Ex Utero intrapartum treatment (EXIT)

Abstract

The anesthesia ex utero intrapartum treatment (EXIT) procedure is a specialized surgical procedure used to deliver babies who have airway compression due to cystic adenomatoid malformation, bronchopulmonary sequestration, cervical teratomas, or other congenital conditions. EXIT is erroneously known as a routine cesarean section (CS), but is rather an extension of CS with discernible differences. The procedure creates an opening in the anesthetized abdomen of the mother and uterus. Once EXIT is complete, the remainder of the CS proceeds. EXIT is much more complex than a routine CS, as it requires coordination between the mother and a multidisciplinary team of surgical and neonatal personnel. This review highlights current anesthetic concepts during the EXIT procedure.

Share and Cite:

Pentyala, S. , Rahman, A. , Mysore, P. , Pentyala, S. , Urbanczyk, K. , Tumillo, T. , Muller, J. , Miao, Y. and Khan, S. (2013) Ex Utero intrapartum treatment (EXIT). Open Journal of Obstetrics and Gynecology, 3, 51-60. doi: 10.4236/ojog.2013.39A007.

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1] Meddings, F., Phipps, F.M., Haith-Cooper, M. and Haigh, J. (2007) Vaginal birth after caesarean section (VBAC): Exploring women’s perceptions. Journal of Clinical Nursing, 16, 160-167.
http://dx.doi.org/10.1111/j.1365-2702.2005.01496.x
[2] Srinivas, S.K., Stamilio, D.M., Sammel, M.D., Stevens, E.J., Peipert, J.F., Odibo, A.O., et al. (2007) Vaginal birth after caesarean delivery: Does maternal age affect safety and success? Paediatric and Perinatal Epidemiology, 21, 114-120. http://dx.doi.org/10.1111/j.1365-3016.2007.00794.x
[3] Cahill, A.G., Stamilio, D.M., Odibo, A.O., Peipert, J.F., Ratcliffe, S.J., Stevens, E.J., et al. (2006) Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery? American Journal of Obstetrics & Gynecology, 195, 1143-1147. http://dx.doi.org/10.1016/ j.ajog.2006.06.045
[4] Crawford, P. and Kaufmann, L. (2006) How safe is vaginal birth after cesarean section for the mother and fetus? Journal of Family Practice, 55, 149.
[5] Guise, J.M., McDonagh, M.S., Hashima, J., Kraemer, D.F., Eden, K.B., Berlin, M., et al. (2003) Vaginal birth after cesarean (VBAC). Evid Rep Technol Assess (Summ), 71, 1-8.
[6] Martel, M.J. and MacKinnon, C.J. (2005) Guidelines for vaginal birth after previous Caesarean birth. Journal of Obstetrics and Gynaecology Canada, 27, 164-188.
[7] Rozenberg, P. (2005) The counselling of patient with prior C-section. Gynecologie, Obstetrique & Fertilite, 33, 1003. http://dx.doi.org/10.1016/j.gyobfe.2005.10.001
[8] Cook, T.M. (2000) Combined spinal-epidural techniques. Anaesthesia, 55, 42-64. http://dx.doi.org/ 10.1046/j.1365-2044.2000.01157.x
[9] Marwan, A. and Crombleholme, T.M. (2006) The EXIT procedure: Principles, pitfalls, and progress. Seminars in Pediatric Surgery, 15, 107-115. http://dx.doi.org/10.1053/j.sempedsurg.2006.02.008
[10] Garcia, P.J., Olutoye, O.O., Ivey, R.T. and Olutoye, O.A. (2011) Case scenario: Anesthesia for maternal-fetal surgery: The Ex Utero Intrapartum Therapy (EXIT) procedure. Anesthesiology, 114, 1446-1452. http://dx.doi.org/10.1097/ALN.0b013e31821b173e
[11] Mota, R., Ramalho, C., Monteiro, J., Correia-Pinto, J., Rodrigues, M., Guimaraes, H., et al. (2007) Evolving indications for the EXIT procedure: The usefulness of combining ultrasound and fetal MRI. Fetal Diagnosis and Therapy, 22, 107-111. http://dx.doi.org/10.1159/000097106
[12] Bouchard, S., Johnson, M.P., Flake, A.W., Howell, L.J., Myers, L.B., Adzick, N.S., et al. (2002) The EXIT procedure: Experience and outcome in 31 cases. Journal of Pediatric Surgery, 37, 418-426. http://dx.doi.org/10.1053/jpsu.2002.30839
[13] Hirose, S. and Harrison, M.R. (2003) The ex utero intrapartum treatment (EXIT) procedure. Seminars in Neonatology, 8, 207-214. http://dx.doi.org/10.1016/S1084-2756(03)00029-0
[14] Nio, M. (2004) Congenital diaphragmatic hernia. Kyobu Geka, 57, 800-806.
