Intrapartum Treatment Procedure Research Articles

Fetal Cystic Lymphatic Malformations: Systematic Review on Pregnancy and Neonatal Outcomes.

Evaluate pregnancy and neonatal outcomes with fetal cystic lymphatic malformations (LMs), excluding those arising from the posterior neck, to facilitate patient counseling. A systematic review was performed in accordance with PRISMA guidance. Case series and case reports published between 2000 and 2022 were included. Sixty-five studies (96 fetuses) met the inclusion criteria. The average gestational age at diagnosis was 25.5 weeks with the commonest location being the anterior neck (28%). All patients were diagnosed with LM using two-dimensional (2D) ultrasound. Prenatal progression in LM size, presence of intralesional bleeding, or fetal hydrops occurred in 70% (41/59), 9% (5/59), and 3% (2/59), respectively. Chromosomal and structural abnormalities were reported in 4% (2/52) and 2% (2/96), respectively. Overall livebirth rate was 94% (79/84); 12/96 resulted in termination and 5/84 in in utero demise. The average gestational age of delivery was 37.7 weeks. Exactly 19% (15/79) had a vaginal birth, of which shoulder dystocia occurred in one infant. Ex utero intrapartum treatment (EXIT) procedure was performed in 13% (10/79). Postnatal treatment commonly involved surgical excision 38% (30/79), sclerotherapy in 21.5% (17/79), or combination of both in 11.4% (9/79). Of those with reported follow-up, 4 died within 1 year, 1 developed heart failure at 2 years of life, and the remaining 44 had normal developmental outcomes. Fetal cystic LMs, excluding those in the posterior neck, are not commonly associated with chromosomal, or additional structural abnormalities. They usually increase in size before delivery with only a minority developing complications. The good developmental outcome was reported in all survivors.

Perinatal management for fetal oral epignathus with duplication of the pituitary gland (DPG)-plus syndrome: A case report and literature review.

The prenatal diagnosis of epignathus presents a unique challenge for physicians. Differential diagnosis is usually based on the anatomic location of the tumor. Typical prenatal ultrasound characteristics of epignathus include a mixed solid and cystic lesion with vascularity in the solid component, originating from the hard or soft palate, and it is often associated with other anomalies such as craniofacial clefts or trans-sphenoidal intracranial extension. Herein, we present a case of prenatal diagnosis of epignathus with rare ultrasonographic findings, prenatal management requiring collaborative efforts of a multidisciplinary team, and a well-planned innovative ex utero intrapartum treatment procedure. In addition, this report highlights the evolving postnatal diagnosis of the rare developmental anomaly, duplication of the pituitary gland-plus syndrome, which includes various midline craniofacial, central nervous system, spinal, and endocrine abnormalities.

Prenatally Diagnosed Congenital High Airway Obstruction Syndrome: Perinatal Management and Outcome—A Single Tertiary Care Center Experience

AbstractTo report our experience with the management of prenatally diagnosed cases of congenital high airway obstruction syndrome (CHAOS) and the postnatal outcome of those who underwent an ex utero intrapartum treatment (EXIT) procedure. This is a single center, retrospective observational study of prenatally diagnosed CHAOS cases using two-dimensional ultrasound from December 2017 to December 2022 in a tertiary care facility. Of the total nine fetuses prenatally diagnosed with CHAOS, three (33.3%) were associated with multiple congenital anomalies, seven out of nine (77.8%) developed ascites, and one had fetal hydrops. Five (55.6%) underwent medical termination of pregnancy and two were lost to follow-up (22.2%). The remaining two continued pregnancy and required EXIT tracheostomy at the time of delivery (22.2%). Microarray was performed in both which was normal. Postnatally, both infants are tracheostomy dependent with one requiring frequent ventilator support. CHAOS even when isolated generally has poor prognosis without intervention. Performing an EXIT procedure at birth can significantly improve postnatal survival by minimizing hypoxic damage. However, the long-term medical and surgical challenges for survivors remain numerous especially speech disorders, even after lifesaving fetal intervention and surgical correction. Therefore, an accurate prenatal diagnosis is necessary to give the couple an option of continuing pregnancy after realistic counseling regarding the prognosis and postnatal outcome.

Maternal anemia and red blood cell requirements in 72 women undergoing ex-utero intrapartum treatment (EXIT) procedure.

