Fetal Surgery for Congenital High Airway Obstruction Technique

Updated: Mar 28, 2023
  • Author: Alyssa Eileen Vaughn, MD; Chief Editor: Hanmin Lee, MD  more...
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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 wi Ex-utero intrapartum treatment (EXIT) procedure with fetus maintained on uteroplacental circulation.
Intubation during ex-utero intrapartum treatment ( Intubation during ex-utero intrapartum treatment (EXIT) procedure.

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

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.