[15] Kunisaki, S.M., Fauza, D.O., Barnewolt, C.E., Estroff, J.A., Myers, L.B., Bulich, L.A., et al. (2007) Ex utero intrapartum treatment with placement on extracorporeal membrane oxygenation for fetal thoracic masses. Journal of Pediatric Surgery, 42, 420-425. http://dx.doi.org/10.1016/j.jpedsurg. 2006.10.035
[16] Partridge, E.A. and Flake, A.W. (2012) Maternal-fetal surgery for structural malformations. Best Practice & Research Clinical Obstetrics & Gynaecology, 26, 669-682. http://dx.doi.org/10.1016/ j.bpobgyn.2012.03.003
[17] Gershanik, J.J., Lacassie, Y., Sargent, W., Thelin, O., Florez, L. and Dildy III, G.A. (2003) EXIT procedure: A case report. Journal of the Louisiana State Medical Society, 155, 46-50.
[18] Midrio, P., Grismondi, G., Meneghini, L., Suma, V., Pitton, M.A., Salvadori, S., et al. (2001) The EX-utero Intrapartum Technique (EXIT) procedure in Italy. Minerva Ginecologica, 53, 209-214.
[19] Stevens, G.H., Schoot, B.C., Smets, M.J., Kremer, B., Manni, J.J., Gavilanes, A.W., et al. (2002) The ex utero intrapartum treatment (EXIT) procedure in fetal neck masses: A case report and review of the literature. European Journal of Obstetrics & Gynecology and Reproductive Biology, 100, 246-250. http://dx.doi.org/10.1016/S0301-2115(01)00467-5
[20] Cass, D.L., Olutoye, O.O., Cassady, C.I., Zamora, I.J., Ivey, R.T., Ayres, N.A., et al. (2013) EXIT-to-resection for fetuses with large lung masses and persistent mediastinal compression near birth. Journal of Pediatric Surgery, 48, 138-144. http://dx.doi.org/10.1016/j.jpedsurg.2012.10.067
[21] Ogamo, M., Sugiyama, T., Maeda, Y., Kusaka, H., Utsunomiya, H., Tsubouchi, M., et al. (2005) The ex utero intrapartum treatment (EXIT) procedure in giant fetal neck masses. Fetal Diagnosis and Therapy, 20, 214-218. http://dx.doi.org/10.1159/000083908
[22] Wagner, W. and Harrison, M.R. (2002) Fetal operations in the head and neck area: Current state. Head & Neck, 24, 482-490. http://dx.doi.org/10.1002/hed.10083
[23] De Wilde, J., Rivers, A. and Price, D. (2005) A review of the current use of magnetic resonance imaging in pregnancy and safety implications for the fetus. Progress in Biophysics and Molecular Biology, 87, 335-353. http://dx.doi.org/10.1016/j.pbiomolbio.2004.08.010
[24] Leva, E., Pansini, L., Fava, G., Maestri, L., Pansini, A. and Selvaggio, G. (2005) The role of the surgeon in the case of a giant neck mass in the EXIT procedure. Journal of Pediatric Surgery, 40, 748-750. http://dx.doi.org/10.1016/j.jpedsurg.2005.01.035
[25] Kill, C., Gebhardt, B., Schmidt, S., Werner, J.A., Maier, R.F. and Wulf, H. (2005) Anesthesiological management of the EXIT procedure. Case report and literature review. Anaesthesist, 54, 1105-1110. http://dx.doi.org/10.1007/s00101-005-0898-y
[26] Glynn, F., Sheahan, P., Hughes, J. and Russell, J. (2006) Successful ex utero intrapartum treatment (EXIT) procedure for congenital high airway obstruction syndrome (CHAOS) owing to a large oropharyngeal teratoma. Irish Medical Journal, 99, 242-243.