The ex-utero intrapartum treatment (EXIT) allows to ensure fetal airway while keeping uteroplacental circulation. However, EXIT may become a life-threatening procedure due to the increased risk of uterine atony or placenta abruption with increased peripartum blood losses and increased transfusion rates. We aim to review maternal anemia prevalence and transfusion requirements in women undergoing EXIT procedure. Using data from the Federal German Statistical Office hospitalized women undergoing EXIT procedure between January 1st 2006 and December 31st 2021 were included. The prevalence of anemia, peripartum hemorrhage, comorbidities and administration of red blood cells (RBC) were analyzed. In total, 72 women underwent EXIT procedure with a median age of 31 years (26;33.5). In 43.1% EXIT was conducted at 34-36 weeks of gestational age. "Anemia during pregnancy" was present in 47.2%, "anemia due to acute bleeding" in 25.0% and "iron deficiency anemia" in 15.3%. Postpartum hemorrhage occurred in 11.1%. RBCs were transfused in 15.3% of all women. Most women required 1-5 units of RBCs. Despite the rarity of this procedure, anemia management and blood conservation strategies in order to reduce the need for RBC transfusion are highly important in women undergoing EXIT procedure.

The silent storm: a case report of missed antenatal diagnosis leading to fatal respiratory distress and death in a rare case of congenital high airway obstruction syndrome

Congenital high airway obstruction syndrome in neonates is a rare, life-threatening condition characterized by upper airway obstruction. Typically diagnosed prenatally through advanced imaging, CHAOS results from anomalies such as laryngeal atresia or web or tracheal stenosis. Neonates with CHAOS face respiratory distress at birth, necessitating prompt intervention. Management often involves ex-utero intrapartum treatment procedure or tracheostomy to establish a secure airway. Timely diagnosis and multidisciplinary collaboration are crucial for optimizing outcomes in affected infants. Despite its rarity, CHAOS demands heightened clinical awareness to ensure swift, tailored interventions and improve the chances of neonatal survival. We report here a case of CHAOS which was not diagnosed on antenatal ultrasonography.

Case Report: Congenital diaphragmatic hernia in one twin followed by ex-utero intrapartum treatment (EXIT) procedure: Pearls & pitfalls

Cases of congenital diaphragmatic hernia (CDH) in one twin have been reported rarely. This study aimed to report a rare case while also analyzing the pearls and pitfalls in diagnosing and managing this case. A 32-year-old multiparous woman referred to a tertiary hospital with multiple pregnancies and suspected CDH on the 1st baby. The patient underwent further investigation and the first fetus had a severe CDH on the left side. The second fetus was in a transverse lie and no other abnormalities were found. The babies were delivered through caesarean section and the first baby underwent the ex-utero intrapartum treatment (EXIT) procedure without prior antepartum fetal therapy. A large defect measuring 7.5 x 6 centimeters on the left side (Bochdalek type) was found in the first baby during surgery to make repairs. The baby died the next day due to some complications from the previous repair. As a pearl of this case, prenatal diagnosis and multidisciplinary approach hold pivotal roles. In prenatal imaging, CDH is distinguished by the visualization of thorax filled with abdominal contents and the mediastinal shifting from the defect to the contralateral side. EXIT procedures could be performed after the baby with CDH is delivered and the infant will still require post-natal surgical repair and its success rate depends on many factors. In conclusion, proper prenatal diagnosis with ultrasound evaluation from the second trimester, close and regular maternal-fetal monitoring, prenatal intervention, intrapartum ultrasound guidance, and post-natal procedures are all critical.

Maternal and Neonatal Outcomes After Ex-Utero Intrapartum Treatment for Congenital Diaphragmatic Hernia: A Case Series.

