Ex utero intrapartum therapy

The hallmark of ex utero intrapartum therapy (EXIT) procedure is the maintenance of uteroplacental blood flow and gas exchange. This goal is achieved with the use of inhalational agents to relax uterine tone, a continuous amnioinfusion to stabilize uterine volume, and partial exposure of the fetus. From March 1996 to December 2002, 43 EXIT procedures were performed at the Children's Hospital of Philadelphia (CHOP). Indications included airway obstruction from fetal neck masses (n = 19), reversal of tracheal occlusion for congenital diaphragmatic hernia (CDH; n = 13), resection of massive congenital cystic adenomatoid malformation of the lung (n = 5), congenital high airway obstruction syndrome (n = 3), EXIT-to-extracorporeal membrane oxygenation for a fetus with CDH and a cardiac defect (n = 1), unilateral pulmonary agenesis (n = 1), and thoracoomphalopagus conjoined twins (n = 1). Eight fetuses required initial tracheotomy at the time of EXIT to secure the airway. One death occurred during the EXIT procedure secondary to inability to secure the airway with parental refusal for tracheotomy. In all cases, the EXIT procedure provided time on uteroplacental gas exchange to perform procedures such as direct laryngoscopy, bronchoscopy, tracheotomy, arterial and venous access, resection of neck or lung masses, and ECMO cannulation, thereby converting an emergent crisis into a controlled situation.