The ex utero intrapartum treatment (EXIT) procedure is a very rare technique performed in cases of fetal congenital malformations. The EXIT procedure increases the rate of survival at delivery by maintaining the uteroplacental circulation until the airway of the fetus is secured. To maintain the uteroplacental circulation, a higher dose of inhalational anesthetics and/or intravenous nitroglycerin can be used as compared to conventional Cesarean section. The aim of this report is to share our anesthetic experience during the EXIT procedure with members of the Korean society of anesthesiology for the first time, and to highlight the maternal implications of the use of inhalational anesthetics and nitroglycerin during Cesarean section for the EXIT procedure.
Anesthesia, General ; Anesthesiology ; Anesthetics ; Cesarean Section ; Female ; Fetus ; Nitroglycerin ; Placental Circulation ; Pregnancy

The ex utero intrapartum treatment (EXIT) procedure was introduced to reduce fetal hypoxic damage while establishing an airway in fetuses with upper and lower airway obstruction. Delivery of the fetal head and shoulders while maintaining the uteroplacental circulation offers time to secure the fetal airway. Here, we report two cases of EXIT procedure for fetal airway obstruction, which were successfully managed with extensive preoperative planning by a professional multidisciplinary team.
Airway Obstruction* ; Fetal Therapies ; Fetus* ; Head ; Laryngeal Diseases ; Lymphangioma ; Placental Circulation ; Prenatal Diagnosis ; Shoulder

Systolic time interval measurements were made sequentially during second, third trimesters and postpartum period. Recordings were made in the supine position after bed rest for at least five minutes in order to obtain a steady state. In second trimester, pre-ejection period index (PEPI) was significantly shortened and left ventricular ejection period index(LVETI) remained normal while PEP/LVET decreased. Four possible mechanisms may be involved to account for the alterations in hemodynamic changes during this period(late stage of second trimester) : (1) increased metabolic demands of pregnancy: (2) hemodynamic effects of hypervolemia: (3) circulatory adjustments secondary to an arteriovenous shunt-like effect of the placental circulation: (4) cardiovascular effect of steroid hormone. The third trimester was characterized-by a markedly shortened LVETI, a prolonged PEPI and PEP/LVET. This findings are consistent with impaired left ventricular performance and are probably due to decreased left ventricular preload resulting from diminished venous return secondary to inferior vena caval obstruction by the large gravid uterus. In the postpartum period, the PEPI and PEP/LVET remained elevated and the LVETI shortened in the supine position. It is concluded that alterations in systolic time intervals occur normally during the course of uncomplicated pregnancy and persist into the postpartum period.
Bed Rest ; Female ; Hemodynamics ; Humans ; Placental Circulation ; Postpartum Period* ; Pregnancy ; Pregnancy Trimester, Second ; Pregnancy Trimester, Third* ; Supine Position ; Systole* ; Uterus

The ex utero intrapartum treatment (EXIT) is used for unborn fetuses in cases of predictable complications of postpartum airway obstruction. The delivered fetus is maintained on placental circulation while airway is established and this is carried out by a multidisciplinary team. Teratomas arising from the palate or pharynx may cause immediate life-threatening airway obstruction to the newborn. In our case, congenital oral teratoma was detected via prenatal ultrasound. The treating team determined that this may induce airway occlusion at birth and decided to perform an EXIT to secure an airway. On the day of birth, debulking of the tumor was performed and the fetus was successfully delivered. Vital signs were stable without intubation management.
Airway Obstruction ; Fetus ; Humans ; Infant, Newborn ; Intubation ; Palate ; Parturition ; Pharynx ; Placental Circulation ; Postpartum Period ; Teratoma* ; Ultrasonography ; Vital Signs

