Two cases of congenital airway obstruction managed with ex utero intrapartum treatment procedures: anesthetic implications

An ex utero intrapartum treatment (EXIT) procedure provides sufficient time to gain control of the potentially obstructed fetal upper airway while uterine placental circulation is maintained during cesarean section. We report 2 cases in which fetal congenital upper airway obstruction was managed without complications during EXIT procedures. We also discuss general considerations concerning the obstetric patient and the performance of intramuscular fetal anesthesia. Before the hysterotomy, sevoflurane at 1.5 minimum alveolar concentration was administered to assure sufficient uterine relaxation during EXIT. The 2 parturients remained hemodynamically stable during the procedure and uterine and placental perfusion was adequate. Nasotracheal intubation was possible in 1 fetus after a cervical mass was dissected. In the other, a tracheostomy was created. After the umbilical cord was clamped, the concentration of sevoflurane anesthetic gas was reduced and oxytocin and methylergometrine were administered to induce adequate uterine contractions within a few minutes. Both neonates survived the EXIT procedure with no complications.     

Anaesthetic management of a neonate with prenatally diagnosed cervical tumour and upper airway obstruction

We report the anaesthetic management of a mother, and airway management of a neonate with a prenatal diagnosis of cervical cystic hygroma causing upper airway obstruction. The mortality of such neonates due to upper airway obstruction is reported to exceed 20% following deliveries. Elective Caesarean section was performed under general anaesthesia, and in utero tracheal intubation of the neonate was accomplished under uninterrupted maternal-fetal circulation. By utilizing isoflurane and ritodrine, the heart rate of the neonate remained between 120 to 150 bpm for four minutes following uterine incision. We believe that it is important that a multidisciplinary approach be initiated for planning of airway management of the neonate soon after the diagnosis is made. Laryngoscopy blades larger than normal for neonates, and a portable Doppler to monitor the viability of the neonate were found to be useful in the management of the neonate during in utero tracheal intubation. Although estimated blood loss was not increased, nor did uterine atony occur postoperatively despite the use of ritodrine during Caesarean section, the efficacy and safety of ritodrine to delay placental detachment have not been proved.     

Case of peripartum cardiomyopathy developed after an emergency cesarean section--a case report

A 28-year-old woman was admitted because of pregnancy induced hypertension at 35 weeks of gestation with twin babies. The premature labor had been inhibited for 2 weeks with ritodrine (100 microg min(-1) continuous infusion). At 37 weeks of gestation, an emergency cesarean section was carried out under combined spinal epidural anesthesia. After the delivery, oxytocin 5 units was injected to the uterine muscle and methylergometrin 0.2 mg was given intravenously to induce uterine contraction. One hour after the operation, she developed severe pulmonary edema. An echocardiography showed diffuse hypokinesis of the left ventricle with ejection fraction of 23%. She was diagnosed as having peripartum cardiomyopathy by cardiologist. The patient's condition improved in a few days but the abnormal cardiac function continued for two months.     

The use of epidural ropivacaine for a gravida with disposition for malignant hyperthermia

It is reported that ropivacaine, a new amide-linked local anesthetic, can be used safely in patients susceptible to malignant hyperthermia. We report a case of the use of epidural ropivacaine for a gravida with disposition for malignant hyperthermia. A 33-year-old female patient, 11 weeks and 2 days pregnant, was admitted for torsion of the right ovarian cyst. Five years before, she had been prepared for operation for uterine myoma. After premedication with atropine 0.5 mg and hydroxyzine 50 mg i.m. her body temperature increased to 39.0 degrees C, and the operation was postponed. By muscle biopsy she was diagnosed susceptible to malignant hyperthermia. Two months thereafter, the operation for uterine myoma was performed under epidural lidocaine and intravenous propofol anesthesia. Three years ago, she had cesarean section under epidural anesthesia using mepivacaine. This time, the epidural catheter was inserted at L 3-4 interspace, and 10 ml of 1.0% ropivacaine was administrated. After fifteen minutes analgesia was obtained to T 10-L 2. Forty minutes later the operation was performed and the patient was safely anesthetized by ropivacaine. Later at 37 weeks and 3 days pregnancy, cesarean section was performed with epidural ropivacaine.     

