EX-utero
Intrapartum Treatment (EXIT) is a procedure that is used to deliver babies with
a neck swelling or where ever a difficult airway is anticipated due to a mass
in the neck or upper chest. The procedure preserves utero-placental gas
exchange ie the baby continues to receive oxygen and nutrients from the mother
until an airway is established by placing an endotracheal tube and lung
ventilated with satisfactory oxygenation
Mrs D who was having antenatal care at Seethapathy Clinic &
Hospital, had an ultrasound for checking the growth of the baby in her 28th
week and this revealed a swelling on front of the neck of that baby possibly
from the thyroid gland. This swelling was large, restricted the baby’s
swallowing causing pressure effect on the neck of the developing baby and
resulted in increase of the fluid around the baby.
A detailed work up was done by the Fetal Medicine team at Mediscan
Systems, and by testing the fluid around the baby and blood sampling, it was
confirmed that the swelling was an enlargement of the fetal thyroid gland due
to hypothyroidism. The baby was treated
in utero. Two injections were given into the amniotic fluid at an interval of 2
weeks which showed improvement in the level of the thyroid hormones in the
fetus. This also helped to reduce the amount of amniotic fluid and a small reduction
in the size of the thyroid swelling.
At 36 weeks a fetal MRI was done which showed compression of the trachea
(airway) which would make it difficult for the baby to breathe if it was
delivered. Anticipating problems in securing airway such a complex delivery is planned in unit
which has the capacity to handle such complex cases.
Dr Mehtas Hospitals who is the leader in handling such complex Obstetric
and Gynec Procedures and has got 40 bedded Level 3 Neonatal Care Team with 24x7
back up to take care of any emergencies was the only choice
The
multidisciplinary team of Fetal Medicine, Obstetricians, Neonatologist, Anesthetists, paediatric ENT, paediatric surgeons and theatre staff of Dr Mehta’s worked for 48 hours continuously
and discussed as a team on various complications, outcomes which can arise and
as a team came with the best recommendation of EXIT Procedure. A mock drill was done
the day prior with the entire team.
Excellent Team coordination and communication Dr Mehtas team made it possible
for the successful outcome of this case.
Ideal
positioning of each team with assistants and necessary equipments were kept
ready so that there is enough room and
coordination for everybody to perform during the procedure.
A caesarean
section was performed under general anesthesia, the baby was delivered only
upto the head and held in position with the body still in the uterus with
intact umbilical cord. An attempt to
intubate the airway with a tube to make an air passage for breathing was
attempted. As we were not able to visualize vocal cords, under bronchoscopic
guidance airway was secured by the team, after the airway was secured, the baby
was delivered and then the cord was cut.
The Baby was ventilated successfully at our 40 bedded Level 3 NICU for 2 days. In the meanwhile baby’s Thyroid function tests and oral thyroid hormone replacement was started by the Neonatal Intensive Care Team. The baby was taken off ventilation on day 3. Baby was able to breath naturally and normally
without difficulty.
The neonatal team from Dr. Mehta’s Hospitals Dr Lakshmi, Dr Jayanthi, Dr
Thirunavukarasu, Dr. Balamurugane.
The obstetric team from Seethapathy Hospital Dr Sowmya Balakrishnan, Dr.
Uma Ram, Dr Vasanthi Vidyasagar and
Fetal medicine Specialist Dr S Suresh and Dr Sudarshan Suresh from Mediscan.
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