Fetoscopic balloon dilation and stent placement of congenital high airway obstruction syndrome leading to successful Caesarian delivery

Introduction: Without fetal or perinatal intervention, congenital high airway obstruction syndrome (CHAOS) is a fatal anomaly. The ex utero intrapartum treatment (EXIT) procedure has been used to secure the fetal airway and minimize neonatal hypoxia, but is associated with increased maternal morbidity. Case Presentation: A 16-year-old woman (gravida 1, para 0) was referred to our hospital at 31 weeks gestation with fetal anomalies, including echogenic lungs, tracheobronchial dilation and flattened diaphragms. At 32 weeks, fetoscopic evaluation identified laryngeal stenosis, which was subsequently treated with balloon dilation and stent placement. The patient developed symptomatic and regular preterm contractions at post-operative day 7 with persistent sonographic signs of CHAOS, which prompted a repeat fetoscopy with confirmation of a patent fetal airway followed by Cesarean delivery under neuraxial anesthesia. Attempts to intubate through the tracheal stent were limited and resulted in removal of the stent. A neonatal airway was successfully established with rigid bronchoscopy. Direct laryngoscopy and bronchoscopy confirmed laryngeal stenosis with a small tracheoesophageal fistula immediately inferior to the laryngeal stenosis and significant tracheomalacia. A tracheostomy was then immediately performed for anticipated long term airway and pulmonary management. The procedures were well tolerated by both mom and baby. The baby demonstrated spontaneous healing of the tracheoesophageal fistula by day of life 7 with discharge home with ventilator support at three months of life. Conclusion: Use of repeated fetoscopy in order to relieve fetal upper airway obstruction offers the potential to minimize neonatal hypoxia, while concurrently decreasing maternal morbidity by avoiding an EXIT procedure. Use of the tracheal stent in CHAOS requires further investigation. The long-term reconstruction and respiratory support of children with CHAOS remain challenging

Fetus diagnosed with cervical teratoma delivered by exit procedure (Extra uterine intrapartum treatment)

Congenital cervical teratomas are rare tumours of germ cells that should be diagnosed antenatally by ultrasound during anomaly scan or even earlier. The incidence of teratomas of the head and neck is 3-5%. We are presenting a case of rare cervical teratoma.1 Congenital cervical tumours are often clinically dramatic, though basically benign. Prognosis is favourable only if the airway is quickly stabilized and necessarily surgical procedure is planned and executed effectively.2 Case presentation: A 34-year-old female presented at 32 weeks of gestation, at Al Amal National Hospital where an ultrasound examination revealed a single viable cephalic fetus with a huge irregular heterogeneous anterior neck mass suspected as congenital cervical neck teratoma. The delivery was planned at 37 weeks gestation. The team was assembled for EXIT procedure which includes the obstetricians, neonatologist, anthologist, ENT surgeons. At 37 weeks of gestation, the child was maintained on maternal circulation after caesarean section until successfully intubated (Extra Uterine Intrapartum Treatment (EXIT) was performed at Al Amal National Hospital after liaison with the anesthetist, neonatologist and the pediatric surgeon. A female fetus weighing 3.8 kg was delivered and intubated immediately. Unfortunately, the newborn died at 48hours of age. Conclusion: Prenatally diagnosed head and neck teratomas can result in early neonatal death if the delivery was not planned correctly with right multidisciplinary team. In this case EXIT is the procedure of choice.

Lean and Computerized Management System for Non-Hospital Owned Medical Equipment in Hospital

Many challenges exist in the management of non-hospital-owned medical equipment. This paper proposes implementing a novel kind of lean and computerized management method, including the management policy, procedures, agreement signing, equipment installation, acceptance and maintenance, and exit procedure. The result shows that the Lean and computerized management system can improve oversight and assure the safe integration of non-hospital-owned equipment to reduce liability exposure and increase compliance with regulations.

Ex-Utero Intrapartum Treatment (EXIT): indications and outcome in fetal cervical and oropharyngeal masses

Background: The “Ex-Utero Intrapartum Treatment” (EXIT) procedure allows to ensure fetal airway before completion of delivery and umbilical cord clamping while keeping uteroplacental circulation. Airway obstruction in fetal oropharyngeal and cervical masses can be life-threatening at birth. In those situations, controlled access to fetal airway performed by a trained multidisciplinary team allows safe airway management, while feto-maternal circulation is preserved. We aim to review the indications and outcome of the EXIT procedure in a case series of fetal cervical and oropharyngeal masses.Methods: We have carried out a retrospective review of all patients with fetal cervical and oropharyngeal masses who underwent an EXIT procedure between 2008 and 2019. Variables evaluated included indication for EXIT, ultrasound and MRI findings, the need of amnioreduction, gestational age at EXIT, birth weight, complications, operative time, survival rate, pathological findings, and postnatal evolution. Five patients are included in this series. One additional case has already been published.Results: The diagnosis were cervical teratoma (n=1), epulis (n=1) and lymphangioma (n=3). Polyhydramnios was present in 2 patients, requiring amnioreduction in one of them. Mean gestational age at EXIT was 36-37 weeks (range, 34-38 weeks). Median EXIT time in placental support was 9 minutes (range, 3-22 minutes). Access to airway was successfully established in EXIT in all cases. All children born by EXIT are currently healthy and without complications. Conclusion: The localization and characteris­tics of the mass, its relationship to the airway, and the presence of polyhydramnios seem to be major factors determining indications for EXIT and clinical outcome.