Despite advances in neonatal intensive care, fetuses with congenital diaphragmatic hernia (CDH) remain to have a poor prognosis. Exclusive postnatal treatment is inadequate in patients with moderate CDH (observed than expected lung-to-head ratio [O/E LHR] 26-45%) and can lead to respiratory failure at birth, requiring extracorporeal membrane oxygenation in 75% of cases. An ex-utero intrapartum treatment (EXIT) procedure may be beneficial in these cases, improving the fetal-neonatal transition. We review all pregnancies with fetal isolated left CDH with moderate O/E LHR delivered by EXIT in our center from January 2007 to December 2022. Maternal and neonatal variables were analyzed. As primary outcomes, we included neonatal survival and mortality rates, surgical and infectious complications, uterine scar dehiscence, and blood loss during EXIT. As secondary outcomes, we studied recurrences of the diaphragmatic defect, long-term evolution, subsequent pregnancies, and mode of delivery. A total of 14 patients were delivered by the EXIT procedure, with a neonatal survival rate of 85.7%. All these children had optimal physical and neurocognitive development and no pulmonary morbidity. We found no major complications and 7.1% of minor maternal complications. There were no cases of surgical wound infection or endometritis. The median decrease in hemoglobin during the EXIT procedure was 1.9 mg/dL, and only one case required postoperative transfusion. Two out of the 14 women became pregnant again, and both pregnancies were uneventful. In our series, the EXIT procedure allows for adequate airway management associated with a high neonatal survival rate in patients with moderate O/E LHR CDH, with a low rate of neonatal and maternal complications.

Approach and Technique for Cesarean Section to Immediate Resection for High-Risk Sacrococcygeal Teratomas

IntroductionEx-utero intrapartum treatment has been established as an option for fetal and perinatal surgeons to deliver patients with sacrococcygeal teratomas (SCTs) which are causing significant fetal distress and possible in-utero fetal demise. However, ex-utero intrapartum treatment procedures carry significant maternal risk and morbidity. Herein, we report an alternative technique of Cesarean section to immediate resection (CSIR) for managing high-risk SCTs. MethodsA retrospective institutional review board–approved review was performed on all SCTs evaluated at our fetal center from May 2014 to September 2020. Demographics; prenatal imaging characteristics; prenatal interventions; and postnatal surgery data including operative time, estimated blood loss, pathology, and outcomes were collected. Outcomes of interest included surveillance serum alpha-fetoprotein levels, imaging surveillance, developmental milestones, and the presence or absence of constipation or fecal incontinence. ResultsA total of 20 patients with prenatal diagnosis of SCT were evaluated. Mothers who transferred their care to another institution after diagnosis were excluded from this study. Twelve neonates underwent standard postnatal resection. Three neonates underwent emergent CSIR for high output cardiac failure, fetal anemia, or concerns for in-utero hemorrhagic rupture. The median (interquartile range) operative time was 231.5 (113) minutes for the standard operative group versus 156 min in the CSIR group. We present three patients who underwent immediate resection after emergent Cesarean section. We report 100% survival for the three consecutive cases. ConclusionsCSIR is a safe and feasible approach for managing appropriately selected high-risk SCTs with signs of hydrops, fetal distress, or fetal anemia. Despite patient prematurity, we demonstrated 100% survival of three consecutive cases. We suggest that CSIR be considered an option in the management algorithm for high-risk SCTs.

Fetal Laryngoscopy and Endoscopic Tracheal Intubation to Avoid ex utero Intrapartum Treatment in the Management of Fetuses with Suspected Airway Obstruction

Introduction: Large congenital neck tumors can cause neonatal death due to airway obstruction. The aim of this study was to report outcomes of the first cohort of fetuses with neck masses and suspected airway obstruction managed with fetal laryngoscopy (FL) and fetal endoscopic tracheal intubation (FETI) to secure fetal airways and avoid ex utero intrapartum treatment (EXIT) procedure. Methods: A prospective observational cohort of consecutive fetuses with neck masses that were candidates for an EXIT procedure due to suspicion of laryngeal and/or tracheal occlusion on ultrasonographic (US) or magnetic resonance imaging (MRI) examination were recruited for FL in a tertiary referral center in Queretaro, Mexico. FETI was performed if the obstruction was confirmed by FL. Maternal and perinatal outcomes were evaluated. Results: Between January 2012 and March 2023, 35 cases with neck masses were evaluated. Airway obstruction was suspected in 12/35 (34.3%), either by US in 10/35 (28.6%) or by fetal MRI in 2/35 (5.7%). In all cases, FL was successfully performed at the first attempt at a median gestational age (GA) of 36⁺⁵ (range, 33⁺⁵–39⁺⁶) weeks^+days, with a median surgical time of 22.5 (12–35) min. In 4 cases, airway patency was confirmed during FL and an EXIT procedure was avoided. In 8/12 cases (66.7%), airway obstruction was confirmed during fetoscopy and FETI was successfully performed at a median GA of 36⁺³ (33⁺²–38⁺⁵) weeks^+days, with a median surgical time of 25.0 (range, 12–45) min. No case required an EXIT procedure. All patients underwent conventional cesarean delivery with no maternal complications and all neonates were admitted to the neonatal intensive care unit with a correctly positioned endotracheal tube (ETT) immediately after delivery. Three neonatal deaths (37.5%) were reported due to postnatal unplanned extubation, failed ETT replacement, and tumoral bleeding. Conclusion: In fetuses with neck masses and suspected airway obstruction, FL and FETI are feasible and could replace EXIT procedures with good maternal and perinatal outcomes.

