Anesthetic management of a patient undergoing an ex utero intrapartum treatment (EXIT) procedure: a case report

The ex utero intrapartum treatment (EXIT) procedure involves partial delivery of the fetus with the fetal-placental circulation maintained. This allows for management of the obstructed fetal airway via direct laryngoscopy, bronchoscopy, tracheostomy, or surgical intervention. These complex and often challenging procedures have been performed about 100 times in the United States to date. Recent advances in prenatal diagnosis of fetal congenital malformations, in particular, abnormalities involving the fetal airway, have allowed for the development of the EXIT strategy to convert potentially catastrophic situations during fetal delivery to a controlled environment. Indications for the EXIT procedure have expanded to a variety of congenital abnormalities, including fetal neck masses, lung or mediastinal tumors, congenital high airway obstruction syndrome, conjoined twin separation, and acute respiratory distress syndrome requiring transitioning from EXIT to extracorporeal membrane oxygen transitioning. Various considerations must be managed by the anesthesia provider during the EXIT procedure to ensure positive maternal and fetal outcomes. Careful attention to achieving adequate uterine relaxation, maintaining maternal blood pressure, avoiding placental abruption, prioritizing fetal airway establishment, and providing return of uterine tone when indicated are examples of these considerations. In this case report, a parturient presented for an EXIT procedure secondary to fetal cystic hygroma.