Ex-Utero Intrapartum Treatment (EXIT): indications and outcome in fetal cervical and oropharyngeal masses

Background The “Ex-Utero Intrapartum Treatment” (EXIT) procedure allows to ensure fetal airway before completion of delivery and umbilical cord clamping while keeping uteroplacental circulation. Airway obstruction in fetal oropharyngeal and cervical masses can be life-threatening at birth. In those situations, controlled access to fetal airway performed by a trained multidisciplinary team allows safe airway management, while feto-maternal circulation is preserved. We aim to review the indications and outcome of the EXIT procedure in a case series of fetal cervical and oropharyngeal masses. Methods We have carried out a retrospective review of all patients with fetal cervical and oropharyngeal masses who underwent an EXIT procedure between 2008 and 2019. Variables evaluated included indication for EXIT, ultrasound and MRI findings, the need of amnioreduction, gestational age at EXIT, birth weight, complications, operative time, survival rate, pathological findings, and postnatal evolution. Five patients are included in this series. One additional case has already been published. Results The diagnosis were cervical teratoma (n = 1), epulis (n = 1) and lymphangioma (n = 3). Polyhydramnios was present in 2 patients, requiring amnioreduction in one of them. Mean gestational age at EXIT was 36–37 weeks (range, 34–38 weeks). Median EXIT time in placental support was 9 min (range, 3–22 min). Access to airway was successfully established in EXIT in all cases. All children born by EXIT are currently healthy and without complications. Conclusion The localization and characteristics of the mass, its relationship to the airway, and the presence of polyhydramnios seem to be major factors determining indications for EXIT and clinical outcome.

Ex-Utero Intrapartum Treatment (EXIT): indications and outcome in fetal cervical and oropharyngeal masses

Background: The “Ex-Utero Intrapartum Treatment” (EXIT) procedure allows to ensure fetal airway before completion of delivery and umbilical cord clamping while keeping uteroplacental circulation. Airway obstruction in fetal oropharyngeal and cervical masses can be life-threatening at birth. In those situations, controlled access to fetal airway performed by a trained multidisciplinary team allows safe airway management, while feto-maternal circulation is preserved. We aim to review the indications and outcome of the EXIT procedure in a case series of fetal cervical and oropharyngeal masses.Methods: We have carried out a retrospective review of all patients with fetal cervical and oropharyngeal masses who underwent an EXIT procedure between 2008 and 2019. Variables evaluated included indication for EXIT, ultrasound and MRI findings, the need of amnioreduction, gestational age at EXIT, birth weight, complications, operative time, survival rate, pathological findings, and postnatal evolution. Five patients are included in this series. One additional case has already been published.Results: The diagnosis were cervical teratoma (n=1), epulis (n=1) and lymphangioma (n=3). Polyhydramnios was present in 2 patients, requiring amnioreduction in one of them. Mean gestational age at EXIT was 36-37 weeks (range, 34-38 weeks). Median EXIT time in placental support was 9 minutes (range, 3-22 minutes). Access to airway was successfully established in EXIT in all cases. All children born by EXIT are currently healthy and without complications. Conclusion: The localization and characteris­tics of the mass, its relationship to the airway, and the presence of polyhydramnios seem to be major factors determining indications for EXIT and clinical outcome.

Ex-Utero Intrapartum Treatment (EXIT): indications and outcome in fetal cervical and oropharyngeal masses

Background The “Ex-Utero Intrapartum Treatment” (EXIT) procedure allows to ensure fetal airway before completion of delivery and umbilical cord clamping, while keeping uteroplacental circulation. Airway obstruction in fetal oropharyngeal and cervical masses can be life-threatening at birth. In those situations, a controlled access to fetal airway carried out by a trained multidisciplinary team allows a safe airway management, while feto-maternal circulation is preserved. We aim to review the indications and outcome of EXIT procedure in a cases series of fetal cervical and oropharyngeal masses. Methods We performed a retrospective review of all patients with fetal cervical and oropharyngeal masses who underwent an EXIT procedure between 2008 and 2019. Variables evaluated included indication for EXIT, ultrasound and MRI findings, need of amnioreduction, gestational age at EXIT, birth weight, complications, operative time, survival rate, pathological findings and postnatal evolution. Five patients are included in this series. One additional case has already been published. Results The diagnosis were cervical teratoma (n=1), epulis (n=1) and lymphangioma (n=3). Polyhydramnios was present in 2 patients, requiring amnioreduction in one of them. Mean gestational age at EXIT was 36-37 weeks (range, 34-38 weeks). Median EXIT time in placental support was 9 minutes (range, 3-22 minutes). Access to airway was successfully established in EXIT in all cases. All children born by EXIT are currently healthy and without complications. Conclusion The localization and characteris­tics of the mass, its relationship to the airway and the presence of polyhydramnios seems to be major factors determining indications for EXIT and clinical outcome.