Approach Considerations
No definitive management strategy has been delineated for fetuses identified with cervical masses and hydrops early in gestation. One current practice is to offer an ex-utero intrapartum treatment (EXIT)-to-airway procedure for viable fetuses with a concerning airway. [21] Antenatal imaging findings that predict the need for an EXIT-to-airway procedure include the following [22] :
-
Location of the mass
-
Presence of an invasive component into the airway
-
Relationship to the airway
Ex-Utero Intrapartum Treatment (EXIT) Procedure
During the procedure, all necessary personnel should be present in the operating room.
EXIT deliveries can lead to tremendous blood loss, in that tocolytics and inhaled anesthetics are used to obtain uterine atony, which, in turn, maintains placental blood flow. To minimize blood loss during the hysterotomy, a specific uterine stapler device with absorbable staples (US Surgical Corporation, Norwalk, CT) is required.
It is paramount to preserve placental blood flow, which requires profound uterine relaxation and caution when entering the uterus. With anterior placentas, a posterior uterine incision is frequently required in an attempt to avoid placental injury and chorioamniotic separation, which can disrupt uteroplacental gas exchange. Additionally, caution should be taken to minimize manipulation of the umbilical cord, which may result in vessel spasm and compromised blood flow. Amnioinfusion with normal saline is employed to reduce the risk of decelerations and fetal distress.
With the fetus still on placental support, the head and one arm are exposed through the uterine incision. A pulse oximeter is then placed on the fetal hand to continuously monitor fetal oxygenation.
At this point, the mass and the airway are evaluated with direct laryngoscopy. If endotracheal intubation is not possible, bronchoscopy may be attempted. If this is unsuccessful, the next step is tracheostomy.
Rarely, resection of the mass during the EXIT procedure is needed to establish an airway. All equipment, including the laryngoscope, must be sterile to minimize the chances of maternal infection.
Once the airway is established, the fetus is delivered and the umbilical cord divided. The uterus and the abdominal wall are closed in the same technique as a cesarean section.
Complications
Esophageal and tracheal obstruction are common complications, leading to polyhydramnios, hydrops fetalis, and in-utero fetal demise (IUFD). Perinatal complications include asphyxia and death. [23, 24] The diagnosis of a fetal cervical lesion is not to be taken lightly, in that it carries an estimated IUFD rate of 20%. [25] However, when an EXIT procedure involves a multidisciplinary team, the perinatal outcome is improved and the safety of both mother and fetus enhanced.
-
Cervical Teratoma in an infant delivered via EXIT procedure
