Intrapartum Treatment Research Articles

The Acceptability of a Novel Group B Streptococcus Vaccine in Pregnant Women

INTRODUCTION: Group B streptococcus (GBS) is the leading infectious cause of neonatal morbidity and mortality. Currently, intrapartum antibiotic treatment is the only means to decrease vertical transmission. Studies have shown that a vaccine administered during the third trimester is the most cost-effective option for GBS prevention, but the acceptability of such a vaccine to pregnant women is unknown. METHODS: Women 18 years of age or older and 20–40 weeks of gestation at the time of their obstetric visit to two university-affiliated clinics were eligible for participation. Participants read an informational handout on GBS and completed a survey rating, on an 11-point scale (0–10), the likelihood they would elect to receive vaccines with five variable characteristics. Statistical analyses were performed with SPSS 17. Conjoint analysis determined importance scores, which reflected the degree to which vaccine dimensions influenced scenario ratings (the sum of importance scores across the five dimensions 100). RESULTS: One hundred of 120 women approached completed the survey. The mean acceptability rating across all scenarios was 6.7 (standard deviation 2.3). Health care provider recommendation was the most influential (importance score 38.5) followed by vaccine efficacy (importance score 29.1). Vaccine cost (importance score 13.2), percentage of women vaccinated (importance score 11.8), and side effects (importance score 8.3) had less influence on ratings. CONCLUSIONS: When a GBS vaccine becomes available, health care provider endorsement, and therefore preemptive education will be critical in achieving high levels of vaccination in the pregnant population.

Cervical rhabdomyosarcoma and EXIT procedure; case report

A 37 year-old primipara women was referred for management of a large solid tumor found in the neck of her fetus, showing the trachea to be compressed by the mass, and intubation through the ex utero intrapartum treatment (EXIT) was planned. After the mother was anesthetized using a Fentanyl with Isofluorane, the head and left arm of the baby were delivered through a standard lower segment cesarean section, and the baby was intubated with a 3.0 mm tracheal tube before clamping and dividing the umbilical cord, then transferred to a resuscitation table. Time from partial delivery to transfer was 9 min, and the baby weighed 3300 g and quickly achieved acceptable oxygen saturations. A tracheostomy and biopsy of the mass were performed on day 1, and Rhabdomyosarcoma was diagnosed. Multiagent chemotherapy was commenced without any reduction in size (82 × 80 × 70 mm), and radical resection was performed 8 weeks after EXIT. Preoperatively, arterial feeders to the mass arising mainly from the right external carotid artery, were selectively embolized, and surgical excision was performed. After additional chemotherapy and radiotherapy, the child is doing well without recurrence after 3 years of follow-up.

Prenatal consultation with the pediatric otolaryngologist

ObjectivesTo examine the spectrum of fetal head and neck anomalies that may prompt prenatal referral and to determine the frequency of these consultations. Study designCase series with chart review. MethodsThe billing databases of two urban pediatric otolaryngology practices were queried for ICD-9 codes corresponding to fetal anomalies between January 2010 and December 2012. The pediatric otolaryngology practices in this study evaluate all fetal head and neck anomalies referred to their respective institutions, including craniofacial disorders. ResultsOver a three-year period, 53 women presented for fetal otolaryngology consultation, with each practice seeing approximately one consultation every 6 weeks (every 5 weeks (JDS) and every 7 weeks (ARS)). The average maternal and gestational age at presentation were 28.7 years and 27.2 weeks, respectively. 83% of the cases (n=44) involved some form of cleft lip with or without cleft palate. Other head and neck anomalies included fetal goiter/other congenital neck mass (9% (n=5)) and micrognathia (6% (n=3)). Macroglossia (n=1) and facial cleft (n=1) each accounted for 2% of cases. Cleft mothers presented earlier in pregnancy (average 26.8 weeks) than those with a neck mass (average 32.3 weeks) (p<0.05). Only 3 cases (6%) merited ex utero intrapartum treatment. ConclusionsDepending on the referral practices at a given medical center, craniofacial surgeons rather than pediatric otolaryngologists may be evaluating the majority of fetal head and neck anomalies, as orofacial clefts account for most prenatal consultations. The wide spectrum of congenital neck masses may or may not demand monitoring of the airway during the peripartum period.

