmacological reversal ofuterine hipotonicity with oxytocin and on fetus stabilizationfor pediatric intensive care unit transportation, which wereboth held uneventfully. Cesarean section was completedunder close supervision of uterine contractility evolutionand hemostasis.

Development of a hypocoagulable state following uterineatony and massive postpartum bleeding has occasion-ally been associated with the occurrence of epiduralhematoma.15 Considering the particular risks of uterineatony and hemorrhage requiring blood transfusion associ-ated with EXIT surgery,7 we decided to replace neuraxialregional analgesia for a conventional postoperative intra-venous analgesia protocol. Effective pain control andpatient satisfaction were observed. No reports of hem-orrhagic incidents were issued following the parturient’stransference to the postanesthetic care unit.

Conclusion

The EXIT is an exceptional obstetric procedure bound forlife-saving fetal airway interventions.

Preparation for an EXIT surgery involves a detailed multi-disciplinary planning, critical for the procedure’s safety andsuccess.

Considering current literature, anesthesia managementfor this procedure is far from unequivocal. Even so anddespite the adopted strategy, uteroplacental circulation anduterus relaxation are to be preserved until the fetus’ airwayis secured.

Anticipation of postoperative coagulation complicationsmay preclude use of unrestricted neuraxial analgesic tech-niques.

Authorship

All authors participated in the procedure that originated thereport. Data collection was performed by all. The report wasdrafted by M.M. and revised by all authors.

Please cite this article in press as: Marques MV, et al. Anesthesia rare procedure. Rev Bras Anestesiol. 2014. http://dx.doi.org

Conflicts of interest

The authors declare no conflict of interest.

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