Intrapartum Therapy Research Articles

Neuraxial anesthesia in ex utero intrapartum therapy for parturients with fetal congenital diaphragmatic hernia: a prospective observational study

BackgroundCongenital diaphragmatic hernia (CDH) is characterized by defects in the fetal diaphragm and thoracic herniation of the abdominal viscera. The ex utero intrapartum treatment (EXIT) procedure is used to establish the fetal airway while on placental support. These EXIT procedures are commonly performed under general anesthesia, which increases maternal bleeding and the risk of insufficient placental perfusion subsequently. This study investigated the feasibility of performing neuraxial anesthesia for the EXIT procedure for fetal congenital diaphragmatic hernia to improve outcomes. MethodsParturients with fetal CDH who underwent an EXIT procedure between January 2019 and May 2021 in our institution were recruited. Variables evaluated included gestational age, surgical time, intra-operative blood loss, peri-operative hemoglobin, maternal complications, fetal lung-to-head ratio, time on placental bypass, and postnatal outcome. ResultsTwenty-two cases were included. All procedures were performed under neuraxial anesthesia. The median gestational age at the time of the EXIT procedure was 37 weeks. The median estimated blood loss was 200 mL. There was no report of an adverse maternal event. The placental bypass time was 142.9 ± 72.6 s, and access to the airway was successfully established within the bypass time. Twenty-one neonates reached an Apgar score of 9 at 5 min. In the first two hours after birth, the average pH of neonatal peripheral arterial blood was 7.35 ± 0.07 (n=19), and lactate level 1.85 ± 0.71 mmol/L (n=19). ConclusionsIn the EXIT procedure to establish an airway for fetal CDH, neuraxial anesthesia proved a feasible technique for maternal anesthesia.

Late referral of fetal congenital cystic adenomatoid malformation in COVID-19 pregnant women: Diagnostic and management dilemma from limited resource setting country: Case report

we reported a case of late congenital cystic malformation (CCAM) diagnosis with problematic COVID-19 infected condition during delivery and dilemmatic neonatal management. A 24-year-old pregnant woman, second pregnancy, came very late in pregnancy (38 weeks gestational age), misdiagnosed with congenital diaphragmatic hernia. Our ultrasound examination revealed congenital cystic malformation type-1 in the right lung, with some of the normal lung lobes. The Left side lung was normal. CCAM volume ratio (CVR) 2,79 cm. Due to COVID-19 infection, our multidisciplinary team decided to perform quick chest tube insertion during the ex-utero intrapartum therapy (EXIT) procedure to avoid pneumothorax complications continued with intubation for the newborn. Neonatal middle right lung lobectomy was done after optimal condition at 20 days old with pathology anatomic result of CCAM type 1. The diagnosis, type, and prognosis of CCAM should be established earlier to make enough time for the better-prepared multidisciplinary management of the newborn.

Ex utero intrapartum therapy in infants with congenital diaphragmatic hernia: a propensity score matching analysis

ObjectivePrevious studies have shown that ex utero intrapartum therapy (EXIT) is safe and feasible for newborns with congenital diaphragmatic hernia (CDH). This study reports our experience with EXIT in fetuses...

Surgical management of complex neonatal airway abnormalities.

The neonatal airway is subject to a variety of developmental abnormalities with a wide range of complexity. Symptomatic pathologies present in a spectrum ranging from simple noisy breathing or poor feeding to frank respiratory distress. Diagnosis requires a high index of suspicion, characterization of noisy breathing, and identification of obstructive symptoms such as increased work of breathing, retractions, and difficulty feeding. Surgical management is directed by the pathology. The past several years have seen an expansion of surgical innovation as endoscopic and open techniques have evolved. We reviewed articles related to neonatal and infant airway diagnoses since 2020 with the goal of providing a current review and update of developing techniques. Specifically, we discuss some of the exciting trends in surgical management of vocal fold paralysis, laryngeal clefts, subglottic stenosis, tracheobronchomalacia as well as the role of ex utero intrapartum therapy (EXIT procedures). An underlying theme in evolving surgical management is the exciting advancements in technology, including 3-D printing, and expansion of minimally invasive endoscopic techniques. Though some of these developments are in the initial stages of utilization, they may be potential sources to transform surgical management in the future.

