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Team performs EXIT procedure on fetus by Maggie Diebolt Public Relations Some of the scariest words an expectant mother could hear are that her pregnancy has complications. Potentially more frightening would be the prospect of surgery to address the problem. In rare instances of specific types of fetal abnormalities, an operation is necessary to correct the abnormality while the fetus and mother are connected by the umbilical cord.   In the first ex-utero intrapartum treatment (EXIT) at MUSC in several years, doctors operated on a fetus that was diagnosed with an estimated 6 cm neck mass detected during a routine ultrasound. The EXIT procedure, developed during the past 20 years at fetal surgery centers worldwide, enables fetal surgical intervention while maintaining fetal oxygen and blood flow by the placental circulation.   An EXIT procedure may be required when a significant risk of obstruction of the fetal airway could result in oxygen deprivation to the fetus or newborn following delivery.   The goal in a preterm fetus is to correct the abnormality and then return it to the uterus for further development. For a pregnancy at term, which is defined as 37 to 42 weeks gestation, the objective of the EXIT procedure is to maintain fetal and placental circulation after the fetus is delivered, but before it is breathing on its own. The procedure is used most commonly in cases of potential airway obstruction, such as an airway malformation or fetal neck mass.   Through a multidisciplinary effort, a team consisting of William Goodnight, M.D., and Gene Chang, M.D., Maternal-Fetal medicine; David White, M.D., ENT; Latha Hebbar, M.D., Anesthesia; Dilip Purohit, M.D., Neonatology; and the OR and obstetrical nursing staff collaborated to perform the procedure without complication. The baby was kept on placental circulation for five minutes and the mother and baby did well following the delivery.   “As this was the first surgery with contemporary methods, it left us with the potential to do more difficult cases, and allows us to provide optimal care for a patient without requiring her to travel to another state,” Goodnight said. “This puts us in the arena of being able to provide these procedures. With the support of anesthesia, our division can provide medically contemporary services for women in the Lowcountry.”   During the procedure a uterine incision is made, similar to an incision made for a cesarean delivery. At this time the fetal head and shoulders are delivered, to allow access to the fetal airway. Oxygen is provided to the fetus through the umbilical cord and placenta during the procedure, though once the airway is established, the baby is delivered and the umbilical cord is cut.   EXIT differs from a cesarean delivery in that great care is taken to preserve utero-placental circulation through uterine relaxation, infusion of fluid into the amniotic cavity, and limiting the delivery of the fetus to the head and shoulders. Because an EXIT procedure poses a higher risk for maternal complications as the uterine relaxation required increases the risk of bleeding after delivery of the baby, close coordination between the anesthesiologist and obstetrician is needed to manage the timing of anesthesia care.   “One of the things that made this procedure work so well is that it was a multidisciplinary approach, it wasn’t just me or my department. Everyone had an equal hand in the process,” Goodnight said. “Dr. Hebbar, Dr. White, Dr. Chang, the NICU … each of us had to adapt what we normally do to this unique technique. What made this work was having all the specialties involved.”     Friday, June 15, 2007 Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, catalyst@musc.edu. Editorial copy can be submitted to Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to catalyst@musc.edu. To place an ad in The Catalyst hardcopy, call Island Publications at 849-1778, ext. 201.