Fetal anterior neck lump and the patency of airway: The ex-utero intrapartum treatment (EXIT procedure)

<p style="margin-bottom: 0in;">No abstract available. <p style="margin-bottom: 0in;">DOI: <a href="http://dx.doi.org/10.4038/sljog.v35i3.6337">http://dx.doi.org/10.4038/sljog.v35i3.6337</a> <p style="margin-bottom: 0in;"><em>Sri Lanka Journal of Obstetrics and Gynaecology </em>2013; 35: 86-87

Ex-utero intrapartum treatment in the Indian scenario: Anesthetic challenges and positioning

Ex-utero intrapartum treatment (EXIT) is performed for fetuses diagnosed with large neck masses. A case report of a fetus diagnosed with a large cystic hygroma and cord around the neck who was delivered by EXIT is presented. The airway challenges and optimal positioning is discussed.

Cesarean section plus delayed cord clamping approach in the perinatal management of congenital high airway obstruction syndrome (CHAOS): A case report

In this case, we describe a newborn with prenatal diagnosis of congenital high airway obstruction syndrome (CHAOS), successfully managed with a cesarean section with delayed cord clamping 180 seconds. In case of prenatal diagnosis of CHAOS, prompt airway intervention at delivery allows survival of this otherwise fatal condition. Ex utero intrapartum treatment (EXIT) is considered the elective procedure to secure the fetal airway before the baby is completely separated from the maternal circulation. In cases where the EXIT procedure is not possible for maternal reasons (Ballantyne's syndrome), delayed cord clamping may serve as an alternative method to manage CHAOS.

Antenatal detection of an intraglossal ranula on ultrasound and magnetic resonance imaging

A lingual ranula is a rare cystic lesion of the tongue. Ranulas are typically sublingual mucoceles. We report perhaps the first lingual ranula identified in a fetus. It was identified by ultrasound and confirmed by magnetic resonance imaging. Knowledge of the presence of such a large intraoral mass antenatally allows diagnosis, monitoring, assessment of potential airway compromise and delivery planning. The possibility of impending airway compromise caused the planning of an ex-utero intrapartum treatment (EXIT) procedure performed at delivery. Identification of tongue tissue below a cystic intraoral mass suggests a lingual rather than a sublingual origin, a finding which helps stratify the differential diagnosis.

Congenital peribronchial myofibroblastic tumor: prenatal imaging clues to differentiate from other fetal chest lesions

We present a prenatal case of congenital peribronchial myofibroblastic tumor referred as a congenital pulmonary airway malformation (CPAM) with hydrops and polyhydramnios at 30 weeks' gestational age. US and fetal MRI findings did not fit with the referral diagnosis, raising the possibility of intrinsic lung tumor. Fetal hydrops worsened and the baby was successfully delivered by ex utero intrapartum treatment (EXIT) to resection at 31 weeks' gestational age. To the best of our knowledge, this is a unique case of congenital peribronchial myofibroblastic tumor that underwent comprehensive prenatal evaluation and EXIT procedure with good outcome.

P07.11: Diagnostic and perinatal management of fetal cervical teratoma: two cases report of ex utero intrapartum treatment (EXIT)

<scp>P07</scp>.11: Diagnostic and perinatal management of fetal cervical teratoma: two cases report of ex utero intrapartum treatment (<scp>EXIT</scp>)

Perinatal management of congenital oropharyngeal tumors: The ex utero intrapartum treatment (EXIT) approach