Prenatal Diagnosis of Fetal Oral Masses by Ultrasound Combined With Magnetic Resonance Imaging.

To analyze the imaging manifestations of common fetal oral masses by ultrasound combined with magnetic resonance imaging (MRI) and to discuss their differential diagnoses. A retrospective study of 6 fetuses with oral masses was performed at a tertiary referral center. The imaging features of prenatal ultrasonography and MRI in the diagnosis of fetal oral masses were analyzed. Histopathological examination and/or postpartum ultrasound revealed lymphangioma malformation in 2 fetuses, and mucosal retention cyst, mature teratoma, immature teratoma, and cranial meningocele in 1 fetus, respectively. The teratoma had a characteristic sonographic appearance. In our study, the 4 cases of cystic masses did not have an abnormal vessel architecture. Supplemental MRI revealed a mass effect at the level of the hypopharynx, and in 2 cases with polyhydramnios, the mass obstructed the fetuses' upper airway. Thus, ex-utero intrapartum therapy surgery was performed to secure the newborn's airway. Oral fetal tumors represent rare congenital malformations. This study shows that a prenatal diagnosis of oral masses is feasible by ultrasound examination. MRI can further confirm the results of ultrasonography and clearly show the relationship between the mass and the hypopharynx. Ultrasonography combined with MRI could, to a large extent, facilitate early detection and appropriate treatment and improve outcome.

Lymphatic malformations adjacent to the airway in neonates: Risk factors for outcome

PurposeTo evaluate imaging, treatment, and outcomes in neonates with a lymphatic malformation (LM) adjacent to the airway and to evaluate risk factors that can predict outcome. MethodsA retrospective case series was conducted of ten patients treated between January 2011 and July 2019. The main outcome measures included airway compromise and clinical response to sclerotherapy ± surgery. Categorical data were compared using the Fisher's exact test. ResultsEx-utero intrapartum therapy was performed in four cases, among whom one died due to sepsis. All patients underwent schlerotherapy, with surgical debulking in two. Four patients showed a good clinical response, and five started experimental systemic treatment. Patients with bilateral disease and patients with an LM with >180° tracheal surrounding were significantly at risk for airway compromise (bilateral: n = 6/6 versus n = 0/4, p = 0.005; >180°: n = 5/5 versus n = 1/5, p = 0.048). The need for LM treatment in the neonatal period was indicative of a poor clinical response (‘non-responders’ 5/6, ‘responders’ 0/4; p = 0.048). ConclusionsThis study indicates that bilateral disease and >180° tracheal surrounding are risk factors for airway compromise in neonates with an LM adjacent to the airway. In addition, the need for early treatment seems to be indicative of a poor clinical response.

REVIEW ARTICLE ON PROSPECTIVE ANALYSIS OF PRISCRIPTION PATTERN OF ANTIMICROBIAL THERAPY FOR URINARY TRACT INFECTION IN PREGNANT FEMALE PATIENT

Urinary tract infection (UTI) are common during pregnancy. These most common causative organism is E.coli.1 A urinary tract infection (UTI) is an infection in any part of urinary system including kidney, ureters, bladder and urethra.2 The urinary can be divided into the upper urinary tract and the lower urinary tract. The upper urinary tract consist of the kidney and ureters and lower urinary tract consist of the bladder and the urethra.2 UTI can be classified by anatomic site of involvement into lower and upper urinary tract infection.3 
 Asymptomatic bacteriuria can lead to the development of cystitis and pyelonephritis. All pregnant women should be screened for bacteriuria and subsequently treated with antibiotics such as Nitrofurantoin, sulfisoxazole,or cephalexin.
 can be life threatening illness, with the increased risk of Perinatal and Neonatal mobility.
 Pregnant women with urinary group B Streptococcal infection should be treated and should receive intrapartum prophylactic therapy.