A case of tracheotomy using the Ex Utero Intrapartum Treatment (EXIT) procedure in cooperation with multiple professions.

In this study, we report a case of tracheotomy using the ex utero intrapartum treatment (EXIT) procedure in a fetus that was pointed out as having bilateral giant cervical cysts at prenatal diagnosis and whose postnatal airway occlusion was predicted. The subject was a female aged 35. She was diagnosed with polyhydramnios at 28 weeks of pregnancy. The fetus was found to have a giant cervical cyst before she was referred to the department of obstetrics and gynecology of our hospital. On the second day of 37 weeks of pregnancy, oral tracheal intubation was attempted on the fetus using the EXIT procedure after the caesarean operation, but intubation was difficult resulting in a tracheotomy. The oxygenation of the fetus during the operation was maintained well without any postoperative complication. Postnatal fetal airway occlusion is a critical incident which may lead to the death of a fetus. It was assumed, however, that the airway management under the same procedure was completed by the preoperative detailed simulation with the staff of the departments of anesthesiology, obstetrics and gynecology and pediatrics as well as the operating room personnel.

Strategies for airway management in neonates : Results of asurvey of German perinatal centers levelsII andIII

Airway management in children, especially in patients with adifficult airway, remains amajor challenge for anesthesiologists, pediatricians, and emergency medicine physicians. In recent years new tools have been introduced into the clinical practice. The aim was to present the current strategies for securing the airway in neonates in perinatal centers levelsII andIII in Germany, and to collect data on the rare event of coniotomy. From 5April 2021 to 15 June 2021, physicians practicing intensive care in pediatrics and neonatology at perinatal centers levels II and III in Germany were surveyed by means of an anonymized online questionnaire. The questionnaire was designed by the authors and verified by pretesting with the help of five pediatric specialists. Contact was made digitally via the e‑mail addresses provided on the websites of the respective centers. The survey was administered through the fee for service provider LimeSurvey©. The collected data were transferred to the IBM© statistical package for the social scientists (SPSS, version28, IBM© Corporation, Armonk, NY, USA) and statistically analyzed. Pearson's χ2-test was used to perform significance testing (significance level p = < 0.05). Only completed questionnaires were included in the analysis. A total of 219participants completed the questionnaire. Available airway devices: 94.5% (n = 207) nasopharyngeal tubes, 79.9% (n = 175) video laryngoscope/fiber optic, 73.1% (n = 160) laryngeal masks, 64.8% (n = 142) oropharyngeal tube (Guedel). Of the participants 6 (2.7%) performed coniotomy (⌀1.6children). Out of six cases five (83.3%) were resuscitation situations caused by complex anatomical malformations. Training of coniotomy was not provided in 98.6% (n = 216). AStandard Operating Procedure (SOP) for difficult airway in neonates was possessed by 20.1% (n = 44). The comparison with international studies showed that the equipment of German perinatal centers is above average. The trend towards acquisition of avideo laryngoscope and its importance in clinical routine could be confirmed by our data; however, the fact that 20% of the respondents did not have access to video laryngoscopy suggests that further acquisitions will have to be made here in the future. Front of neck access (FONA) methods remain acritically questioned component of neonatal difficult airway algorithms due to their rarity and the resulting lack of data. In summary of the recommendations of the British Association of Perinatal Medicine (BAPM) and the collected data on the theoretical and practical education of the FONA methods in Germany, the implementation of the FONA methods by pediatricians and neonatologists cannot be recommended. As most resuscitation situations were caused by complex anatomical malformations, the early detection of such malformations by means of high-resolution ultrasound seems to be of particular importance. With improvement of early detection, neonates with potentially unmanageable airway problems can be left on uteroplacental circulation for aprolonged period in order to perform necessary interventions, such as tracheostomy, bronchoscopy, or extracorporeal membrane oxygenation (ECMO) device known as the ex utero intrapartum treatment (EXIT) procedure.