Anesthetic management of a pregnant woman with Gorham-Stout disease

Gorham-Stout disease is a rare disorder of bone loss and proliferation of lymphatic and vascular tissue (lymphangiomatosis). A 30-year-old nulliparous woman with Gorham-Stout disease presented at 8 weeks of gestation with a fused cervical spine. At 31 weeks she developed basilar invagination and neurological symptoms that were managed with a neck brace. Anesthetic considerations were those of airway compromise, development of severe preeclampsia and Kasabach-Merritt coagulopathy. Elective tracheostomy was declined. She presented two days before a planned cesarean delivery at 35 weeks in preterm labor. A semi-urgent cesarean delivery under spinal anesthetic proceeded uneventfully, with an otolaryngologist present in case a surgical airway was required. Mother and baby were discharged home after three days. Maternal postpartum recovery was complicated by episodes of respiratory compromise and critical bone loss in the cervical spine, necessitating further surgical reinforcement.     

Anesthesia for Ex Utero Intrapartum Treatment (EXIT procedure) in Fetus with Prenatal Diagnosis of Oral and Cervical Malformations: Case Reports

Background and objectivesFetus prenatally diagnosed with neck tumors, or with any other disease that obstructs the airways, should not be treated conventionally, as the assistant physician has to face two challenges right after the infant's delivery: the limited time to establish the access to the potentially difficult airways and the lack of anesthesia of the neonate in case of instrumentation of the airways. The ex utero intrapartum treatment, i.e., the EXIT procedure consists of maintaining the fetoplacental circulation during the cesarean section, until the airways of the fetus be secured.Case ReportsFemale patient, 37 years old, G3P2, 38 weeks pregnant, having polyhydramnios and fetus diagnosed with large cervical masses by prenatal ultrasound. A cesarean section was performed using the EXIT procedure to enable safe access to the infant's airways. After hysterotomy, the fetus was intubated by direct laryngoscopy. The neonate was immediately transferred to another operating room, where cervical tumor resection of the neck tumor and tracheostomy were successfully performed. Female patient, 27 years old, G3P1A1, 32 weeks pregnant, whose fetus was prenatally diagnosed with a large oral tumor. As the tumor obstructed the fetus’ airways, a tracheostomy was performed when the fetus underwent EXIT procedure. It was then possible to use direct laryngoscopy for neonate intubation. The fetus underwent tumor resection and was sent to the Neonatal Intensive Care Unit.ConclusionsReports describe the successful use of general anesthesia with isoflurane for cesarean delivery followed by the EXIT procedure in fetus diagnosed with tumors obstructing the airways.     

An unusual presentation of idiopathic thrombocytopenic purpura in pregnancy

A 35-year-old, 39-week pregnant woman underwent an uneventful emergent cesarean delivery for suspected placental abruption or uterine dehiscence. Given the urgency of the situation and the unremarkable airway anatomy, general anesthesia was the chosen technique. Four hours after her surgery, she returned to the operating room for persistent vaginal bleeding. Hematology tests performed before the cesarean delivery revealed severe thrombocytopenia. This was later diagnosed as idiopathic thrombocytopenia, which was treated successfully with steroid therapy.     

Care of a parturient with preeclampsia, morbid obesity, and Crouzon's syndrome

We present the case of a 31-year-old woman with severe preeclampsia, morbid obesity, and a craniofacial syndrome who developed respiratory failure necessitating intubation and delivery by cesarean section. Her airway management was complicated by supraglottic edema and macroglossia. Fiberoptic intubation was difficult but successful. After delivery of the infant, tracheostomy was performed to provide a secure airway until the supraglottic edema resolved over the subsequent two weeks. The airway implications of preeclampsia and Crouzon’s syndrome are reviewed.     

Four cases of the ex utero intrapartum treatment (EXIT) procedure: anesthetic implications

The ex utero intrapartum treatment (EXIT) procedure is a method of maintaining utero-placental circulation during cesarean section to gain time to secure a potentially obstructed fetal airway. Four cases of the EXIT procedure are described with special reference to the maternal anesthetic technique. Deep volatile anesthesia (approximately 2 MAC) with isoflurane or sevoflurane for a prolonged period of time, in three cases in combination with an intravenous nitroglycerin infusion, was used to ensure a fully relaxed uterus during the procedure. All mothers were maintained hemodynamically stable with preserved utero-placentary perfusion. It was possible to intubate the tracheas of two fetuses, whereas in the other two tracheostomies had to be performed. Fetal gas exchange was not negatively affected during the EXIT procedure as evidenced by normal blood gas values in the umbilical artery at the time of delivery. After reducing the concentration of volatile anesthetic, delivery of the neonate and administration of oxytocin, uterine contractility was promptly re-established and there were no signs of uterine atony in the postoperative period. All four neonates survived the procedure without complications.     

Prenatal percutaneous needle drainage of cystic sacrococcygeal teratomas.