Antepartum and Intrapartum Characteristics Associated With Postpartum Blood Transfusion [03M

INTRODUCTION: Risk assessment is the first step in an Obstetrics Hemorrhage Safety Bundle. Accurate elucidation of prenatal and intrapartum risk factors can facilitate the reduction of severe maternal morbidity and mortality due to postpartum hemorrhage. METHODS: Retrospective cohort study of 27,886 women evaluated for antepartum and intrapartum factors associated with postpartum blood transfusion. Univariate and multivariate logistic regression and propensity score analyses were performed, and odds ratio were derived. P-values<0.05 were considered statistically significant. RESULTS: 245 of 27,886 mothers required blood transfusion. On multivariate logistic regression adjusting for all factors, statistically significant independent associations of blood transfusion were general anesthesia (OR 6.01; P=.0002), severe preeclampsia (OR 3.34; P<.0001), chorioamnionitis (OR 3.09; P<.0001) and the use of multiple methods for cervical ripening (OR 2.03; P=.0098). Milder independent associations were previous cesarean delivery (OR 1.83; P=.0037), gestational hypertension (OR 1.55; P=.0283), and gestational diabetes (OR 1.55; P=.0410). Using propensity score inverse probability of treatment weighting multivariable model, independent associations of blood transfusion were cervical dilation on admission <2 cm, effacement <60%, and station <-3, duration of all stages of labor (all P<.0001) and intrapartum therapy with intravenous anti-hypertensives (ORPS 2.53; P<.0001), Magnesium (ORPS 2.94; P<.0001), opioids (ORPS 2.17; P<.0001), Clindamycin/Gentamicin (ORPS 3.91; P<.0001), and uterotonics (ORPS 14.3; P<.0001). CONCLUSION: Treatment of intrapartum complications contribute more to the need for blood transfusion than prenatal risk factors. Avoiding general anesthesia, reducing labor induction and prolonged labor are potential preventable causes of postpartum hemorrhage requiring blood transfusion.

Perinatal Outcome of Patients Undergoing Ex-Utero Intrapartum Therapy at the Fetal Therapy Units of Two Reference Centers in Bogota, Colombia

Perinatal Outcome of Patients Undergoing Ex-Utero Intrapartum Therapy at the Fetal Therapy Units of Two Reference Centers in Bogota, Colombia

P09.03: MR of fetal neck and face masses: prediction of high morbidity neonatal outcome, including ex utero intrapartum therapy (EXIT)

P09.03: MR of fetal neck and face masses: prediction of high morbidity neonatal outcome, including ex utero intrapartum therapy <b>(</b>EXIT)

Prognostic significance of an antenatal magnetic resonance imaging staging system on airway outcomes of fetal craniofacial venolymphatic malformations

BackgroundThe aim of the article was to determine if anatomical findings on fetal magnetic resonance imaging (MRI) of venolymphatic malformations of the face and neck (VLMFN) can be used to create a staging system predictive of airway outcomes. MethodsWe reviewed 13 fetuses evaluated for VLMFN. Stage was assigned based on anatomical findings on fetal MRI. Stage I: no evidence of polyhydramnios with free egress of amniotic fluid and clear visualization of the aryepiglottic folds and larynx. Stage II: lesions of the tongue or epiglottis but with normal aryepiglottic folds without polyhydramnios. Stage III: lesions of the tongue or larynx; nonvisualization of the aryepiglottic folds without free egress of amniotic fluid along with polyhydramnios. ResultsSix met stage I criteria with no airway involvement, nor any subsequent issues. Two met stage II criteria and were managed by ex-utero intrapartum therapy and intubated. One had minimal involvement of the upper airway, was extubated, and had no subsequent issues. Child two had involvement of the tongue and larynx and received a tracheostomy. Five were assigned stage III, delivered by ex-utero intrapartum therapy and intubated. Postnatal evaluation showed involvement of the upper airway by the lesion and was managed with tracheostomy. All treated by tracheostomy remain cannulated because of persistent symptomatic lesions at follow-up (relative risk 4.0; confidence interval 1.2-13.3). Median follow-up was 4 y (range 2-7 y). ConclusionsAlthough numbers are small, data suggest anatomical details obtained by antenatal fetal MRI appear to correlate with airway outcomes in children affected by a VLMFN. This information may be useful when counseling expectant families of affected fetuses.