[27] Kanamori, Y., Kitano, Y., Hashizume, K., Sugiyama, M., Tomonaga, T., Takayasu, H., et al. (2004) A case of laryngeal atresia (congenital high airway obstruction syndrome) with chromosome 5p deletion syndrome rescued by ex utero intrapartum treatment. Journal of Pediatric Surgery, 39, E25-E28. http://dx.doi.org/10.1016/j.jpedsurg.2003.09.041
[28] Myers, L.B., Bulich, L.A., Mizrahi, A., Barnewolt, C., Estroff, J., Benson, C., et al. (2003) Ultrasonographic guidance for location of the trachea during the EXIT procedure for cervical teratoma. Journal of Pediatric Surgery, 38, E12. http://dx.doi.org/10.1053/jpsu.2003.50150
[29] Shih, J.C., Hsu, W.C., Chou, H.C., Peng, S.S., Chen, L.K., Chang, Y.L., et al. (2005) Prenatal three-dimensional ultrasound and magnetic resonance imaging evaluation of a fetal oral tumor in preparation for the ex-utero intrapartum treatment (EXIT) procedure. Ultrasound in Obstetrics & Gynecology, 25, 76-79. http://dx.doi.org/10.1002/uog.1791
[30] Dahlgren, G., Tornberg, D.C., Pregner, K. and Irestedt, L. (2004) Four cases of the ex utero intrapartum treatment (EXIT) procedure: Anesthetic implications. International Journal of Obstetric Anesthesia, 13, 178-182. http://dx.doi.org/10.1016/j.ijoa.2004.01.007
[31] Recasens Urbez, J., Boada Pie, S., Solsona Della, E., Saludes Serra, J., Bueno Izquierdo, J.M. and Rull Bartomeu, M. (2000) Elective cesarean section with epidural anesthesia in a pregnant woman with obstructive hypertrophic myocardiopathy. Revista Espa?ola de Anestesiología y Reanimación, 47, 320-322.
[32] Myers, L.B., Cohen, D., Galinkin, J., Gaiser, R. and Kurth, C.D. (2002) Anaesthesia for fetal surgery. Pediatric Anesthesia, 12, 569-578. http://dx.doi.org/10.1046/j.1460-9592.2002.00840.x
[33] Kuczkowski, K.M. (2006) Images in Anesthesia: Ex utero intrapartum treatment (exit procedure): Fetal airway management. Canadian Journal of Anesthesia, 53, 1117. http://dx.doi.org/10.1007/ BF03022880
[34] Lee, S.J., Ralston, H.J., Drey, E.A., Partridge, J.C. and Rosen, M.A. (2005) Fetal pain: A systematic multidisciplinary review of the evidence. JAMA, 294, 947-954. http://dx.doi.org/10.1001/jama. 294.8.947
[35] Klein, L.V. and Wilson, D.V. (1989) An unusual cause of increasing airway pressure during anesthesia. Veterinary Surgery, 18, 239-241. http://dx.doi.org/10.1111/j.1532-950X.1989.tb01078.x
[36] Zadra, N., Giusti, F. and Midrio, P. (2004) Ex utero intrapartum surgery (EXIT): Indications and anaesthetic management. Best Practice & Research Clinical Anaesthesiology, 18, 259-271.