OBJECTIVE: This study was conducted to compare the safety and efficacy of transdermal glyceryl trinitrate (GTN) in initial therapy for preterm labor with those of intravenous ritodrine hydrochloride and the effects of tocolytics in uteroplacental circulation, as assessed by uterine artery doppler velocimetry. METHODS: Patients between 24 and 34 weeks gestation with documented preterm labor were randomly assigned to receive transdermal GTN (n=24) or intravenous ritodrine (n=35) as initial tocolytic therapy. Patients in the GTN group were administered 0.2 mg/h released transdermal patch on the pregnant women's abdomen directly. Patient in the ritodrine group were treated 0.025 mg/min as initial dose. The dose increased at 15 minute intervals until uterine contractions were inhibited or side effects become intolerable. The maximum recommended dose was 0.20 mg/min. The main outcome examined were failure of tocolysis, time to uterine quiescence, time gained in utero, and frequency of adverse effects. We obtained both right and left uterine artery doppler velocity waveform before and after tocolytics therapy. The mean values of the right and left uterine artery systolic and diastolic ratio were calculated and used for analysis. RESULTS: There were no significant difference in maternal demographic between the groups. Successful tocolysis was observed in 79.2% in the GTN group, and 85.7% in the ritodrine group (p=0.726). Time to uterine stop contraction was 5.5 +/- 5.3 hr in ritodrine group and 1.1 +/- 0.3 hr in GTN group. There were no different in time to gain in uterus between the two groups. The patient in the ritodrine group had more adverse side effects, mainly maternal tachycardia (p=0.002), chest pain and tremor (p=0.035). There was no significant difference in uterine S/D ratios between the pretherapy and posttherapy GTN group. However, we found statistically significant difference between the pretherapy and 24 hr-posttherapy in ritodrine group. CONCLUSION: Transdermal GTN was effective, safe, and well tolerable tocolytic agent. Patients who received ritodrine hydrochloride were more likely to have adverse effects. We also conclude that GTN do not affect uteroplacental circulations as measured by S/D ratios but ritodrine does. This results suggest that progressively increasing dose of ritodrin and GTN maybe associated with a statistically significant decrease S/D ratios. However, further investigations needs to be performed.
Abdomen ; Chest Pain ; Female ; Humans ; Nitroglycerin* ; Obstetric Labor, Premature* ; Placental Circulation ; Pregnancy ; Rheology ; Ritodrine* ; Tachycardia ; Tocolysis* ; Tocolytic Agents* ; Transdermal Patch ; Tremor ; Uterine Artery ; Uterine Contraction ; Uterus

In adults, hypothyroidism caused by thyroid stimulation blocking antibody (TSB Ab) is rare, and confirmed cases are even fewer, as TSB Ab levels are rarely assayed. However, this may create problems in babies, as the transplacental passage of maternal TSB Ab can cause a rare type of hypothyroidism in the infant. Prompt levothyroxine replacement for the baby starting immediately after birth is important. We describe a congenital hypothyroid baby born to a hypothyroid mother who was not aware of the cause of her hypothyroid condition, which turned out to be associated with the expression of TSB Ab. This cause was confirmed in both the infant and mother using a series of thyroid function tests and measurements of autoantibody levels, including TSB Ab. During periodic follow-up, the TSB Ab and thyroid stimulating hormone receptor antibody titers became negative in the baby at 8 months of age, but remained positive in the mother. Evaluation of hypothyroidism and its cause in mothers during pregnancy is important for both maternal and child health.
Adult ; Child Health ; Congenital Hypothyroidism* ; Follow-Up Studies ; Humans ; Hypothyroidism ; Infant ; Mothers* ; Parturition ; Placental Circulation ; Pregnancy ; Receptors, Thyrotropin ; Thyroid Function Tests ; Thyroid Gland* ; Thyroxine

In adults, hypothyroidism caused by thyroid stimulation blocking antibody (TSB Ab) is rare, and confirmed cases are even fewer, as TSB Ab levels are rarely assayed. However, this may create problems in babies, as the transplacental passage of maternal TSB Ab can cause a rare type of hypothyroidism in the infant. Prompt levothyroxine replacement for the baby starting immediately after birth is important. We describe a congenital hypothyroid baby born to a hypothyroid mother who was not aware of the cause of her hypothyroid condition, which turned out to be associated with the expression of TSB Ab. This cause was confirmed in both the infant and mother using a series of thyroid function tests and measurements of autoantibody levels, including TSB Ab. During periodic follow-up, the TSB Ab and thyroid stimulating hormone receptor antibody titers became negative in the baby at 8 months of age, but remained positive in the mother. Evaluation of hypothyroidism and its cause in mothers during pregnancy is important for both maternal and child health.
Adult ; Child Health ; Congenital Hypothyroidism* ; Follow-Up Studies ; Humans ; Hypothyroidism ; Infant ; Mothers* ; Parturition ; Placental Circulation ; Pregnancy ; Receptors, Thyrotropin ; Thyroid Function Tests ; Thyroid Gland* ; Thyroxine

The survival rate and prognosis for neonates with airway obstruction is poor if not managed immediately after delivery. Ex utero intrapartum treatment (EXIT) is indicated for cases in which airway obstruction is anticipated. The procedure establishes the fetal airway prior to complete delivery while maintaining an intact uteroplacental circulation. Maintaining uteroplacental circulation, ensuring uterine relaxation, and temporizing placental detachment during the EXIT procedure are achieved by administering a higher dose of inhalation anesthetic and intravenous nitroglycerine. However, this can lead to maternal hypotension and compromised feto-placental perfusion, reduced fatal cardiac output and acidosis. It is therefore essential that these be managed using vasopressors and inotropes. This paper reports the first institutional experience with the EXIT procedure in the Philippines, presenting two cases of neonates with large cystic hygroma. One case was performed as an elective procedure, the other as emergency treatment.