Anesthetic Management of 65 Cases of Ex Utero Intrapartum Therapy: A 13-Year Single-Center Experience.

The anesthetic management for open fetal surgery has been described, but many therapeutic tenets have not been supported with data. We present data on the anesthetic management and outcomes of 65 patients undergoing ex utero intrapartum therapy procedures at the Children's Hospital of Philadelphia between 1998 and 2011. Patients were identified, and medical records were retrospectively reviewed. Maternal general anesthesia combined with postoperative epidural analgesia was commonly used. High levels of volatile anesthetic were used for uterine relaxation. Case characteristics such as fetal procedure, operative time, blood loss, transfusion requirements, vasopressor use, and fetal resuscitative measures are described.

Can we make an accurate diagnosis of pyriform sinus fistula by fetal MRI?

To review the fetal magnetic resonance imaging (MRI) features of pyriform sinus fistula (PSF) and to compare them with the postnatal clinical and surgical findings. The relevant medical literature is also discussed. The location, shape, signal, effects of adjacent structures and in utero changes detected on fetal MRI were reviewed in three cases of PSF. The patient's respiratory status at birth, the application of ex utero intrapartum therapy (EXIT), infectious complications in the neonatal period, and the surgical and pathological findings were also reviewed and discussed. The study consisted of three pregnant women between 18 and 38 years of age, each with a single fetus. Fetal MRI was performed at 26 and 38 weeks of gestation in case 1, at 34 weeks of gestation in case 2, and at 34 and 38 weeks of gestation in case 3. Postnatal clinical follow-up extended from 9 months to 3 years. All lesions were well-circumscribed unilobular cysts with slightly thickened walls at the neck area. Case 1 was irregular in shape, and the other two cases were oval and extended longitudinally along the neck. The fluid contents showed signals consistent with amniotic fluid. Close contact with the thyroid gland was demonstrated to be a fairly characteristic feature that could be recognised on fetal MRI. The in utero follow-up detected slight changes in the signal, wall characteristics, contour, and airway deviation. Case 1 was bilaterally affected, causing it to be initially mistaken as macro-cystic lymphangioma. The diagnosis was corrected with the aid of postnatal imaging; however, a prenatal diagnosis was correctly made in cases 2 and 3. Airway obstruction was not observed in any of the three cases, and thus, EXIT was not applied. The fetal MRI findings were in good agreement with the postnatal clinical and surgical findings. In addition to the higher spatial delineation provided by fetal MRI, as described in the literature, the observation of close contact with the thyroid gland and a flattened deformity of the thyroid gland are other characteristic features. Fetal MRI is useful for displaying characteristics of PSF that can enable an accurate prenatal diagnosis.

Ex-utero Intrapartum Treatment (EXIT) Procedure for Giant Fetal Epignathus.

Large fetal oropharyngeal tumors are rare, and have the potential to cause airway obstruction during birth. A 35-year-old woman with antenatally diagnosed large heterogenous mass in fetal neck displacing trachea and filling up the orophanygeal space. The infant was delivered at 31 weeks of gestation by ex-utero intrapartum therapy procedure to secure the airway. Tumor was resected successfully on day 8 of life. Histopathology revealed mixed teratoma. Ex-utero intrapartum therapy for fetuses with severe upper airway compromise may prove life-saving.

Fetal Oropharyngeal and Neck Tumors: Determination of the Need for Ex-Utero Intrapartum Treatment Procedure.