http://dx.doi.org/10.1016/j.bpa.2003.11.001
[37] Farrell, J. and Howell, L.J. (2012) An overview of surgical techniques, research trials, and future directions of fetal therapy. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 41, 419-425. http://dx.doi.org/10.1111/j.1552-6909.2012.01356.x
[38] Hullett, B.J., Shine, N.P. and Chambers, N.A. (2006) Airway management of three cases of congenital cervical teratoma. Pediatric Anesthesia, 16, 794-798. http://dx.doi.org/10.1111/j.1460-9592.2006. 01859.x
[39] Froese, A.B. and Kinsella, J.P. (2005) High-frequency oscillatory ventilation: Lessons from the neonatal/pediatric experience. Critical Care Medicine, 33, S115-S121. http://dx.doi.org/10.1097/01. CCM.0000155923.97849.6D
[40] Konduri, G.G. and Kim, U.O. (2009) Advances in the diagnosis and management of persistent pulmonary hypertension of the newborn. Pediatric Clinics of North America, 56, 579-600.
http://dx.doi.org/10.1016/j.pcl.2009.04.004
[41] Liechty, K.W. (2010) Ex-utero intrapartum therapy. Seminars in Fetal & Neonatal Medicine, 15, 34-39. http://dx.doi.org/10.1016/j.siny.2009.05.007
[42] Bayrakci, B., Josephson, C. and Fackler, J. (2007) Oxygenation index for extracorporeal membrane oxygenation: is there predictive significance? Journal of Artificial Organs, 10, 6-9. http://dx.doi.org/ 10.1007/s10047-006-0359-7
[43] Schwarz, U. and Galinkin, J.L. (2003) Anesthesia for fetal surgery. Seminars in Pediatric Surgery, 12, 196-201. http://dx.doi.org/10.1016/S1055-8586(03)00025-8
[44] Elliott, R., Vallera, C., Heitmiller, E.S., Isaac, G., Lee, M., Crino, J., Boss, E.F. and Ishman, S.L. (2013) Ex utero intrapartum treatment procedure for management of congenital high airway obstruction syndrome in a vertex/breech twin gestation. International Journal of Pediatric Otorhinolaryngology, 77, 439-442. http://dx.doi.org/10.1016/j.ijporl.2012.11.023
[45] De Backer, A., Madern, G.C., van de Ven, C.P., Tibboel, D. and Hazebroek, F.W. (2004) Strategy for management of newborns with cervical teratoma. Journal of Perinatal Medicine, 32, 500-508. http://dx.doi.org/10.1515/JPM.2004.122
[46] Gyure, K.A., Thompson, L.D. and Morrison, A.L. (2000) A clinicopathological study of 15 patients with neuroglial heterotopias and encephaloceles of the middle ear and mastoid region. The Laryngoscope, 110, 1731-1735. http://dx.doi.org/10.1097/00005537-200010000-00032
[47] Ba, M.C., Kabre, A., Badiane, S.B., Ndoye, N., Ly Ba, A., Gueye, E.M. and Sakho, Y. (2003) Fronto-ethmoidal encephaloceles in Dakar. Report of 9 cases. Dakar Medical, 48, 131-133.
