The EXIT Procedure performed at the St John of God San Pietro Hospital


Specialists from the Bambino Gesł Hospital havesaved the life of a unborn baby girl with a massive growth in her oral cavity.


A complex EXIT (Ex Uterus Intrapartum Therapy) procedurewas successfully performed on 6 July at the St John of God San Pietro Hospital thanksto collaboration between specialists from the Bambino Gesł and the San PietroHospitals, to ensure that a baby girl suffering in utero from a massivegrowth in her oral cavity, which would have jeopardised her chances of survival,could be delivered safely.  The surgerywas performed by a mixed group of 8 different teams from the two hospitals of gynaecologistsand obstetricians, anaesthesiologists, neonatologists and otolaryngologists,neonatal surgeons and airway surgeons, heart surgeons and an ECMO team, andnurses and technicians specialising in all these fields.


The Diagnosis and TherapeuticStrategy

The baby's condition had been diagnosed after an morphologicalultrasound examination in the second quarter of the pregnancy. The growth in heroral cavity would have seriously prevented her from breathing because of the blockageand compression of the upper airways. This condition would have made it verydifficult, if not impossible, to perform the urgent tracheal intubation whichis essential at birth if a newborn is unable to breathe unaided. In this case, theEXIT procedure was the best strategy to turn what would certainly have been an emergencysituation into a controlled intervention that would reduce the high risk ofcausing life-threatening or neurological damage to the baby.


The Exit Procedure

The EXIT Procedure (an acronym for Ex UterusIntrapartum Therapy) is performed at birth during a Caesarean section. It is acoordinated intervention during which the foetus/newborn is only partially deliveredfrom the uterus, while remaining attached by the umbilicalcord to the placenta inorder to leave the utero-placental blood-flow unaffected. This enables the babyto continue receiving oxygen even if not breathing fully as a result of the largeobstruction in the oral cavity. Specialists have the time to intervene andsecure the infant's airways by calmly performing carefully controlled highlycomplex manoeuvres .


The procedure at San Pietro

To perform the procedure, the mother must be underspecific and deep general anaesthesia to fully relax the muscles of the uterusfor a prolonged period to avoid detaching the placenta and interrupting theblood supply of oxygen to the newborn. This is a key aspect of the anaesthesiologicprocedure, which gives rise to the risk of intra- and post-operative,especially haemorrhagic, complications.

For this reason it was decided to perform the procedureat the San Pietro Hospital, which is an maternity hospital of excellence and a partnerover many years with the Bambino Gesł in the field of obstetrics and foetal andperinatal medicine and surgery.

On 6 July, eight multi-specialist teams from thetwo hospitals participated in the surgery -- gynaecologists and obstetricians expertsin maternal-foetal medicine, neonatologists, anaesthesiologists and intensivecare specialists, otolaryngologists, heart surgeons and cardioanaesthesiologists,as well as highly specialised team of nurses. More than 30 professionals workedin the operating theatre, each one playing their part according to a preciseprotocol, repeatedly agreed upon and checked out during the days before thesurgery.

The procedure, which began at the time when the foetushad been partially removed from the uterus, took about 25 minutes overall.Since the growth could not be removed from the oral cavity so quickly, and itwas necessary to decide in the right surgical strategy, the baby was given atemporary tracheotomy, ensuring optimal ventilation. Once her general andcardiorespiratory condition had stabilised, the baby was transferred to theneonatal intensive care unit at the Bambino Gesł, where the diagnostic processwill be completed and a personalised treatment programme will be designed.


Motivation and Team Spirit

The success of such a complex an intervention inboth organisational and technical terms is determined by good coordination, andrespect for the roles of all the various specialists in the team, as well asthe closely-knit team spirit and great human and professional motivation drivingall the Operational Units of our Hospital, coordinated by the Department ofMedical and Surgical Neonatology and the St John of God San Pietro Hospital dedicatedto perinatal care under the OPGB Birth Project.


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