Approach Considerations

A low transverse abdominal incision is used to expose the uterus. Placental position is mapped by means of sterile intraoperative ultrasonography (US).

Ex-Utero Intrapartum Treatment (EXIT) Procedure

During the ex-utero intrapartum treatment (EXIT) procedure, continuous fetal pulse oximetry is used to monitor fetal oxygenation. US is additionally employed to monitor the fetal heart during the procedure. With uteroplacental support in place (see the first image below), endotracheal intubation is attempted (see the second image below).

Ex-utero intrapartum treatment (EXIT) procedure with fetus maintained on uteroplacental circulation.

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Intubation during ex-utero intrapartum treatment (EXIT) procedure.

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If endotracheal intubation is unsuccessful, rigid bronchoscopy with or without wire tracheoplasty is attempted. If this fails, a tracheostomy is performed (see the image below).

Tracheostomy performed during ex-utero intrapartum treatment (EXIT) procedure for difficulty obtaining oral airway.

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EXIT deliveries can lead to tremendous blood loss. Tocolytics and inhaled anesthetics are used to reduce contractions, and these agents frequently result in uterine atony, which contributes to substantial potential blood loss. To minimize blood loss during the hysterotomy, a specific uterine stapler device with absorbable staples is required.

It is paramount to preserve placental blood flow during the procedure, which requires profound uterine relaxation and caution in entering the uterus. Anterior placentas frequently necessitate a posterior uterine incision in an attempt to avoid placental injury and chorioamniotic separation, which can disrupt uteroplacental gas exchange. Additionally, care should be taken to minimize manipulation of the umbilical cord, which may result in vessel spasm and compromised blood flow.

If necessary, the procedure can last several hours.

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Media Gallery

Ex-utero intrapartum treatment (EXIT) procedure with fetus maintained on uteroplacental circulation.
Intubation during ex-utero intrapartum treatment (EXIT) procedure.
Tracheostomy performed during ex-utero intrapartum treatment (EXIT) procedure for difficulty obtaining oral airway.
Fetoscopic approach for in-utero tracheoplasty.

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Author

Alyssa Eileen Vaughn, MD Resident Physician, Department of Surgery, University of Colorado School of Medicine; Research Fellow in Pediatric Surgery, Children's Hospital of Colorado

Alyssa Eileen Vaughn, MD is a member of the following medical societies: American College of Surgeons, Association for Academic Surgery, Association of Women Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Shinjiro Hirose, MD Clinical Assistant Professor of Surgery, Pediatrics, and Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, School of Medicine; Clinical Director, Division of Pediatric Surgery, Director of Surgical Services, Fetal Treatment Center, Surgical Director of ECMO Services, Division of Pediatric Surgery, Department of Surgery, UCSF Medical Center

Shinjiro Hirose, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, International Fetal Medicine and Surgery Society, International Pediatric Endosurgery Group, Pacific Association of Pediatric Surgery

Disclosure: Nothing to disclose.

S Christopher Derderian, MD, FAAP Assistant Professor of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine; Pediatric and Fetal Surgeon, Pediatric and Fetal Surgery Program Lead, Children’s Hospital Colorado

S Christopher Derderian, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, International Fetal Medicine and Surgery Society, North American Fetal Therapy Network

Disclosure: Nothing to disclose.

Chief Editor

Hanmin Lee, MD Professor of Surgery, Pediatrics, Obstetrics/Gynecology and Reproductive Health Sciences, University of California, San Francisco, School of Medicine; Chief, Division of Pediatric Surgery, Director, Fetal Treatment Center, Michael R Harrison, MD, Endowed Chair in Fetal Surgery, Surgeon-in-Chief, UCSF Benioff Children’s Hospital

Hanmin Lee, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, Society of American Gastrointestinal and Endoscopic Surgeons, Society of University Surgeons, International Pediatric Endosurgery Group

Disclosure: Nothing to disclose.

Sections Fetal Surgery for Congenital High Airway Obstruction
Overview
Periprocedural Care
Technique
Media Gallery
References

Fetal Surgery for Congenital High Airway Obstruction Technique

Approach Considerations

Ex-Utero Intrapartum Treatment (EXIT) Procedure

References

Tables

Contributor Information and Disclosures

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