Prenatal ultrasound (US) permits in utero diagnosis of sacrococcygeal teratoma (SCT), follow-up of tumor size, and the early identification of complications, allowing for a more timely and appropriate delivery. The recommended management of large SCTs is delivery by cesarean section (CS) to prevent dystocia, tumor rupture, hemorrhage, and death. However, even delivery by CS can be difficult, necessitating a large hysterotomy that adds to maternal morbidity. The authors report two cases of cystic SCTs in which prenatal percutaneous drainage allowed for an uncomplicated vaginal delivery. In the first case, a large unilocular cystic SCT was diagnosed at 31 weeks' gestation on prenatal US. The fetal presentation was breech, and the mass was steadily increasing in size, preventing spontaneous version. At 37 5/7 weeks, the cyst was percutaneously drained under US guidance allowing for successful external version. Repeat drainage just before induction of labor permitted a successful vaginal delivery. In the second case, the cystic SCT was percutaneously drained just before induction of labor at full term, again allowing for an uncomplicated vaginal delivery. Prenatal percutaneous needle drainage of cystic SCTs offers an alternative to CS that results in decreased risks for both mother and fetus.     

Uterine prolapse during late pregnancy in a nulliparous woman

A pregnancy that is complicated by a uterine prolapse is rare and primarily occurs in multiparous women during their first or second trimester. In the present report, we describe a case of a 31-year-old nulliparous woman who experienced sudden uterine prolapse at 38 weeks’ gestation without labor pains. The cervix was congested, the cervical mucosa was partially lacerated, and bleeding was noted; the protruding cervix could not be repositioned into her vagina. Although the cervical congestion worsened over time, she still did not experience any labor pains. She was delivered by emergency cesarean section. Following delivery, the prolapse promptly improved and did not recur before her 1-month postpartum examination. To our knowledge, this is the first case where uterine prolapse occurred in a nulliparous woman during late gestation.     

Perinatal management of a neonate with airway obstruction caused by rhabdomyosarcoma of the tongue

Intra-oral masses in neonates can seriously compromise the airway, potentially causing hypoxia and death if not recognized and managed appropriately. We report a case in which an intra-oral mass was diagnosed on antenatal ultrasound scan. Preparation for delivery involved a multidisciplinary team approach, with a strategy for management at delivery. The child was delivered by elective Caesarean section and had a patent airway. A tracheostomy was performed immediately after delivery. The infant underwent a debulking procedure 3 weeks after birth. A histological diagnosis of embryonal rhabdomyosarcoma was made and a course of chemotherapy commenced. The child had a partial response to treatment with considerable shrinkage of the tongue mass. We discuss the management options in neonates with intra-oral masses to provide an adequate airway and maintain fetal oxygenation. The differential diagnosis of fetal oral masses is reviewed.      

剖宫产术后再次妊娠分娩方式150例分析

目的探讨剖宫产术后再次妊娠的分娩方式,分析经阴道分娩的可能性。方法回顾性分析2009年3月～2012年9月我院收治的既往有剖宫产史的150例孕妇的分娩方式。结果 150例孕妇中,126例选择再次择期剖宫产,24例选择经阴道试产,17例阴道试产成功,阴道试产成功率70.8%,7例试产失败转行剖宫产。再次剖宫产率88.7%（133/150）。结论对于符合条件的剖宫产术后再次妊娠分娩的孕妇可以在严密监护下阴道试产。     

A case of anaphylactic shock induced by latex during cesarean section

We report a 39-year-old woman who showed intraoperative anaphylactic shock during elective cesarean section in the 38th week of pregnancy. She underwent cesarean sections under general anesthesia at 33 years of age, and under spinal anesthesia at 37 years without any complication; other past history was unremarkable. Spinal anesthesia was performed with 0.5% hyperbaric bupivacaine 2.5 ml and analgesia level up to T2 was obtained 12 minutes later. The operation was uneventful at the birth of a neonate weighing 2700 g delivered with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. Drip infusion of oxytocin was started after the delivery and uterine contraction was good. Five minutes later, blood pressure decreased abruptly to 70/40 mmHg, heart rate increased to 130 beats min(-1) and the patient complained of chest discomfort. Bolus injections of ephedrine and phenylephrine were ineffective, and continuous infusion of adrenaline was started to maintain blood pressure. The operation was finished and the patient was intubated for artificial ventilation to prevent airway obstruction. The tracheal tube was removed the following day and the postoperative course was uneventful thereafter. Plasma tryptase levels at 1 and 6 hours after the episode of hypotension were 9.0 and 1.3 ng x ml(-1). Postoperative blood tests revealed an increase in latex-specific immunoglobulin E, suggesting that anaphylactic shock was induced by latex.     