[48] Adzick, N.S. (2009) Management of fetal lung lesions. Clinics in Perinatology, 36, 363-376. http://dx.doi.org/10.1016/j.clp.2009.03.001
[49] Hedrick, H.L., Flake, A.W., Crombleholme, T.M., Howell, L.J., Johnson, M.P., Wilson, R.D. and Adzick, N.S. (2005) The ex utero intrapartum therapy procedure for high-risk fetal lung lesions. Journal of Pediatric Surgery, 40, 1038-1043. http://dx.doi.org/10.1016/j.jpedsurg.2005.03.024
[50] Logan, J.W., Rice, H.E., Goldberg, R.N. and Cotton, C.M. (2007) Congenital diaphragmatic hernia: A systematic review and summary of best-evidence practice strategies. Journal of Perinatology, 27, 535-549. http://dx.doi.org/10.1038/sj.jp.7211794
[51] Orr, L.S., Osher, R.H. and Savino, P.J. (1978) The syndrome of facial nevi, anomalous cerebral venous return, and hydrocephalus. Annals of Neurology, 3, 316-318. http://dx.doi.org/10.1002/ana. 410030407
[52] Williams, H. (2008) A unifying hypothesis for hydrocephalus, Chiari malformation, syringomyelia, anencephaly and spina bifida. Cerebrospinal Fluid Research, 5, 7. http://dx.doi.org/10.1186/1743-8454-5-7
[53] Ghi, T., Pilu, G., Falco, P., Segata, M., Carletti, A., Cocchi, G., Santini, D., Bonasoni, P., Tani, G. and Rizzo, N. (2006) Prenatal diagnosis of open and closed spina bifida. Ultrasound in Obstetrics & Gynecology, 28, 899-903. http://dx.doi.org/10.1002/uog.3865
[54] Golalipour, M.J., Mansourian, A.R. and Keshtkar, A. (2006) Serum zinc levels in newborns with neural tube defects. Indian Pediatrics, 43, 809-812.
[55] Kalkan, E., Karabagli, P., Karabagli, H. and Baysefer, A. (2006) Congenital cranial and spinal dermal sinuses: A report of 3 cases. Advances in Therapy, 23, 543-548. http://dx.doi.org/10.1007/BF 02850043
[56] Batukan, C., Ozgun, M.T., Basbug, M., Caglayan, O., Dundar, M. and Murat, N. (2007) Sacrococcygeal teratoma in a fetus with prenatally diagnosed partial trisomy 10q (10q24.3-->qter) and partial monosomy 17p (p13.3-->pter). Prenatal Diagnosis, 27, 365-368. http://dx.doi.org/10.1002/pd.1653
[57] Bulic-Jakus, F., Ulamec, M., Vlahovic, M., Sincic, N., Katusic, A., Juric-Lekc, G., Serman, L., Kruslin, B. and Belicza, M. (2006) Of mice and men: Teratomas and teratocarcinomas. Collegium Antropologicum, 30, 921-924.
[58] Turchetti, G., Labella, B., Valdastri, P., Menciassi, A. and Dario, P. (2007) The importance of giving an alternative: The case of fetal surgery. International Journal of Healthcare Technology and Management, 8, 250-267. http://dx.doi.org/10.1504/IJHTM.2007.013163
[59] Chervenak, F.A. and McCullough, L.B. (2009) Ethics of fetal surgery. Clinics in Perinatology, 36, 237-246. http://dx.doi.org/10.1016/j.clp.2009.03.002
[60] Flake, A.W. (2001) In utero transplantation of haemopoietic stem cells. Best Practice & Research Clinical Haematology, 14, 671-683. http://dx.doi.org/10.1053/beha.2001.0166
[61] Deprest, J., Jani, J., Lewi, L., Ochsenbein-Kolble, N., Cannie, M., Done, E., et al. (2006) Fetoscopic surgery: Encouraged by clinical experience and boosted by instrument innovation. Seminars in Fetal & Neonatal Medicine, 11, 398-412. http://dx.doi.org/10.1016/j.siny.2006.09.003
[62] Kohl, T., Hering, R., Van de Vondel, P., Tchatcheva, K., Berg, C., Bartmann, P., Heep, A., Franz, A., Müller, A. and Gembruch, U. (2006) Analysis of the stepwise clinical introduction of experimental percutaneous fetoscopic surgical techniques for upcoming minimally invasive fetal cardiac interventions. Surgical Endoscopy and Other Interventional Techniques, 20, 1134-1143. http://dx.doi.org/10.1007/s00464-005-0662-z
