Successful ultrasound-guided intraoperative external cephalic version of fetus in breech presentation immediately before ex-utero intrapartum treatment (EXIT) procedure.

Abstract

A 32-year-old pregnant woman was referred to our hospital at 22 weeks of gestation because of fetal ascites. Ultrasound examination revealed massive ascites, enlarged hyperechogenic lungs with diaphragmatic inversion, dilated trachea and polyhydramnios, suggestive of congenital high airway obstruction syndrome (CHAOS) (Figure 1). The patient and her husband consented to undergo an ex-utero intrapartum treatment (EXIT) procedure, however the pregnancy had been complicated by a breech presentation throughout the whole gestational period (Figure 2). For a successful EXIT procedure, we planned to correct the fetal presentation by intraoperative external cephalic version (ECV). At 36 weeks of gestation, deep general anesthesia was achieved with desflurane and an abdominal midline incision was made. We performed an intraoperative ECV from the anterior wall of the uterus using sterile ultrasound guidance. We attempted first a forward roll of the fetus (counterclockwise rotation), which failed owing to the right-sided placental location preventing a forward roll of the fetal head (Figure 2). Therefore, we then attempted a backward roll of the fetus (clockwise rotation) and successfully moved the fetal head to the lower uterine segment. After the transverse incision was made at the lower uterine segment, the fetal head and neck were exposed. It was impossible to insert a tracheal tube through the larynx, thus a surgical airway was established by placement of an endotracheal tube via a tracheotomy. After delivery, congenital laryngeal atresia was confirmed by laryngoscopy (Figure S1). Fetuses with CHAOS cannot survive without appropriate perinatal management, owing to the lack of an airway for ventilation. An EXIT procedure, performed immediately prior to delivery, enables an airway to be secured by laryngoscopy, bronchoscopy or tracheostomy while being maintained on placental support1. Although EXIT procedures in fetuses with CHAOS have been reported many times, reports on its use in a breech case are quite limited. As far as we know, only one such case of intraoperative ECV has been reported previously in the English medical literature2. Miwa et al. describe a fetus with CHAOS in breech presentation, for which ultrasonography was used to map the position ofthe placenta2. During ECV, they first approached from the anterior wall of the uterus, but it was unsuccessful due to the anterior placenta. They therefore performed ECV from the posterior wall of the uterus and consequently the fetus changed to cephalic presentation. However, they did not mention the direction in which the fetus rotated. ECV was originally recognized as a useful approach to reduce the rate of Cesarean section in healthy singleton breech pregnancy3, 4. Generally, a forward roll of the fetus is attempted first, and if unsuccessful a backward flip is attempted5. In our case, we found that the right-sided placental location prevented us from rotating the fetal head (Figure 2). In conclusion, intraoperative ECV using sterile ultrasonography immediately before the EXIT procedure may be an effective technique for management of a fetus in breech presentation. Moreover, it seems that the direction in which to rotate the fetus, according to its position and the placental location, should be given careful consideration in this situation. T. Kanasugi, A. Kikuchi*, M. Murai, Y. Sasaki, C. Isurugi, R. Oyama and T. Sugiyama Department of Obstetrics and Gynecology, Iwate Medical University School of Medicine, 19–1 Uchimaru, Morioka, Iwate 020-8505, Japan *Correspondence. (e-mail: [email protected]) Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.