P016: ANESTHETIC MANAGEMENT AND CHALLENGES OF EX UTERO INTRAPARTUM TREATMENT (EXIT) FOR PEDIATRIC TERATOMA: A CASE REPORT
Matthew J McIntyre, BS; Rohan Dureja, BS; Erick Rodriguez, MD; Paloma Toledo, MD, MPH, FASA
University of Miami / Jackson Memorial Hospital
Introduction: The ex utero intrapartum treatment (EXIT) procedure is a specialized cesarean delivery that maintains uteroplacental circulation during a partial delivery of the fetus to allow time for life-saving procedures to be performed before the umbilical cord is clamped. Common procedures performed during the EXIT procedure include fetal intubation, bronchoscopy, tracheostomy, ECMO cannulation, and tumor resection. Fetal diseases that often call for the EXIT procedure include cervical teratomas, congenital goiters, congenital heart disease, and congenital high airway obstruction syndrome. OB anesthesiologists must ensure optimal placental perfusion and relaxation during delivery and adequate uterine tone following delivery. Furthermore, the EXIT procedure is a highly specialized procedure requiring precise coordination between multiple teams.
Methods: We present the case of a 31-year-old female ASA II-E, G1P0 at 35.2 weeks, 180 cm, 122.7 kg, BMI 37.7, with no significant past medical history, who presented to the OB emergency department for vaginal pressure, yellow discharge, and for additional evaluation due to a known complex fetal mass that was discovered via OB ultrasound in the Bahamas. The pregnancy was complicated by polyhydramnios. OB ultrasound on admission showed a heterogeneous cystic fetal cervical mass with internal vascularity measuring 14.7 x 10.4 x 11.0 cm, concerning for a cervical teratoma. Fetal MRI was consistent with a 12 x 12.6 x 10.0 cm cervical teratoma with intracranial extension and displacement of the trachea. Preoperative labs showed HgB 12.4, Hct 38.6, Plt 256, PT 13.5, INR 1.01, APTT 25, with normal electrolytes.
Results: A plan was devised for the EXIT procedure with subsequent fetal intubation after multidisciplinary discussion with OB/pediatric anesthesiology, MFM, OB, pediatric surgery/ENT, and pediatric ECMO. An arterial line and a 16-G large-bore IV were placed in preop. Four units of PRBC/FFP and one unit of platelets were held in the room. Sodium citrate, ondansetron, famotidine, and midazolam were given before induction. A CSE was performed with intrathecal fentanyl and morphine for post-op pain. RSI with propofol and succinylcholine with video laryngoscopy was performed. Anesthesia was maintained with high-dose sevoflurane with a 1.5 MAC goal to optimize uterine relaxation and placental perfusion. After delivery, nitrous oxide was used to allow for uterine contraction. Sympathectomy and hypotension were managed with a phenylephrine drip and norepinephrine/calcium chloride boluses. The fetus was successfully intubated by ENT. The umbilical cord was clamped. A high-dose oxytocin bolus and drip were started, along with carboprost, for uterine atony. The fetus was stable, and the mother was discharged on post-op day three with no complications.
Discussion: This case discusses the anesthetic management of a maternal EXIT procedure for a fetal cervical teratoma. Careful preparation is required with a multidisciplinary team to ensure optimal outcomes for both the mother and the fetus. The EXIT procedure provides valuable time for essential fetal procedures to be completed while the fetus still receives placental blood flow. High-dose volatile maternal anesthesia is required to maintain adequate uterine relaxation and placental blood flow during the procedure. After complete delivery of the fetus, anesthetic goals shift to prevent uterine atony.