PurposeTo present our experience in the perinatal management of fetuses with large oropharyngeal tumors by ex utero intrapartum treatment (EXIT). MethodsWe performed a retrospective chart review of all patients with congenital oropharyngeal tumor who underwent an EXIT procedure between May 2006 and June 2012. ResultsFour patients were included in the series, three females and one male. The diagnoses were epignathus (n=2) and congenital epulis (n=2). Three EXITs were done at term and one at late preterm due to premature rupture of membranes. Median maternal time under anesthesia was 185min (range: 166–281) and median maternal operative time was 99min (range: 85–153). Median maternal blood loss was 550ml (range: 350–2000); one mother required a blood transfusion. Mean maternal hospital stay was 4days. Median hysterotomy-to-cord clamp time was 24min (range: 18–66). Mean fetal birth weight was 2.7kg (range: 2.4–3). The airway was successfully accessed and secured under placental circulation in all cases. In the two patients with congenital epulis the tumors were resected at the base of their pedicles and the airway accessed via direct laryngoscopy before the umbilical cord was clamped. One patient with epignathus underwent a retrograde tracheal intubation under placental circulation and had the tumor resected thereafter. The second patient with epignathus had a tracheostomy done under placental circulation and then had tumor debulking immediately after the EXIT. The maternal morbidity was minimal and there were no mortalities. ConclusionsWe conclude that the EXIT procedure is the ideal delivery strategy for fetuses with prenatally diagnosed oropharyngeal tumors and potential airway obstruction at birth. Patients with prenatally diagnosed oropharyngeal tumors should be promptly referred to a fetal treatment center with a dedicated multidisciplinary team and EXIT capabilities.

Optimizing Outcome: Use of a Checklist for Otolaryngologists Overseeing Ex Utero Intrapartum Treatment (EXIT)

Objectives: Evaluate elements necessary in the decision making and execution during ex-utero intrapartum treatment (EXIT) and operation on placental support (OOPS) procedures to ensure superior outcomes. Methods: Retrospective review of neonatal head and neck obstruction cases from January 1998 to January 2013 at two tertiary referral centers. Main outcome measures: Data regarding prenatal care, delivery details, pathology of lesion, and postnatal course. Results: From 1998-2013, 13 of the 15 cases of prenatally-diagnosed potentially severe head and neck obstruction used an EXIT or OOPS procedure to secure the airway. The decision making process leading to whether an EXIT procedure needed to be performed was reviewed. Additionally, we analyzed elements that must be addressed in the checklist, including defined tasks for the specialties of perinatology, neonatology, anesthesia, fetal imaging, pediatric otolaryngology, and operative services to optimize outcome. Equipment and space needs are addressed as well. Multidisciplinary rehearsal of the procedure is strongly recommended, with the pediatric otolaryngologist leading the process. We offer a comprehensive checklist for the otolaryngologist overseeing such procedures. Conclusions: Medical checklists are increasingly being used to ensure safety and improve outcomes in complex patient care situations. Obstructive masses of the head and neck in the fetus present a difficult and potentially fatal clinical problem. Based on our experience, we offer the otolaryngologist a structured and well-choreographed approach in dealing with such complex situations, with the incorporation of a comprehensive checklist for EXIT procedures.

Lingual choristoma with gastric and respiratory epithelium in a neonate-prenatal MRI of lingual cyst

Abstract The lingual cyst lined by respiratory and gastrointestinal epithelium is unusual. There have been reports of respiratory or gastrointestinal epithelium-lined lingual cysts, but few report both features presenting within the same cyst. Prenatal diagnosis of lingual cysts is exceptional with only few case reported to date. Prenatal magnetic resonance imaging in utero is the best complete investigation of the nature and anatomical relationship of the congenital lingual cyst. It makes us to prepare for emergency situation and EXIT (Ex-utero intrapartum treatment) operation.

Multidisciplinary perinatal management of the compromised airway on placental support: lessons learned

The aims of this study were to review fetal and maternal outcomes after management of the compromised perinatal airway via operation on placental support or ex utero intrapartum treatment and to discuss implications for future management of these complex and rare cases. We have presented a retrospective case series of 12 neonates requiring airway management on placental support at a single tertiary care, academic center. One mother experienced significant blood loss. Operative recovery times were unremarkable. Eight neonates required airway management due to mass obstruction, two for removal of an endotracheal balloon for fetoscopic treatment of congenital diaphragmatic hernia, one for laryngeal atresia, and one for severe retrognathia. One of our series is an unusual case of management on placental support after vaginal delivery. Another child would have ideally been managed on placental support, but an extremely short umbilical cord prevented this. Even though the airway was secured in all 12 cases, five neonates died in the perinatal period. These procedures have a risk for substantial maternal blood loss. Despite excellent rates of success securing the neonatal airway, children who require management on placental support still have high mortality. A formalized multidisciplinary approach at our institution has enhanced preparedness for these cases.