The aim of this study was to assess the ex-utero intrapartum therapy (EXIT) applied to 3 of the 7 cases with oropharyngeal or neck masses and review the indicators of the need for an EXIT procedure. Prenatal presentation, size and localization of the masses, existence of fetal hydrops and associated findings such as polyhydramnios, intraoperative managements, complications, and maternal and neonatal outcomes were evaluated through a retrospective analysis. Four cases had neck masses and three cases had oropharyngeal masses. Prenatal sonography was used as the main diagnostic tool for all patients. The median gestational age was 34.5 weeks at the time of diagnosis and 36 weeks at delivery. Polyhydramnios was observed in three of the seven cases and they were delivered prematurely. Interventions such as endotracheal intubation or tracheostomy were performed to provide patency of the airway during delivery by the EXIT procedure in three cases. Hemangioma was found in two cases, teratoma in two cases, lymphangioma in two cases and hamartoma in one case following pathological examination of the masses. The localization of mass, its characteristics, invasion (if it exists), and relation to the airway are the main factors used to determine the need for EXIT. The presence of polyhydramnios may be an important indicator to predict both the need for EXIT and fetal outcomes.

Shnider and Levinson’s Anesthesia for Obstetrics, Fifth Edition

Most practicing physician anesthesiologists in community hospitals and teaching hospitals are obliged to cover obstetrical anesthesia during the work day and call coverage, which may be the most stressful part of a practice. Keeping up with the literature specific to obstetric anesthesia may be a challenge to the busy practitioner. The revised and updated 5th edition of Shnider and Levinson’s Anesthesia for Obstetrics will significantly help with this.It has been 11 yr since the 4th edition of Shnider and Levinson’s Anesthesia for Obstetrics was released. There have been advances in the field of obstetric anesthesiology since then, focusing on neonatal resuscitation and management of neonatal neurologic injury. The editors in the new edition were eager to improve the content by providing the most up-to-date information, while preserving the original quality of the text as they did in the 4th edition.The updated edition is divided into 11 parts. The first section reviews physiology and pharmacology. The initial topic focuses on the areas of uteroplacental circulation, physiological changes of pregnancy, and placental transfer of drugs. The second, third, and fourth parts cover assessment of fetus, labor analgesia, and anesthesia for cesarean delivery. This goes in depth looking at intrapartum fetal monitoring as well as regional anesthesia techniques. The fifth, sixth, and seventh portions cover neonatal concepts of wellbeing, anesthetic considerations for obstetric complications, and management of anesthetic complications. There is in depth look at abnormal fetal positions, obstetric hemorrhage, NPO controversies, and postdural puncture headaches management.The latter sections cover anesthetic management of parturients, ethical challenges, maternal morbidity and mortality. Very difficult topics we face are covered, including the Jehovah’s Witness patient, trauma resuscitation, and the global perspective of obstetric anesthesia. Some detail is provided for in vitro fertilization and nonobstetric surgery during pregnancy. Fortunately, given its emergence and growing popularity, the newer, ex utero intrapartum therapy surgical procedure is discussed.The appendix has updated guidelines for neuraxial anesthesia and practice guidelines for obstetric anesthesia along with intrapartum fetal heart rate monitoring.Shnider and Levinson’s chapters are well organized, contain excellent depth, and are informative. The online access offers a full version site with full images to view.What sets this text apart is the detail in each of its chapters. For those of us who cover obstetric anesthesiology regularly while on call, a review of it is a must. This is an excellent resource for the clinician in training, such as residency or fellowship, or in practice. The chapters are detailed, with complete images, and online access make this a must own reference. The only area for future improvement would be adding ultrasound-guided neuraxial techniques, given the trend in anesthesiology.I strongly recommend this book as a priceless addition to the library of any well-rounded anesthesiologist who covers obstetrics full time or part time.

