EXIT and Fetal Airway Management

What is EXIT?

EXIT stands for “ex utero intrapartum treatment,” which is Latin for “removing from the uterus during delivery.” EXIT-to-airway is a surgical procedure for safely delivering babies who have dangerous airway obstructions. It’s a partial delivery through a cesarean section followed by securing the airway, which is conducted before the umbilical cord is cut. The baby continues to be supported by the placenta and mom’s circulation during the procedure. The EXIT-to-airway procedure has three main stages:

• Partial delivery by cesarian (conducted by the Maternal-Fetal Medicine surgical OB/GYN and the pediatric surgery teams) so that a pediatric otolaryngologist–head and neck surgeon has full access to the airway while the baby remains connected to its mother by its umbilical cord and placenta.
• The airway is secured by the ENT surgery team —with a breathing tube or a tracheostomy—so the newborn can breathe once the umbilical cord is cut.
• The Maternal-Fetal Medicine surgical OB/GYN and the pediatric surgery teams step back in to complete the delivery and repair the cesarean.

Who needs an EXIT-to-airway procedure?

When an unborn baby is found to have an airway obstruction that could keep it from breathing freely once its umbilical cord is cut at birth, that baby may need an EXIT-to-airway procedure. There are several conditions that can cause such fetal airway obstruction. Indications for EXIT-to-airway include:

• Neck mass
• Cervical teratoma: a rare germ cell tumor that occurs in the neck
• Vascular lymphatic malformation
• Goiter: enlarged thyroid gland
• Neuroblastoma
• Micrognathia: disproportionately small lower jaw
• Chest mass
• Tracheal atresia (also called tracheal agenesis): an abnormal narrowing of the trachea or absence of the trachea
• Laryngeal atresia: condition caused by the voice box (larynx) not opening normally and blocking the airway
• Congenital high airway obstruction syndrome (CHAOS): a complex genetic condition that can result in blockage of the trachea or larynx

What goes into the care and management of an EXIT-to-airway procedure?

Patients requiring an EXIT procedure are usually first identified through fetal ultrasound, and their diagnoses are often made more specific using MRI and sometimes genetic analysis. EXIT requires extensive preparation and coordination. The team first needs to precisely describe the problem and find any genetic syndromes or additional malformations that might be associated with it.

Three surgical teams (the OB/GYN team, the pediatric surgery team, and the pediatric otolaryngology airway team) are required to work closely together, focusing on the mother’s delivery and on the baby’s airway repair. Several other specialists also must be on hand and ready for anything that might go wrong for either the mother or the baby.

Depending on the cause and nature of a baby’s airway obstruction, different interventions will be required for a long-term solution. Babies with airway problems often have other emerging special needs as well. The pediatric otolaryngology airway team works closely with many other subspecialties, including plastic surgery, speech pathology, pediatric dentistry, and genetics.