Ex-utero intrapartum treatment in the Indian scenario: Anesthetic challenges and positioning
A 29-year-old multi-gravida was referred to our hospital with an antenatal diagnosis of a large cystic hygroma diagnosed at 38 weeks of gestation. Fetal MRI revealed a large multiseptated cystic mass (measuring 12 × 8 cm) involving both sides of the neck with compression over the trachea []. Hence a difficulty in securing the airway was anticipated and EXIT procedure was planned. The parents were counseled and informed written consent was obtained. A multispecialty team comprising of obstetricians, anesthesiologists, pediatric surgeons, neonatologists, and radiologists were involved in planning and executing the procedure. Under general anesthesia elective Cesarean section was performed. Two teams of anesthesiologists were present, one for the mother and the other for the fetus. Apart from the routine monitoring, radial artery cannulation was done for invasive blood pressure monitoring. Patient was positioned in the supine position with left lateral tilt to prevent compression on the aorta. The legs were slightly abducted in order to allow easy access to the fetus for intubation. General anesthesia was commenced and maintained with higher concentration of isoflurane (for complete uterine relaxation), oxygen, nitrous oxide, and muscle relaxants. Before skin incision, ultrasound was done to locate the placental edge which revealed two loops of umbilical cord around the fetal neck. After skin and uterine incision, the fetal head and neck with the mass was delivered []. Warm Ringer lactate was infused into the uterine cavity to maintain the uterine volume. Fetal heart rate was monitored with an ultrasound probe and manually by umbilical cord pulsation. Initial attempts at intubation failed. Ultrasound-guided aspiration of the cyst was done but since most of the cysts were microcystic, adequate decompression could not be obtained. The neck was delivered up to the sternal notch [] and then intubated. Intubation could be accomplished in 3 minutes and 47 seconds and airway was secured with a 3-mm ID oral endotracheal tube and then ventilated with 100% oxygen. There was no fetal bradycardia and cord was clamped and handed over to the neonatologist for further resuscitation. Isoflurane was stopped and oxytocin 20 units in 500 ml Ringer Lactate solution was administered. Hemostasis was achieved and patient was extubated at the end of surgery. The neonate was taken up for definitive surgery after 4 hours of stabilization in the NICU. The lesion was excised and elective tracheostomy was done due to tracheomalacia. Second sitting of excision was done after 4 months and tracheostomy has been decannulated.