Pregnancy in the severely mentally ill patient as an opportunity for global coordination of care

Although obstetricians commonly care for pregnant patients with psychiatric disorders, little has been written about the implications of managing a pregnancy during a prolonged psychiatric hospitalization for severe mental illness. Multidisciplinary care may optimize obstetric and psychiatric outcomes. We describe a severely mentally ill patient at 27 weeks' gestation (G1P0) who was admitted after a suicide attempt. She exhibited intermittently worsening depression and anxiety throughout a 2-month inpatient psychiatric hospitalization, during which her psychiatric and obstetric providers collaborated regarding her care. We review recommendations for antepartum and intrapartum treatment of the acutely suicidal and severely mentally ill patient and, in particular, the evidence that a multidisciplinary coordinated approach to planning can maximize patient physical and mental health and facilitate preparedness for delivery.

Ex-utero-intrapartum-treatment-Manöver

The ex utero intrapartum treatment (EXIT) procedure is used for unborn fetuses in cases of predictable complications of postpartum airway obstruction. Indications for the EXIT procedure are fetal neck tumors, obstruction of the trachea, hiatus hernia of the diaphragm and congenital high airway obstruction syndrome (CHAOS). Large cervical tumors prevent normal delivery of a fetus due to reclination of the head with airway obstruction. Therefore, a primary caesarean section or the EXIT procedure has to be considered. The EXIT procedure has time limitations as the blood supply by the placenta only lasts for 30-60min. Airway protection has to be ensured during parturition.This article reports the case of an unborn fetus with a large cervical teratoma where an obstruction of the cervical airway was detected and monitored by ultrasound and magnetic resonance imaging (MRI) during pregnancy. The EXIT procedure was therefore used and successfully accomplished. The features of the interdisciplinary aspects of the EXIT procedure are described with the special aspects of each medical discipline.

The ex utero intrapartum treatment (EXIT) procedure: Application of a new therapeutic paradigm

The ex utero intrapartum treatment (EXIT) procedure is a term given to a technique that can transform a potentially fatal neonatal emergency to a controlled intervention with an improved outcome. It has revolutionised the care of prenatally diagnosed congenital malformations in which severe upper airway obstruction is anticipated. An extended period of utero-placental circulation can be utilised to avoid profound cardiopulmonary compromise. Its therapeutic applications have been broadened to include fetuses with congenital diaphragmatic hernia after tracheal plugging, high-risk intrathoracic masses, severe cardiac malformations and conjoined twins. It requires the co-ordination of a highly skilled and experienced multidisciplinary team. The recent enthusiasm for the EXIT procedure needs to be balanced against maternal morbidity. Specific indications and guidelines are likely to be refined as a consequence of ongoing advances in fetal intervention and antenatal imaging.

Maternal morbidity and reproductive outcomes related to fetal surgery

PurposeThe purpose of this manuscript was to examine the maternal morbidity and reproductive outcomes following maternal–fetal surgery with an emphasis on the EXIT procedure. MethodsThe medical records of all women who underwent an ex-utero intrapartum treatment (EXIT) procedure or mid-gestation open maternal fetal surgery (OMFS) at our center from December 2001 to December 2011 were reviewed retrospectively. Future reproductive outcomes were obtained via telephone questionnaire. ResultsThirty-three women underwent maternal–fetal surgery. Twenty-six had EXIT, and seven had OMFS. The questionnaire response was 82% (27/33). Eighty-one percent (17/21) of the EXIT cohort desired future pregnancy. All who attempted (13/13) were successful. The majority (85%) conceived spontaneously and within 2.5years on average. In the OMFS group, 40% experienced complications. One had uterine dehiscence, and another had uterine rupture requiring urgent delivery at 36weeks. In subsequent pregnancies, 20% of OMFS cases were complicated by uterine rupture, and 8% of EXIT patients had uterine dehiscence. All had good maternal–fetal outcome. ConclusionFuture reproductive capacity and complication rates in subsequent pregnancies following EXIT procedure are similar to those seen in the general population. In contrast, mid-gestation OMFS remains associated with relatively morbid complications. This evidence can help guide in counseling expectant mothers who are faced with the challenge of considering fetal surgery.