Surgical Management and Outcomes of Pediatric Congenital Head and Neck Teratomas: A Scoping Review.

To perform a scoping review to characterize postoperative outcomes of pediatric patients (ages 0-18) with a history of congenital head and neck teratomas. PubMed, EMBASE, Web of Science, Cochrane, Clinicaltrails.gov. A search of multiple databases was performed. Studies were included if they detailed the surgical management and outcomes of pediatric patients with a history of congenital head and neck teratomas. One hundred and eight studies totaling 137 patients were identified. The median gestational age at birth was 37 weeks. Respiratory distress, prompting emergent endotracheal intubation or tracheostomy, was present in most patients (58%). The ex utero intrapartum treatment (EXIT) procedure was utilized for 21 (15%) patients. The teratomas were resected after a median duration of 4 days from birth. The most common postsurgical complications were vocal cord paralysis (3%), hemorrhage (2%), and tracheomalacia (2%). Death occurred perioperatively in 2 patients (2%). Twenty-six patients (19%) required additional surgery, and 5 patients (4%) needed adjuvant chemotherapy. Patients were monitored for a median duration of 24 months with a recurrence rate of 6%. Four recurrent cases (50%) had intracranial extension, and 88% of the recurrent cases were mature teratomas at initial histopathological diagnosis. Most patients with congenital head and neck teratomas require emergent airway management perinatally. Excisional and surgical complications are rare, and most patients are cured of their disease with a single operation. Recurrent teratomas tend to have an intracranial extension and are likely to be of mature pathology at the time of initial diagnosis.

Indications, Resource Allocation, and Outcomes Associated with Ex-Utero Intrapartum Treatment Procedures: A North American Fetal Therapy Network Survey

Introduction: Neonates with cardiorespiratory compromise at delivery are at substantial risk of hypoxic neurologic injury and death. Though mitigation strategies such as ex-utero intrapartum treatment (EXIT) exist, the competing interests of neonatal beneficence, maternal non-maleficence, and just distribution of resources require consideration. Due to the rarity of these entities, there are few systematic data to guide evidence-based standards. This multi-institutional, interdisciplinary approach aims to elucidate the current scope of diagnoses that might be considered for such treatments and examine if treatment allocation and/or outcomes could be improved. Methods: After IRB approval, a survey investigating diagnoses appropriate for EXIT consultation and procedure, variables within each diagnosis, occurrence of maternal and neonatal adverse outcomes, and instances of suboptimal resource allocation in the last decade was sent to all North American Fetal Treatment Network center representatives. One response was recorded per center. Results: We received a 91% response rate and all but one center offer EXIT. Most centers (34/40, 85%) performed 1–5 EXIT consultations per year and 17/40 (42.5%) centers performed 1–5 EXIT procedures in the last 10 years. The diagnoses with the highest degree of agreement between centers surveyed to justify consultation for EXIT are head and neck mass (100%), congenital high airway obstruction (90%), and craniofacial skeletal conditions (82.5%). Maternal adverse outcomes were noted in 7.5% of centers while neonatal adverse outcomes in 27.5%. A large percentage of centers report cases of suboptimal selection for risk mitigation procedures and several centers experienced adverse neonatal and maternal outcomes. Conclusion: This study captures the scope of EXIT indications and is the first to demonstrate the mismatch in resource allocation for this population. Further, it reports on attributable adverse outcomes. Given suboptimal allocation and adverse outcomes, further examination of indications, outcomes, and resource use is justified to drive evidence-based protocols.

Successful management of a large lingual foregut duplication cyst with an ex-utero intrapartum treatment procedure

Successful management of a large lingual foregut duplication cyst with an ex-utero intrapartum treatment procedure

Recent advances in anaesthesia for intrauterine and foetal surgery.

