DP39: EX-UTERO INTRAPARTUM TREATMENT PROCEDURE
Grace Chalhoub, DO1; Gianfranco Molfetto, DO2; Aaron Wong, MD1; Benjamin Houseman, MD, PhD2
1Memorial Healthcare System; 2Envision Physician Services
Introduction: The Ex-utero Intrapartum Treatment (EXIT) procedure permits management of severe fetal abnormalities prior to delivery. During these procedures, the placenta functions as a cardiopulmonary bypass circuit while a procedure is performed. Following treatment, the fetus is either returned to the uterus with closure of hysterotomy or delivered following umbilical cord clamping. The multidisciplinary teams required for EXIT limit this procedure to only a small number of highly specialized centers, and these centers only perform a small number of cases each year. Here we describe challenges encountered during a late-stage EXIT procedure in a fetus with severe airway abnormalities.
Case Report: A 39-year-old G6P2032 at 37 weeks and 5 days gestation presented in active labor. Past surgical history was significant for a prior c-section. Her fetus was known to have multiple abnormalities, including severe retrognathia, edema of the face and scalp, severe fetal growth restriction, and polyhydramnios. Shortly after admission, she developed recurrent prolonged decelerations with a nonreassuring fetal status. An urgent multidisciplinary discussion involving the anesthesia, NICU, pediatric surgery, and obstetric teams, determined that a repeat C-section with EXIT protocol was indicated.
General endotracheal anesthesia was induced, and vapor anesthesia and intravenous nitroglycerin were administered to maintain uterine relaxation. Following hysterotomy, significant blood loss was noted, prompting administration of oxytocin (33 Units) and tranexamic acid (2 g). The fetus was intubated successfully by the NICU team and delivered. Massive transfusion protocol was initiated, and the patient was given a total of 1,425 mL PRBC, 928 mL FFP, 273 mL of platelets, and 223 mL of cryoprecipitate. Quantitative blood loss was 4,577 mL. Postoperatively, her hemoglobin was 8.7 g/dL, platelets were 61k/uL, PT/INR was 12.8/1.2, and APTT was 38.2.
The patient required uterine artery embolization due to severe peripartum hemorrhage and was treated following development of disseminated intravascular coagulation (DIC). She was extubated on postpartum day 1 and transferred out of the ICU on postpartum day 3.
Discussion: In our case, EXIT was performed due to fetal airway concerns. NICU, pediatric anesthesia, and pediatric surgery prepared a detailed plan for airway management in the event that initial attempts at intubation were unsuccessful. We note that simulation has been shown to enhance team-based performance of EXIT procedures, and our teams held a simulation activity to prepare for this case.
Anesthetic management for an EXIT procedure differs markedly from that of a conventional cesarean section due to the need to maintain uterine relaxation and uteroplacental blood flow. This goal is accomplished with high levels of anesthetic vapor (1.5-3 MAC) as well as tocolytic agents such as nitroglycerin and magnesium sulfate. Bleeding from the hysterotomy incision is a known risk, and in our case, significant bleeding led to massive transfusion, DIC, and uterine artery embolization. Fortunately, multidisciplinary planning enabled our team to ensure appropriate care.
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