Human ; Female ; Adult ; Acidosis ; Airway Obstruction ; Anesthetics, Inhalation ; Cardiac Output ; Emergency Treatment ; Fetus ; Hypotension ; Infant, Newborn ; Lymphangioma, Cystic ; Philippines ; Placental Circulation ; Pregnancy ; Prognosis ; Survival Rate

OBJECTIVE: To study the effects of maternal epidural anaesthesia on the maternal uterine circulation and the fetal umbilical placental circulation by using Doppler ultrasound techniques. STUDY DESIGN: Twenty-seven patients delivered by elective caesarean section under lumbar epidural anaesthesia were studied. All had a normal pregnancy with no indication of fetal compromise and no indication of maternal disease. Each patient received a 1 litre intravenous crystalloid infusion over 20~30 minutes before an epidural bupivacaine injection. The uterine and fetal umbilical artery velocity waveforms were recorded. And then intravenous cannula and an epidural catheter were inserted. The local anaesthetic agent were injected through the epidural catheter(0.5% bupivacaine 10ml, 20% lidocaine 10 ml). At achieve sensory blockade to the T-4 level after the injection of the anaesthetic agent, the uterine and fetal placental circulation flow velocity-time waveforms were again recorded by using Doppler ultrasound(Multigon 500A, 4 MHz). Significance was tested by means of the paired student t-test. RESULTS: 1. Significant differences were observed between the two groups(Before anaesthesia, S/D ratio of fetal umbilical artery was 2.48+/-0.50. Following anaesthesia, S/D ratio of fetal unbilical artery was 2.24+/-0.40, p < 0.005). 2. Significant differences were observed between the two groups(Before anaesthesia, S/D ratio of maternal uterine artery was 2.29+/-0.41. Following anaesthesia, S/D ratio of maternal uterine artery was 1.95+/-0.25, p < 0.001). CONCLUSION: This study suggests a beneficial fetal effect from the improved maternal uterine perfusion after epidural anesthesia.
Anesthesia, Epidural ; Arteries ; Blood Flow Velocity* ; Bupivacaine ; Catheters ; Cesarean Section* ; Female ; Humans ; Lidocaine ; Perfusion ; Placental Circulation ; Pregnancy ; Ultrasonography ; Umbilical Arteries* ; Uterine Artery

OBJECTIVE: Unexplained elevations of midtrimester human chorionic gonadotrophin(hCG) or alpha fetoprotein(AFP) have known to be at increased risk for a variety of third trimester pregnancy complication, such as preeclampsia. The causes of these were thought to be made by impaired placental function, as a reflection of impaired uteroplacental circulation. Our purpose was to determine if amniotic fluid total -hCG and AFP levels are elevated in women with severe preeclampsia and if these levels correlated with other laboratory features of disease severity. METHODS: Seventeen women with severe preeclampsia were matched with 16 women with the diagnosis of either preterm labor and intact membranes(n=10) or preterm premature rupture of membranes(n=6) who met the following criteria: 1) singleton gestation 2) absence of congenital anomaly 3) absence of active labor 4) confirmed getational age by ultrasonography 5) transabdominal amniocentesis performed to obtain amniotic fluid to assess fetal lung maturity. Amniotic fluid total -hCG and AFP were measured by double antibody radioimmunoassay(RADIM, Italy). Mann-Whitney U test and multiple linear regression analysis were used. RESULTS: 1) Concentrations of amniotic fluid total -hCG but not amniotic fluid AFP, maternal blood total -hCG and AFP were significantly higher in severely preeclamptic women than in their matched controls(amniotic fluid total -hCG; median 28.5, range 4.3-120.3 IU/ml vs. median 9.4, range 2.7-99 IU/ml, p < 0.01). 2) Amniotic fluid total -hCG levels correlated positively with maternal blood BUN(blood urea nitrogen) levels(r= 0.66, regression coefficients 5.57, standard error 2.4021, p< 0.05, multiple linear regression) after correction for known confounding variables(i.e., maternal weight, gestational age at sampling, hematocrit). CONCLUSION: Amniotic fluid total -hCG levels are elevated in women with severe preeclampsia and correlate closely with maternal blood BUN levels. These observation suggest that the pathologic changes of preeclampsia might occur in the placenta and involve in change of a significantly secretory reaction of the placenta.
alpha-Fetoproteins* ; Amniocentesis ; Amniotic Fluid* ; Chorion ; Chorionic Gonadotropin* ; Diagnosis ; Female ; Gestational Age ; Humans* ; Linear Models ; Lung ; Obstetric Labor, Premature ; Placenta ; Placental Circulation ; Pre-Eclampsia* ; Pregnancy ; Pregnancy Trimester, Second ; Pregnancy Trimester, Third ; Rupture ; Ultrasonography ; Urea