[63] Basude, S. and Overton, T.G. (2012) Advances in fetal therapy. Obstetrics, Gynaecology & Reproductive Medicine, 22, 223-228. http://dx.doi.org/10.1016/j.ogrm.2012.05.005
[64] Neuman, J., Calvo-Garcia, M.A., Kline-Fath, B.M., Bitters, C., Merrow, A.C., Guimaraes, C.V. and Lim, F.Y. (2012) Prenatal imaging of amniotic band sequence: Utility and role of fetal MRI as an adjunct to prenatal US. Pediatric Radiology, 42, 544-551. http://dx.doi.org/10.1007/s00247-011-2296-8
[65] Helfer, D.C., Clivatti, J., Yamashita, A.M. and Moron, A.F. (2012) Anesthesia for ex utero intrapartum treatment (EXIT procedure) in fetus with prenatal diagnosis of oral and cervical malformations: Case reports. Brazilian Journal of Anesthesiology, 62, 411-423. http://dx.doi.org/10.1016/S0034-7094 (12)70141-1
[66] Kudo, T., Kimura, F., Hashimoto, H., Wada, M. and Hirota, K. (2012) Anesthetic management for EXIT (ex-utero intrapartum treatment) of a twin gestation: One normal and one with a large epignathus. Masui, 61, 307-310.
[67] Choleva, A.J. (2011) Anesthetic management of a patient undergoing an ex utero intrapartum treatment (EXIT) procedure: A case report. Journal of the American Association of Nurse Anesthetists, 79, 497-503.
[68] Ioscovich, A., Shen, O., Sichel, J.Y., Lajos, Y., Orkin, D., Bromiker, R. and Briskin, A. (2011) Remifentanil-nitroglycerin combination as an anesthetic support for ex utero intrapartum treatment (EXIT) procedure. Journal of Clinical Anesthesia, 23, 142-144. http://dx.doi.org/10.1016/j.jclinane. 2009.12.014
[69] Garcia, P.J., Olutoye, O.O., Ivey, R.T. and Olutoye, O.A. (2011) Case scenario: Anesthesia for maternal-fetal surgery: The ex utero intrapartum therapy (EXIT) procedure. Anesthesiology, 114, 1446-1452. http://dx.doi.org/10.1097/ALN.0b013e31821b173e
[70] Fink, R.J., Allen, T.K. and Habib, A.S. (2011) Remifentanil for fetal immobilization and analgesia during the ex utero intrapartum treatment procedure under combined spinal-epidural anaesthesia. British Journal of Anaesthesia, 106, 851-855. http://dx.doi.org/10.1093/bja/aer097
[71] Lee, H., Ryu, J.W., Kim, D.Y. and Lee, G.Y. (2010) Anesthetic management of the ex utero intrapartum treatment (EXIT) procedure—A case report. Korean Journal of Anesthesiology, 59, S154-S157. http://dx.doi.org/10.4097/kjae.2010.59.S.S154
[72] Butwick, A., Aleshi, P. and Yamout, I. (2009) Obstetric hemorrhage during an EXIT procedure for severe fetal airway obstruction. Canadian Journal of Anesthesia, 56, 437-442. http://dx.doi.org/10. 1007/s12630-009-9092-z
[73] Bilgin, F., Cekmen, N., Ugur, Y., Kurt, E., Güngor, S. and Atabek, C. (2009) Congenital cervical teratoma: Anaesthetic management (The EXIT Procedure). Indian Journal of Anaesthesia, 53, 678-682.
[74] Cha, H.-H., Seo, E.S., Choi, S.-J., Oh, S., Roh, C. and Seo, J. (2009) The ex utero intrapartum treatment (EXIT) procedure for a fetal neck mass: A case report. Journal of Women’s Medicine, 2, 39-43.
[75] Chang, L.C. and Kuczkowski, K.M. (2008) The ex utero intrapartum treatment procedure: Anesthetic considerations. Archives of Gynecology and Obstetrics, 277, 83-85. http://dx.doi.org/10.1007/s 00404-007-0402-9

Copyright © 2024 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.