Omaha, Neb. – A multidisciplinary team of physicians recently performed the first “ex utero intrapartum treatment” or “EXIT” procedure at The Nebraska Medical Center – successfully securing an airway for a baby girl with a benign tumor in her mouth before fully delivering the infant by Cesarean section.
EXIT is an innovative procedure developed to deliver infants with severe congenital abnormalities usually of the head and neck that may make breathing after delivery difficult or impossible. During EXIT, the newborn is partially delivered by a C-section, but the umbilical cord supplying oxygen from mother to baby is not immediately cut. Next, the baby is intubated – a breathing tube is inserted through the mouth or nose into the windpipe. Finally, the delivery of the infant is completed and the cord cut only after a clear airway has been established.
“The biggest challenge in this type of procedure is establishing an airway for the baby quickly and maintaining a steady supply of oxygen so that no neurological damage occurs,” said Teresa Berg, MD, maternal-fetal medicine specialist at The Nebraska Medical Center. “If you can’t successfully intubate on the first several attempts, a tracheotomy, without a secure airway, is required and that potentially increases the risk for both the baby and the mother.”
This is an uncommon procedure – only about 100 cases have been documented in the United States.
Ultrasound Discovery: Mass on Mouth Will Prevent Baby From Breathing
A prenatal ultrasound at 22 weeks delivered the frightening news. Dan and Megan Hanson of Denison, Iowa were told that their baby girl had a mass in her mouth and wouldn’t be able to breathe on her own after delivery.
“It was an extremely anxious and overwhelming pregnancy,” said Megan.
“Prenatal care saved this baby’s life,” said Ann Anderson-Berry, MD, neonatologist and medical director of the Newborn Intensive Care Unit (NICU) at The Nebraska Medical Center. “We have fascinating technology like fetal MRIs and ultrasounds to help us plan for high-risk deliveries like this. If we had not discovered the mass in an early ultrasound and the baby was delivered in a normal delivery room, the risk of death or at the very least severe neurological problems is very high.”
Because the EXIT procedure is a complex and delicate operation, it requires careful planning and coordination between the mother’s physicians, anesthesiologists and the neonatal and pediatric specialists charged with the care of the newborn. Before the actual operation, the medical center’s teams established protocols and contingency plans for the surgery.
Shahab Abdessalam, MD, pediatric surgeon at The Nebraska Medical Center and Children’s Hospital & Medical Center helped to coordinate the procedure in the days leading up to delivery – putting into action expertise learned through experience with previous EXIT procedures.
“We were all familiar with our roles, our equipment and what steps needed to be taken when. We prepared for the best and worst case scenarios,” said Dr. Anderson-Berry. “The EXIT procedure required tremendous collaboration, and the successful outcome speaks of the excellent teamwork.”
“This is a complex and highly synchronized operation that requires a great deal of medical collaboration. We’re bringing together a team of experts dedicated to mom and a team of experts dedicated to the newborn. Our ability to provide this lifesaving procedure in Omaha speaks volumes about the caliber of our medical community,” said Dr. Abdessalam.
The Day of the EXIT Procedure
July 29, 2010, more than 34 physicians, nurses and other health care professionals filled the operating room, prepared for the complex, high-risk delivery of Haylee Hanson.
“From ultrasounds, we had determined that Haylee has a mass in her mouth that would interfere with her ability to breathe on her own,” said Rodney Lusk, MD, airway consultant for The Nebraska Medical Center and pediatric ENT (ear, nose and throat) specialist at Boys Town National Research Hospital.
Dozens of doctors and nurses begin the EXIT Procedure to deliver Haylee
In addition to a mass blocking the baby’s airway, masses can lead to an accumulation of excess amniotic fluid. Before the procedure would begin, the maternal-fetal medicine specialists removed about two liters of excess amniotic fluid from Megan’s uterus through a process called amnioreduction.
The EXIT procedure is an extension of the Cesarean section wherein an incision is made in mother’s abdomen and uterus. The baby is only partially delivered – her head, chest and shoulders are visible outside of the uterus while the rest of the body remains inside.