Anesthetic management of the ex-utero intrapartum treatment (EXIT) procedure for congenital high airway obstruction syndrome (CHAOS)

We report an experience of anesthetic management of the ex-utero intrapartum treatment (EXIT) procedure performed in a fetus with congenital high airway obstruction syndrome (CHAOS) due to laryngeal atresia at 30 weeks' gestation. Anesthesia of the mother was induced with rapid sequence, and maintained with 3.5% sevoflurane in 100% oxygen and fentanyl before delivery. Two minimum alveolar concentration (MAC) sevoflurane provided excellent uterine relaxation without maternal hypotension. After hysterotomy, a sterile pulse oxymeter was placed on the fetus hand for monitoring fetal SpO2 and pulse rate, and a Doppler ultrasound transducer was applied to monitor fetal heart rate. Fentanyl (5 microg x dl(-1)) and pancuronium (0.2 mg x dl(-1)) were injected into the fetal upper arm in addition to transplacental anesthetic agents. The fetal heart rate and SpO2 were stable throughout the fetal manipulations, but the rise in SpO2 after initiating ventilation via tracheostomy was very slow. The uterine tone improved soon after discontinuing sevoflurane and oxytocin infusion was started after delivery. Surfactant administration before first ventilation is recommended in preterm babies undergoing EXIT procedure, and capnometer may be useful to confirm the adequate ventilation before cutting the umbilical cord.     

Anesthetic management of cesarean section for a patient with idiopathic thrombocytopenic purpura

A 39-year-old parturient with idiopathic thrombocytopenic purpura (ITP) was scheduled for cesarean section at 37 weeks gestation. ITP, diagnosed during the first pregnancy, recurred during the second pregnancy, and she was treated with high dose gamma-globulin and platelets transfusion to increase her platelets count over 5.0 x 10(4) x microliter-1 before cesarean section. During the operation under general anesthesia with propofol and pentazocin, atonic hemorrhage occurred gradually with increasing blood loss after the parturition. Since administration of oxytocin, ergometrine maleate, and prostaglandin E1 could not improve the uterine contraction, the hysterectomy was performed to control massive bleeding (finally 8200 g). Packed red cells (22 units) and platelets (40 units) were transfused and fresh frozen plasma (28 units) was infused during anesthesia. Management of ITP during pregnancy is important to prevent hemorrhagic complications because of a narrow safety margin of parturient and fetus.     

Laryngeal cystic hygroma

An unusual case of cervical cystic hygroma with laryngeal extension is reported. A patient with acute upper airway obstruction due to a laryngeal lesion was seen 18 years after the original cervical surgery. Maintenance of an adequate airway has required a partial laryngectomy in addition to repeated endoscopic procedures for removal of recurrent disease. The rationale for this therapy is discussed in light of the current literature.     

Surgical treatment for acute type A aortic dissection during pregnancy (16?weeks) with Loeys-Dietz syndrome

A 32-year-old woman at 16?weeks of pregnancy was diagnosed with acute type A aortic dissection and severe aortic regurgitation. Aortic valve and aortic arch replacement was successfully performed under circulatory arrest with deep hypothermia. After the operation, she was diagnosed with Loeys-Dietz syndrome. At 36?weeks of gestation, the patient underwent a cesarean section and delivered a healthy baby.     

Surgical management of parapharyngeal cystic hygroma causing sudden airway obstruction

Parapharyngeal cystic hygroma is a rare tumor of the neck. This report describes two cases in which surgical resection was necessary to overcome sudden airway obstruction and details the surgical technique. These cases were considered "near misses" for sudden infant death syndrome (SIDS) and were revealed by computed tomography (CT) and echography to be parapharyngeal cystic hygroma. The location of this malformation could have produced sudden airway collapse and be erroneously diagnosed as SIDS. The postoperative follow-up was satisfactory and no recurrence was detected. We believe CT and echography should be included in the evaluation of such cases.     

Anesthesia for cesarean section in a parturient taking risperidone and haloperidol

We report a case of anesthesia for cesarean section in a schizophrenic patient. Her psychiatric symptoms were well controlled with low doses of risperidone until 35 weeks' gestation, when she suddenly developed psychotic manifestations. Risperidone 6 mg x day(-1) and haloperidol 12 mg x day(-1) PO were given for 3 weeks before delivery. Elective cesarean section was performed under spinal anesthesia at 38 weeks. The parturient showed good psychiatric condition during and after the surgery. The neonate did not show any symptoms which antipsychotics could have caused. Maternal and umbilical blood concentrations of risperidone and haloperidol are reported.