Cesarean to Immediate Neonatal Intervention: A Multidisciplinary Approach to the Perinatal Care of a Pregnancy Complicated by a Fetal Airway Obstruction

Abstract

Paper Presentation Background Oropharyngeal teratomas (epignathus) are rare (1:35,000–200,000) tumors composed of all three germ cell layers. They appear as heterogeneous masses with solid and cystic components and are believed to result from a migration and entrapment of mesoderm and endoderm with ectoderm during embryogenesis of the oral cavity. Fetuses diagnosed with oropharyngeal teratomas are at risk of life-threatening airway obstruction necessitating the establishment of a stable airway, usually with a tracheostomy, while on placental bypass during an ex utero intrapartum treatment (EXIT) procedure or within minutes of birth. Polyhydramnios, preterm labor, and preterm delivery are additional risk factors. We review the multidisciplinary perinatal care of a pregnant woman whose fetus was diagnosed with an oropharyngeal teratoma. Case A 32-year-old, gravida 3, para 1011, presented for initial evaluation at 25 weeks 2 days gestation. A large mass originating from the base of the tongue and protruding from the mouth of the fetus with a volume of 16.5 ml was seen on imaging studies. Mild polyhydramnios was present with an amniotic fluid index (AFI) of 24 cm. Weekly ultrasounds demonstrated the increasing size of the teratoma and AFI. Delivery via an EXIT procedure was scheduled for 35 weeks gestation. At 32 weeks 5 days gestation, the woman presented with an AFI of 48 cm and maternal complaints related to the polyhydramnios. An amnioreduction was performed for 2,000 ml. During fetal monitoring post procedure, late decelerations were noted, and the woman underwent a stat cesarean for placental abruption. A tracheostomy was performed within minutes of delivery, and the infant was subsequently transferred to the NICU. Conclusion Nurses were ideally suited to provide family-centered and holistic care to this woman and her family. Nurses with varying areas of expertise participated in her care in the outpatient and inpatient settings. Throughout the pregnancy continuum, nurses were the primary sources of clinical care, education, and psychosocial support. Timely, articulate communication between nurses at the time of the cesarean facilitated the rapid assembly of the multidisciplinary team and the procurement of the required instruments from the main perioperative area allowing for immediate, successful, neonatal intervention.