February 26, 2023 | Richard Hong, MD
In January 2023, a large multidisciplinary team performed the first full-scale ex-utero intrapartum treatment (EXIT) procedure in the Main Operating Room (OR) of the Ronald Reagan UCLA Medical Center. The intervention involved careful coordination between many services, including Obstetrics and Gynecology, the Neonatal ICU, Labor & Delivery Nursing, Head and Neck Surgery, Pediatric Surgery, Main OR Nursing, and both Pediatric and Obstetric Anesthesiology.
The EXIT procedure was originally developed to secure the airways of babies with severe congenital diaphragmatic hernia who had undergone fetal surgery. Since then, physicians have performed the EXIT procedure for fetal airway tumors and malformations, thoracic masses, and extracorporeal membrane oxygenation (ECMO) cannulation of fetuses with life-threatening disease. In this case, antepartum fetal imaging raised concerns about the patency of the fetal airway and, by extension, the ability of the neonate to oxygenate after delivery.
The goal of the EXIT procedure is to secure the neonatal airway during partial delivery of the upper body while maintaining oxygenation through the placenta for as long as possible. Placental oxygenation is difficult to maintain once delivery begins due to changes in the uterine environment, but it potentially buys the fetus some time before it must receive oxygen through another route. Fetal procedures under these uncertain and time-sensitive circumstances can be very stressful and challenging.
Ihab Ayad, MD, pediatric anesthesiologist, and Shatira Wilson, MD, pediatric anesthesiology fellow physician, managed the neonatal airway while Richard Hong, MD, obstetric anesthesiologist, and Brittany Burton, MD, MHS, MAS, future obstetric anesthesiology fellow physician, provided anesthesia for the mother and optimized uterine conditions for placental support. They were assisted by Cristianna Vallera, MD, obstetric anesthesiologist, and Swati Patel, MD, pediatric anesthesiologist, in supervisory roles, as well as Tina Yu, MD, obstetric anesthesiologist, and Eric Van Baarsel, MD, anesthesiology resident physician.
Both mother and baby did well, and everyone involved learned a great deal about maternal-fetal physiology and multidisciplinary teamwork.