ROLE OF ANESTHESIOLOGIST IN EX UTERO INTRAPARTUM TREATMENT

PROCEDURE
Adriana Jardine, Mariza Fitriati
Anesthesiology dan Reanimation Department. Soetomo General Hospital, Surabaya, East Java, Indonesia

INTRODUCTION • The key of EXIT procedure for Anesthesiologist is Uterine relaxation,

Securing the fetal airway, and Ensuring return of uterine tone4.
• The mother was stable during surgery, extubated in the operation room, brought • The two main physiological goals during EXIT are uterine hipotonicity
Over the last several decades, advances towards early diagnosis of fetal anomalies to ward after 4 hours observation on recovery room preservation which facilitates partial extraction of the fetus and prevents
have led to a huge expansion in fetal surgery. The EXIT procedure is a rare surgical • Both baby had a definitive surgery 5-7 days after, and brought home after 2-3 placental dissociation and placental perfusion pressure conservation that
procedure performed in cases of expected post partum fetal abnormalites 1. The key months stay in hospital ensures fetal oxygenation. 5
feature of EXIT for anesthesia is continued intactness of the feromaternal circulation by •Both general as well as regional anesthesia have been used for maternal
uterine relaxation with anesthetic gases in general anesthesia or NTG if EXIT is management during EXIT.
performed under neuraxial anesthesia 2. Anesthesiologist plays an integral role within • General anesthesia involves endotracheal intubation and maintaining a
the large multispecialty and multidisciplinary team involving planning and delivery care • Picture 1.
deep level of inhalational anesthesia, which results in the reduction of uterine
for complex surgical procedure 1. USG for CCAM tone (tocolysis). Optimal tocolysis is one of the cornerstones of EXIT as the
(left), in the fetal survival depends on an intact uteroplacental circulation. All inhalational
CASE baby’s right lung agents used for general anesthesia are excellent tocolytics. Anesthetic depth
is initially kept at 1 MAC and subsequently stepped up to 2–3 MAC guided by
Patient 1 Patient 2 uterine tone estimation by the obstetricians 3.
Insertion of
Maternal Problem Anemia (10.2) Anemia (9.2) •A few case reports have been published describing the use of neuraxial
thoracic drain
Hypoalbumin (3.1) anesthesia for EXIT. Neuraxial techniques require additional IV NTG use for
(right) was done
Examination on mother BP 120/80 BP 110/60 uterine relaxation that can lead to problematic hypotension and uterine
HR 90 HR 82 before umbilical
hypoperfusion 4
Physical Status PS ASA 2 PS ASA 2D cord id cut
Fetal Problem Congenital Cystic Adenomatoid Gastroschizis
Malformation (CCAM) in the right lung • Picture 2 SUMMARY
Intubation of the
Other Problem None. Premature rupture of membrane with
Elective surgery fetal distress (Fetal Heart Rate 120 baby (left), In summary, both GA and RA were successfully practiced for EXIT procedures,
with downward trend) but based on research conducted so far, GA was performed in a majority of
Emergency surgery
The baby after
modified cases. The goals of uterine relaxation, maintenance of placental perfusion, and
EXIT procedure Insertion of thoracic drain Xyloplasty
chilopasty (right) fetal anesthesia must always be considered when choosing the anesthetic
• The caesarian surgery was elective for the first case, we used subarachnoid anesthesia with was done technique. Consideration for anesthetic technique should be done on a
26 G needle inserted in L4-5, we administered 75 mg of lidodex, the block reached to case-by-case basis
sensory level of T6. Pfannenstiel insicion was made, the baby is born within 5 minutes after
incision, thorax drain was inserted to the right thoracic cavity when the baby came up to the
chest, and after that, the baby is fully delivered, the umbilical cord is cut, 10 units of oxytocin
DISCUSSION REFERENCES
is administered right after. Apgar score is 4-6-8 . Steps involved in EXIT procedure 1. Dick JR, Wimalasundera R, Nandi R. Maternal and fetal anaesthesia for fetal surgery.
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Steps involved in the
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• The mother was stable during surgery, and brought to the ward after 2 hours observation in treatment procedure. 3. Kumar K, Miron C, Singh S. Maternal anesthesia for EXIT procedure: A systematic
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• For the second case, due to instability of the baby, we used general anesthesia for faster 4. Weber SU, Kranke P. Anesthesia for predelivery procedures: Ex-utero intrapartum
induction, we used 60 mg of ketamin and 30 mg of rocuronium. Intubation was done while treatment/intrauterine transfusion/surgery of the fetus. Vol. 32, Current Opinion in
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Anesthesia for ex utero intrapartum treatment: renewed insight on a rare procedure.
the baby is intubated to secure the airway, xyloplasty was done, umbilical cord is cut, baby is
Brazilian Journal. 2015 Nov;65(6):525–8.
brought to neonatal intensive care unit for observation dan further examination