Tracheal agenesis with tracheoesophageal fistulae: fetal MRI diagnosis with confirmation by ultrasound during an ex utero intrapartum therapy (EXIT) delivery and postdelivery MRI

Tracheal agenesis is a rare and essentially lethal anomaly with divergent prenatal imaging findings depending on the presence or absence of a tracheoesophageal fistula. All prenatally diagnosed cases of tracheal agenesis reported to date have not had a tracheoesophageal fistula and presented with thoracoabdominal findings similar to congenital high airway obstruction syndrome. We present the case of a 32-week gestation fetus with rapid onset of polyhydramnios and no persistent findings of congenital high airway obstruction syndrome that was ultimately diagnosed with tracheal agenesis plus tracheoesophageal fistula by fetal MRI. Additionally, we present the novel uses of intraoperative US during a staged ex utero intrapartum therapy delivery and postdelivery MRI, facilitated by proximity within the neonatal ICU, to confirm diagnosis and direct patient management while minimizing unnecessary investigations.

Quantification of Serum Fentanyl Concentrations From Umbilical Cord Blood During Ex-Utero Intrapartum Therapy

Quantification of Serum Fentanyl Concentrations From Umbilical Cord Blood During Ex-Utero Intrapartum Therapy

Congenital high airway obstruction sequence (CHAOS): A new case and a review of phenotypic features

Congenital high airway obstruction sequence (CHAOS) has traditionally been defined as airway obstruction with ultrasound evidence of distal airway dilatation, expanded lungs, ascites, and hydrops. It can result from aplasia or intrinsic obstruction to the formation of the upper airway (larynx and trachea) during development. CHAOS is commonly sporadic and there is no known causative gene. In this comprehensive review on CHAOS, we examined 117 reported cases of this sequence and describe a new case. Malformations in addition to high airway obstruction were present in 64/118 (54.2%) of patients. The most frequent anomalies affected the digits and musculoskeletal system, but there was no distinct phenotype or characteristic dysmorphic appearance associated with CHAOS. The ex utero intrapartum therapy (EXIT) procedure has greatly improved survival for these patients and 36/118 (30.5%) were alive at the time of reporting. Only 2 patients out of 12 who underwent laryngotracheoplasty were tracheostomy-free at the time of their reporting. Six out of 13 were able to produce some speech. Our review provides valuable information on associated anomalies and survival in this complex sequence. The phenotypic variability seen in this review of patients makes it likely that the causes of CHAOS are genetically heterogeneous.

Early Neurodevelopmental Outcome of Infants with High-Risk Fetal Lung Lesions

Objective: To evaluate the neurodevelopmental outcome of infants with high-risk fetal lung lesions defined as (1) requiring fetal intervention and/or ex utero intrapartum therapy (EXIT), or (2) acute respiratory decompensation postnatally necessitating emergent resection within 48 h of life. Methods: We reviewed the medical records of 13 consecutive patients with high-risk fetal lung lesions who were enrolled in our prospective interdisciplinary follow-up program. Neurodevelopmental status was evaluated using the Bayley Scales of Infant Development-III (children ≤3 years, n = 12), or the Wechsler Preschool and Primary Scale of Intelligence-III (children ≥4 years, n = 1). Results: Eight children (62%) underwent prenatal intervention (EXIT, n = 6; fetal resection, n = 1; intrauterine shunt placement, n = 1), and 5 (38%) required emergent resection postnatally. Median age at evaluation was 25 months (range: 5–80). Average scores for cognitive development were found in all children assessed under 3 years of age. The one child who was tested for cognitive ability at 6 years of age scored in the borderline range of intellectual functioning. For language outcome, 15% scored above average, 54% scored within the average range, and 31% had mild deficits. Overall, 77% scored within the average range for neuromotor outcome, while 23% scored within the mildly delayed range. None of the children had severe delays. Cognitive, language, and psychomotor scores were similar between both groups. Hypotonicity was found in 23%. Autism was suspected in one child who underwent an EXIT procedure and was postnatally diagnosed with mosaic trisomy 18. Conclusion: The majority of children with high-risk fetal lung lesions have age-appropriate neurodevelopmental scores.