“This allows us to maintain volume in the uterus and prolong placental support, meaning mom is still breathing for baby through the umbilical cord,” said Dr. Berg. “It is optimal for there to be as much uterine relaxation as possible and this can be provided by anesthesia to the mother and by a medication to prevent contractions. If the uterus does not remain relaxed, the placenta will separate with the onset of maternal bleeding and the oxygen supply from the mother to baby would be stopped.”
The team has to move quickly. Placental support usually lasts for 30 minutes or less.
“At this point, the baby’s life is dependent on whether or not we can establish an airway in a short period of time,” said Dr. Anderson-Berry.
Dr. Lusk who is nationally known for pediatric airway management was in the “hot seat.” Using a laryngoscope (viewing instrument with a light), Dr. Lusk could see that Haylee’s mass was attached to the top of her mouth and down the back of her throat.
“The good news was I could see her larynx (voice box) so I believed I would be successful at placing a thin, plastic tube into her airway,” said Dr. Lusk.
A minute after delivering the baby’s head, an airway had been established. The tube was suctioned free of amniotic fluid and Dr. Anderson-Berry began hand ventilation until the baby could be hooked up to the ventilator machine.
“We were very fortunate to be able to establish an airway so quickly,” said Dr. Lusk. “We had several backup techniques with rigid and flexible scopes available if the initial intubation was not successful.”
Dr. Abdessalam was on standby in case intubation proved difficult, and an emergency tracheotomy (a hole made in the windpipe) would need to be performed. He also assisted in stabilizing the newborn.
Once physicians were confident that the baby’s breathing tube was secure and her heart rate stable, the medical team delivered Haylee completely, cut her umbilical cord and rushed her to a second operating room. Here Dr. Anderson-Berry did a complete physical exam of Haylee.
Before Haylee was safely transferred to the Newborn Intensive Care Unit (NICU), the doctors obtained a CT scan to better visualize the facial mass.
“It was determined that the mass was a teratoma, benign tumor that was relatively small,” said Dr. Anderson-Berry. This type of tumors often has teeth, bone, skin or even hair inside. “It’s essentially an error in development,” she said.
On Aug. 5, little Haylee went back into the operating room for a second time. Dr. Lusk and Jason Miller, MD, plastic and reconstructive surgeon at The Nebraska Medical Center, completely removed the mass.
“The mass came out very cleanly,” said Dr. Lusk. “However, because of the positioning of the mass, Haylee is left with a large cleft palette.” Another surgery at nine to 12 months of age will be required to reconstruct the palette.
“We are very blessed with the outcome,” said Haylee’s mother, Megan. “The first time I heard her cry was after she had her breathing tube removed on Aug. 9 and that was so thrilling to hear.”
Dr. Anderson-Berry does not predict any significant problems for Haylee.
“Because of her cleft palette, sucking is more difficult, so our goal now is to get her to nipple her feedings so she can be taken off the feeding tube.”
Once that happens, little Haylee can go home.
The following were the key physicians on the EXIT delivery team:
Maternal-Fetal Medicine – Dr. Teresa Berg, Dr. Serena Wu, Dr. Carl Smith
Anesthesia – Dr. Sheila Ellis, Dr. Joseph Kalamaja, Dr. Shawna Freeman-Ngau
Neonatology – Dr. Ann Anderson-Berry
Pediatric ENT (ear, nose and throat) – Dr. Rodney Lusk
Pediatric Surgery – Dr. Shahab Abdessalam, Dr. Robert Cusick
With a reputation for excellence, innovation and extraordinary patient care, The Nebraska Medical Center has earned J.D. Power and Associates’ Hospital of Distinction award for inpatient services for four consecutive years. It also received the 2009 Consumer Choice Award, a mark of patient satisfaction as selected by healthcare consumers and has achieved Magnet recognition status for nursing excellence, Thomson Reuters 100 Top Hospitals Performance Improvement Leader recognition, as well as the Award of Progress from the state of Nebraska’s Edgerton Quality Awards Program. As the teaching hospital for the University of Nebraska Medical Center, this 624 licensed bed academic medical center has an international reputation for providing solid organ and bone marrow transplantation services and is well known nationally and regionally for its oncology, neurology and cardiology programs. The Nebraska Medical Center can be found online at www.nebraskamed.com