Advances in prenatal diagnostic techniques have enabled early detection of potentially correctable foetal anomalies. Here, we summarise recent developments in anaesthesia for foetal surgery. Types of foetal surgery include minimally invasive, open mid-gestational and ex-utero intrapartum treatment (EXIT) procedures. Foetoscopic surgery avoids hysterotomy, with risk of uterine dehiscence, preserving the possibility of subsequent vaginal delivery. Minimally invasive procedures are performed under local or regional anaesthesia; open or EXIT procedures are usually done under general anaesthesia. Requirements include maintenance of uteroplacental blood flow, and uterine relaxation to prevent placental separation and premature labour. Foetal requirements include monitoring of well-being, providing analgesia and immobility. EXIT procedures require maintenance of placental circulation till the airway is secured, requiring multidisciplinary involvement. Here, the uterine tone must return after baby delivery to prevent major maternal haemorrhage. The anaesthesiologist plays a crucial role in maintaining maternal and foetal homeostasis and optimising surgical conditions.

ANESTHESIA FOR FETAL SURGERY - PRINCIPLES AND CONSIDERATIONS: A CONCISE REVIEW.

Fetal surgery, an integral part of fetal therapy has undergone evolution since is conception, which was possible due to continuous renements in surgical as well as anesthetic techniques The fetal surgery can be done in various stages of the gestation for corrective treatment. Time tested criteria have been laid down for patient selection which help improve the outcome of the whole exercise. The anesthesia concerns and considerations are unique as are the ethical issues involved in this treatment modality involving two patients with contrasting physiological needs. This article reviews salient aspects of fetal physiology in detail. Anesthesia for the fetal interventions is curated as per the invasive nature of surgical interventions. The type of fetal interventions are classied as minimally invasive procedures, Open mid gestation procedures and Ex-utero intrapartum treatment (EXIT) procedures. Preoperative evaluation is dictated by extent of gestation, and invasiveness of the surgical procedure apart from medical status of mother and fetus. This review also tries to enumerate number of clinically useful pharmacological agents in fetal anesthesia including essential tocolytic agents, in addition to management of common fetal complications with a separate section on fetal bradycardia.

Anesthetic consideration for ex-utero intrapartum treatment procedure: A case series

Anesthetic consideration for ex-utero intrapartum treatment procedure: A case series

Successful Management of Ex-Utero Intrapartum Treatment Procedure for Cystic Teratoma Under Sole Spinal Anesthesia: an Anesthetic Challenge Case Report

The Ex-Utero Intrapartum Treatment (EXIT) procedure is a technique that establishes the fetus’s airway, while uteroplacental fetal circulation is still maintained. Anesthesia for this specific procedure requires special anesthetic considerations; such as, uterine relaxation, maternal hemodynamic parameters, the establishment of a fetal airway and maintenance of postpartum uterine contraction. In most cases, general anesthesia is used as the preferred method, due to its effect on uterine relaxation. This presented case demonstrated that a sole spinal anesthetic technique can be used safely for an EXIT procedure.

Changing indications and antenatal prognostic factors for ex-utero intrapartum treatment procedures.

In cases of suspected neonatal airway obstruction, the ex-utero intrapartum treatment (EXIT) procedure is used to secure the airway while a fetus remains on placental circulation. We report indications and outcomes from all EXIT procedures at a tertiary obstetric unit between 1997 and 2020. Retrospective cohort study with data collected from maternal and neonatal medical records. Indications for EXIT procedures were micrognathia (n=7), lymphatic malformations (n=5), cervical teratomas (n=4), goiters (n=2), and intra-oral epulis (n=1). Infants with a fetal teratoma were delivered earliest due to 75% presenting with preterm premature rupture of membranes or preterm labor. Low birth weight was found in 75% of these neonates; they did not survive 1year. Intubation at EXIT occurred for 58% (n=11) of babies, and six neonates required a tracheostomy. In four cases of fetal micrognathia, the inferior facial angle (IFA) was noted to be <5th centile. All but one micrognathia case had polyhydramnios. Of the total cohort, 75% of neonates were alive at 1year. Risks for neonatal demise with EXIT include fetal teratoma, low birth weight, and prematurity. Micrognathia has become an increasingly valid indication for the procedure. The combination of polyhydramnios and IFA <5% correlates well with severe airway obstruction and suggests consideration of EXIT.

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.