An ex utero intrapartum treatment procedure in a patient with a family history of malignant hyperthermia

In the EXIT (ex utero intrapartum treatment) procedure, after uterine incision, uterine relaxation is maintained to prevent placental separation and the fetus is supported via the placenta until the airway is successfully established. The traditional method to maintain uterine relaxation is with the use of high-dose potent inhaled anesthetics during general anesthesia. A patient with a family history of malignant hyperthermia required an EXIT procedure. The history of malignant hyperthermia precluded the use of potent inhaled anesthetics and an alternate plan using propofol and remifentanil infusions for anesthesia and nitroglycerin 16μg/kg/min for uterine relaxation allowed for good surgical conditions. The presence of malignant hyperthermia required an alternate plan and close collaboration in order to ensure good patient outcome.

The use of remifentanil in ex utero intrapartum treatment procedures

Purpose: We propose that using remifentanil in ex utero intrapartum treatment (EXIT) procedures reduces the need for maternal exposure to general anesthesia. Using remifentanil along with spinal anesthesia eliminates the fetal and maternal risks associated with inhalational general anesthesia, allows the mother to be awake, and obviates the need for and costs associated with general anesthesia and a second anesthesia team. Materials and Methods: We performed a retrospective review of all sequential patients undergoing ex utero intrapartum treatment procedure at our hospital from 1/1/2009 to 11/1/2010. All procedures were performed under regional neuraxial analgesia, using nitroglycerine as a tocolytic agent and remifentanil for analgesia. Variables included indication, time to secured fetal airway, complications, estimated blood loss, need for additional anesthetics, participating personnel, and survival. Results: All five of our ex utero intrapartum treatment procedures were successfully completed with combined spinal epidural remifentanil anesthetic. No patient was required additional alternative anesthetic. There were no complications with mother or fetus. Indications for procedure were arthyrogryposis (n = 3), fetal goiter, and micrognathia. Average time to secured airway was 10.25 minutes. Average estimated blood loss was 1010 ml. All five mothers were conscious during their procedure. Conclusions: We report the largest series of ex utero intrapartum treatment procedures performed with remifentanil regional anesthesia. We found that the combined use of nitroglycerin and regional remifentanil anesthesia is a safe alternative to the pediatric otolaryngologist for performing ex utero intrapartum treatment procedures without the risks of general anesthesia, allowing the mother to be awake for the delivery, and reducing the cost of providing care.

Marqueurs systémiques de l’inflammation et dilatation des bronches à l’état stable

To identify prenatal diagnostic features that will help select fetuses with lung masses (LM) who may benefit from ex-utero intrapartum treatment (EXIT procedure) as the preferred mode of delivery.The CCAM–volume ratio (CVR), fetal treatment, and outcomes of all fetuses with LM evaluated between 2001 and 2011 were reviewed retrospectively. Fetuses with hydrops or CVR > 1.6 were classified as high risk. Indications for fetal interventions included hydrops and heart failure, and indication for EXIT-to-resection was the finding of persistent mediastinal compression (PMC) near birth.Of 110 fetuses evaluated for LM, 78 were classified as low-risk. No fetus in this group had PMC near birth and none required perinatal treatment. Of 32 high-risk fetuses, 8 developed heart failure of which 4 survived (3 following fetal surgery). Nine high-risk fetuses with no PMC near birth were asymptomatic postnatally and treated electively. Sixteen high-risk fetuses had PMC near birth. All 9 babies with PMC treated with EXIT-to-resection did well with discharge at a median of 10 days post-operatively. All 7 fetuses treated without an EXIT developed respiratory distress following birth requiring an urgent operation; 2 died.The EXIT-to-resection procedure is a favorable delivery approach for those fetuses with large LM and PMC near birth.