EXIT Procedure in a Twin Gestation and Review of the Literature

ABSTRACT

Prenatal diagnosis can show masses of the fetal neck, mouth, and face that can potentially cause respiratory distress at birth. To prevent such an emergency, the EXIT (ex utero intrapartum technique) is performed: it is the intrapartum intubation of the fetus at term while still connected to the placenta. The EXIT procedure was first performed in a case of cervical teratoma. Up to now a total of 34 cases are described, mostly cervical teratomas (13 cases), lymphangiomas (7), epignathus (3); babies' outcome has been successful in 25 of them, with one death related to the procedure. Among the reported cases we are aware of only one where EXIT was performed in a twin gestation, in which the normal twin was delivered first. In our case the normal fetus was posterior to the twin with cervical malformation, requiring us to work on the latter while the former was still in the uterus. After having safely secured the airway in twin A, twin B was prompt delivered with excellent general conditions. Our limited experience enlarges the possibility to perform this prenatal procedure even in ``nonstandard'' conditions, such as a twin gestation, and may prove useful to those who are going to deal with such issues.

KEYWORD

EXIT procedure - lymphangioma - prenatal diagnosis

REFERENCES

• 1 Norris M C, Joseph J, Leighton B L. Anesthesia for perinatal surgery.  Am J Perinatol . 1989;  6 39-40
• 2 Kelly M F, Berenholz L, Rizzo K A, Greco R, Wolfson P, Zwillenberg D A. Approach for oxygenation of the newborn with airway obstruction due to cervical mass.  Ann Otol Rhinol Laryngol . 1990;  99 179-182
• 3 Zerella J T, Finberg F J. Obstruction of the neonatal airway from teratomas.  Surg Gynecol Obstet . 1990;  170 126-131
• 4 Levine A B, Alvarez M, Wedgwood J, Berkowitz R L, Holzman I. Contemporary management of a potentially lethal fetal anomaly: a successful perinatal approach to epignathus.  Obstet Gynecol . 1990;  76 962-966
• 5 Langer J C, Tabb T, Thompson P, Paes B A, Caco C C. Management of prenatally diagnosed tracheal obstruction: access to the airway in utero prior to delivery.  Fetal Diagn Ther . 1992;  7 12-16
• 6 Richards D S, Yancey M K, Duff P, Stieg F H. The perinatal management of severe laryngeal stenosis.  Obstet Gynecol . 1992;  80 537-540
• 7 Catalano P J, Urken M L, Alvarez M. New approach to the management of airway obstruction in ``high risk'' neonates.  Arch Otolaryngol Head Neck Surg . 1992;  118 306-309
• 8 Schwartz M Z, Silver H, Schulman S. Maintenance of the placental circulation to evaluate and treat an infant with massive head and neck hemangioma.  J Pediatr Surg . 1993;  28 520-522
• 9 Tanaka M, Sato S, Naito H, Nakayama H. Anaesthetic management of a neonate with prenatally diagnosed cervical tumour and upper airway obstruction.  Can J Anaesth . 1994;  41 236-240
• 10 Skarsgard E D, Chitkara U, Krane E J, Riley E T, Halamek L P, Dedo H H. The OOPS procedure (operation on placental support): in utero airway management of the fetus with prenatally diagnosed tracheal obstruction.  J Pediatr Surg . 1996;  31 826-828
• 11 Mychaliska G B, Bealer J F, Graf J L, Rosen M A, Adzick N S, Harrison M R. Operating on placental support: the ex utero intrapartum treatment procedure.  J Pediatr Surg . 1997;  32 227-231
• 12 Liechty K W, Crombleholme T M, Weiner S, Bernick B, Flake A W, Adzick N S. The ex utero intrapartum treatment procedure for a large fetal neck mass in a twin gestation.  Obstet Gynecol . 1999;  93 824-825
• 13 Luzzatto C, Midrio P, Tchaprassian Z, Guglielmi M. Sclerosing treatment of lymphangiomas with OK-432.  Arch Dis Child . 2000;  82 316-318
• 14 Azizkhan R G, Haase G M, Applebaum H. Diagnosis, management, and outcome of cervicofacial teratomas in neonates: a Children's Cancer Group study.  J Pediatr Surg . 1995;  30 312-316
• 15 Liechty K W, Crombleholme T M, Flake A W. Intrapartum airway management for giant fetal neck masses: the EXIT (ex utero intrapartum treatment) procedure.  Am J Obstet Gynecol . 1997;  177 870-874
• 16 Raveh E, Papsin B C, Farine D, Kelly E N, Forte V. The outcome after perinatal management of infants with potential airway obstruction.  Int J Pediatr Otorhinolaryngol . 1998;  46 207-214
• 17 Shih G H, Boyd G L, Vincent Jr D R, Long G W, Hauth J C, Georgeson K E. The EXIT procedure facilitates delivery of an infant with a pretracheal teratoma.  Anesthesiology . 1998;  89 1573-1575
• 18 Gagnon A L, Bebbington M W, Kamani A, Solimano A. Prenatally diagnosed fetal neck teratoma: case report and novel management options.  Fetal Diagn Ther . 1998;  13 266-270
• 19 DeCou J M, Jones D C, Jacobs H D, Touloukian R J. Successful ex utero intrapartum technique (EXIT) procedure for congenital high airway obstruction syndrome (CHAOS) owing to laryngeal atresia.  J Pediatr Surg . 1998;  33 1563-1565