Articulo anestesio

EDUCATION
Bruno Riou, M.D., Ph.D., Editor

Case Scenario: Anesthesia for Maternal-Fetal Surgery
The Ex Utero Intrapartum Therapy (EXIT) Procedure
Priscilla J. Garcia, M.D., M.H.A.,* Oluyinka O. Olutoye, M.B.Ch.B., Ph.D.,† Richard T. Ivey, M.D.,‡ Olutoyin A. Olutoye, M.D.§

ETAL anomalies such as giant neck masses can result in perinatal death or hypoxia and anoxic brain injury due toinability to secure an airway in a timely fashion after delivery. Modern technology, ultrasound, and ultrafast magnetic resonance imaging have enabled intrauterine diagnosis and fetal interventions as a mode of therapy, thereby giving such affected fetuses a chance at survival. Initially, the Ex Utero Intrapartum Therapy (EXIT) procedure was exclusively performed in large tertiary children’s hospitalsbecause of the easy availability of pediatric practitioners who can adequately manage the baby-related issues. These hospitals are often in close proximity to or affiliated with maternal obstetric units and involve a multidisciplinary team approach to provide care for both mother and baby. However, these types of procedures are increasingly being performed in diverse hospital settings1; therefore,adequate knowledge about the related intricacies of these cases is warranted.
* Assistant Professor, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas. † Associate Professor, Departments of Surgery, Pediatrics and Obstetrics and Gynecology, Baylor College of Medicine, Texas Children’s Fetal Center, Texas Children’s Hospital. ‡ Assistant Professor, Department of Obstetrics andGynecology, Baylor College of Medicine, Texas Children’s Fetal Center. § Associate Professor, Departments of Anesthesiology and Pediatrics, Baylor College of Medicine, Texas Children’s Fetal Center, Texas Children’s Hospital. Received from the Department of Anesthesiology and Pediatrics, Baylor College of Medicine, Texas Children’s Fetal Center, Texas Children’s Hospital, Houston, Texas.Submitted for publication December 14, 2010. Accepted for publication March 7, 2011. Support was provided solely from institutional and/or departmental sources. The tables in this article were prepared by Annemarie B. Johnson, C.M.I., Medical Illustrator, Wake Forest University School of Medicine Creative Communications, Wake Forest University Medical Center, Winston-Salem, North Carolina. Addresscorrespondence to Dr. O. A. Olutoye: 6621 Fannin Street, MC 2-1495, Houston, Texas 77030. oao@bcm.edu. This article may be accessed for personal use at no charge through the Journal Web site, www.anesthesiology.org.
Copyright © 2011, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology 2011; 114:1446 –52

F

We present the case of a mother carrying a fetus of37 weeks’ gestation with a giant cervical teratoma who underwent the EXIT procedure for fetal airway access. This discussion will focus on the multiple management issues and concerns to be contemplated before embarking on the care of a pregnant mother whose child may need surgery shortly before delivery to ensure neonatal survival.

Case Report
A 35-yr-old healthy, uniparous woman, gravida 2,was referred to our institution’s fetal center at 21 weeks’ gestation after diagnosis of a giant neck mass with associated moderate polyhydramnios on a routine obstetric ultrasound examination. Fetal magnetic resonance imaging revealed findings consistent with a cervical teratoma and significant airway compromise (fig. 1). Given the degree of airway compromise and distortion of the fetus’ anatomy,a multidisciplinary meeting that included anesthesiologists, pediatric surgeons, maternal-fetal medicine specialists, obstetricians, neonatologists, cardiologists, operating room nurses, and labor and delivery room nurses was organized to discuss the fetal anomaly and management approach to delivery of the fetus. Conventional delivery followed by airway maneuvers to intubate the trachea or...