The ex utero intrapartum therapy procedure for high-risk fetal lung lesions

https://doi.org/10.1016/j.jpedsurg.2005.03.024Get rights and content

Abstract

Background

Indications for the ex utero intrapartum therapy (EXIT) procedure have expanded to include any fetal anomaly in which resuscitation of the neonate may be compromised.

Methods

We reviewed the medical records of 9 patients after resection of lung lesions during the EXIT procedure.

Results

The mean gestational age at EXIT procedure was 35.4 weeks. All lung masses maintained large sizes late into gestation with mean mass volume/head circumference ratio of 2.5 at presentation and 2.2 at EXIT. Seven of 9 fetuses demonstrated hydropic changes (n = 6) and/or polyhydramnios (n = 5), and underwent prenatal intervention including thoracentesis, thoracoamniotic shunt placement, amnioreduction, and/or betamethasone administration. Overall survival after EXIT for lung mass resection was 89%. The average time on placental bypass was 65 minutes. Postnatal complications included reoperation for air leak (n = 1), reoperation for bleeding (n = 1), and death from sepsis and prematurity (n = 1). Venoarterial extracorporeal membrane oxygenation was used in 4 neonates for persistent pulmonary hypertension. Maternal prenatal complications included polyhydramnios (n = 5), preterm labor (n = 4), and chorioamnionitis (n = 1). One mother required perioperative blood transfusion.

Conclusion

The EXIT procedure allows for controlled resection of large fetal lung lesions at delivery, avoiding acute respiratory decompensation related to mediastinal shift, air trapping, and compression of normal lung.

Section snippets

Patient population

From September 1995 through March 2004, a total of 272 pregnant women with fetal lung lesions were referred to The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia (CHOP). The initial evaluation at CHOP includes detailed fetal ultrasonography and fetal ultrafast magnetic resonance imaging. Assessment includes the type of fetal lung lesion, CVR, placental size and location, and the presence or absence of hydrops. Fetal echocardiography and Doppler flow

Results

During the study period, 272 pregnant women underwent evaluation for a prenatally diagnosed lung lesion. Sixteen patients with solid masses and hydrops underwent open fetal surgery with 50% survival. Twenty-three patients with macrocystic masses underwent shunt placement with 74% survival. Of those that continued postnatal care at CHOP, 35 patients underwent urgent operative intervention within the first week of life for respiratory distress (16 in first 24 hours) and 113 underwent elective

Discussion

The alternative to the EXIT procedure for resection of high-risk lung lesions is immediate decompressive thoracotomy in an often unstable hypoxic neonate. Patient selection for the EXIT procedure in the setting of a fetal lung lesion relies heavily on serial prenatal surveillance. The CVR is a useful objective measurement in tracking growth and regression of the lung mass [11]. Magnetic resonance imaging is useful for delineating feeding vessels, assessing lobar involvement, and more clearly

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    Citation Excerpt :

    Although some smaller lesions will remain stable or regress, almost half of lesions can have rapid growth to 28 wk gestation, when the lesion reaches a growth plateau.4-6 Rapid growth during this period has significant implications for the fetus, as it can cause mediastinal compression with high output cardiac failure leading to hydrops and potentially intrauterine fetal demise (IUFD).7,8 The CLM volume ratio (CVR) has been described as a metric to help identify patients who are at risk for prenatal hydrops and perinatal respiratory distress.9-13

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Presented at the 56th Annual Meeting of the Section on Surgery of the American Academy of Pediatrics, San Francisco, California, October 8-10, 2004.

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