Doctors at the University of California, San Diego (UCSD) Medical Center performed a complicated fetal surgery that placed a breathing tube into a 39-week infant while it was partially out of the womb. Doctors opted for the procedure to ensure survival for the baby who was likely to die upon birth without prior intervention. The baby was known to have a rare abnormality that doctors were aware would render it unable to swallow and breathe at birth.
The Ex Utero Intrapartum Treatment (EXIT) performed July 18 at UCSD’s Hillcrest Medical Center maintained the placenta and umbilical cord to gain time to secure the obstructed fetal airway, allowing the baby to continue receiving oxygenated blood. The highly unusual and complicated procedure, involving a team of 40 medical personnel, took 1-1/2 hours to complete and resulted in the successful birth of the infant.
The procedure was performed by a multi-disciplinary medical team of doctors, nurses and respiratory therapists from anesthesia, neonatology, reproductive medicine, and pediatric ear, nose and throat specialties. The team was led by Andrew Hull, MD, Reproductive Medicine and included Krzysztof M. Kuczkowski, M.D., Maternal Anesthesiology, Mark Greenberg M.D., Neonatal Anesthesiology, Neil Finer, MD, Neonatology, and Tony Magit, M.D, Ear Nose and Throat Pediatrics of Rady Children’s Hospital.
Kuczkowski began the procedure by placing the mother under a general anesthetic and administering special inhalation medications to the mother to relax her uterus and maintain her blood pressure and cardiac output during the surgery.
"It was imperative to ensure a fully relaxed uterus during the procedure," said Kuczkowski, "so that the mother would not spontaneously begin labor and expel the placenta or baby."
Hull performed a partial cesarean section, or hysterotomy. Using ultrasound to guide him, Hull made a small incision into the mother’s uterus. He lifted out the head, one shoulder and one arm of the baby, leaving the rest of the body, the placenta and umbilical cord intact in the womb. He stapled the edges of the incision to minimize bleeding and hold the baby in place.
"By keeping the placenta in place it functioned as a lung assist device, keeping the baby alive during the operation," said Hull.
Next the team placed a pulse oximeter on the baby’s arm to monitor its oxygen level and heart rate. Greenberg began the difficult task of inserting a breathing tube into the baby’s airway to ensure adequate oxygen to the lungs and avoid a dangerous period of low oxygen. Once the tube was in Hull completed the cesarean section fully removing the baby from the uterus. The infant was transferred to the Infant Special Care Center for observation and follow-up care.
In utero the baby developed a cleft palate, a small mid-face and an exceptionally small jaw. From ultrasound examinations during the pregnancy the doctors knew the three conditions combined would restrict the infant’s airway, and inhibit the baby’s breathing upon birth, causing a life-threatening respiratory problem. The condition was identified in the second trimester at which time doctors determined that the surgery was the baby’s best chance of survival.
"We knew if we waited until the baby was born to insert a breathing tube that it might be extremely difficult to put the tube into the baby’s trachea," Hull explained. "We were concerned we could lose the baby or that the baby could suffer irreparable brain damage from a lack of oxygen while we tried to insert the tube. With small babies time is critical. By going in before the baby was removed from the placenta and umbilical cord we gave ourselves the time we needed to intubate the baby properly and ensure survival."
Since the delivery the neonatal team has confirmed that the airway was very compromised and that the infant will require a surgical procedure to create an artificial airway.
This is only the second time an EXIT procedure has been done at UCSD Medical Center. The first was performed nine years ago on a fetus with a tumor that was obstructing the airway. A highly uncommon surgery, it is believed these are the only two cases ever performed in San Diego County.
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