Complex Care Spotlight: Ex Utero Intrapartum Treatment
Tampa General Hospital (TGH) receives referrals from centers across Florida to perform complex, highly specialized surgeries on babies in utero. One example is the EXIT procedure, short for Ex Utero Intrapartum Treatment. TGH is one of the few hospitals in Florida with this level of expertise.
The team at TGH combines maternal-fetal medicine, neonatology, pediatric anesthesia, pediatric surgery, as well as specialists from ENT and the NICU. Working together, the multidisciplinary team carefully choreographs run-throughs and video conferences to create plans and backup strategies in the event of any unexpected development.
“The commitment from every department for the EXIT procedure goes beyond just the day of delivery,” said Sarah Obican, MD. “The team usually has a practice delivery two to three weeks prior to the actual delivery. At this time, we address all aspects of the procedure including questions and concerns from everyone in the room. The teams then commit to being on call 24/7 for the next two to three weeks in case the expectant mother goes into labor early.”
During the EXIT procedure, the mother is anesthetized and undergoes a cesarean where the baby’s head and shoulders are delivered while the uterus is perfusing, and the placenta is providing life-sustaining cardiopulmonary bypass support. From there, surgeons intubate the baby before completing delivery and cutting the umbilical cord.
The difficulty is relaxing the uterus enough to prevent it from contracting. Otherwise, the placenta will deliver and the opportunity for bypass will be lost. If that happens, the baby must be delivered immediately without intubation, reducing the odds of a positive outcome.
There are other potential complications as well. If the intubation prior to bypass cannot be successfully performed, a tracheotomy will be required. And the mother’s life depends on a uterine stapling device that makes a large incision in the uterus while simultaneously stitching up the sides of the cut to reduce bleeding. If it fails, the mother’s blood pressure could drop, or blood could pool internally. Surgeons at TGH can employ other types of sutures in that case to ensure a successful procedure. This demonstrates the importance of surgical expertise and several backups.
Specialists at TGH and USF Health performed the complicated EXIT procedure on a mother who had been referred to TGH when she was seven months pregnant. Her baby’s airway was completely displaced by the development of an abnormal, fluid-filled sac-like structure in his neck. Called a cystic hygroma, the growth would impair the baby’s ability to breathe as soon as he was born.
For this mother and baby, the procedure worked perfectly without complications. The baby spent his first four months in the NICU, then came home and was doing well, reaching all normal milestones by his first birthday. The growth on his neck is being treated with injections of medication to shrink it. When he’s older, the child will be evaluated for surgical removal. In the meantime, he still has a tracheostomy tube to make sure he can breathe safely.
This family’s successful outcome is one of many and a testament to the dedication of TGH’s team.
“These deliveries are so complex that they require the expertise of specialists who have met, planned, and practiced performing as a team,” said center co-director Alejandro Rodriguez, MD. “And it is the teamwork at TGH that demonstrates to patients they are receiving the very best patient care.”
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