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Wednesday 13 February 2019

A case of Multidisciplinary team work to save a life

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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