A case of Multidisciplinary team work to save a life First time in Chennai
Photo: Left to right –Dr.Jayanthi, Dr.Thirunavakarasu, Dr. Suresh, Dr.Lakshmi & Dr.Uma Ram
EX-utero Intrapartum Treatment (EXIT) is a procedure that is used to deliver babies with a neck swelling or where ever a difficult airway is anticipated due to a mass in the neck or upper chest. The procedure preserves utero-placental gas exchange ie the baby continues to receive oxygen and nutrients from the mother until an airway is established by placing an endotracheal tube and lung ventilated with satisfactory oxygenation
Mrs D who was having antenatal care at Seethapathy Clinic & Hospital, had an ultrasound for checking the growth of the baby in her 28th week and this revealed a swelling on front of the neck of that baby possibly from the thyroid gland. This swelling was large, restricted the baby’s swallowing causing pressure effect on the neck of the developing baby and resulted in increase of the fluid around the baby.
A detailed work up was done by the Fetal Medicine team at Mediscan Systems, and by testing the fluid around the baby and blood sampling, it was confirmed that the swelling was an enlargement of the fetal thyroid gland due to hypothyroidism. The baby was treated in utero. Two injections were given into the amniotic fluid at an interval of 2 weeks which showed improvement in the level of the thyroid hormones in the fetus. This also helped to reduce the amount of amniotic fluid and a small reduction in the size of the thyroid swelling.
At 36 weeks a fetal MRI was done which showed compression of the trachea (airway) which would make it difficult for the baby to breathe if it was delivered. Anticipating problems in securing airway an EXIT procedure was planned at Dr. Mehta’s Hospitals
The details were discussed with the parents and family and after explaining the need for an elective caesarean with EXIT procedure and possible problems, informed consent was obtained.
The multidisciplinary team of fetal medicine, obstetricians, neonatologist, anesthetists, paediatric ENT, paediatric surgeons and theatre staff came together and planned for the procedure. A mock drill was done the day prior with the entire team
The maternal team included the anesthetist, Obstetrician and fetal medicine. They needed to keep the mother under general anesthesia and keep the uterus relaxed at the same time keep the placental circulation going till the procedure on the baby is over.
The multi-disciplinary team involving a neonatologist, pediatric anaethetist, pediatric ENT Surgeon, Pediatric surgeon in case a surgical resection of the mass is required for the baby was the key. Ideal positioning of each team with assistants and necessary equipments were kept ready so that there is enough room for everybody to perform once their turn comes.
A caesarean section was performed under general anesthesia, the baby was delivered only upto the head and held in position with the body still in the uterus with intact umbilical cord. An attempt to intubate the airway with a tube to make an air passage for breathing was attempted. As we were not able to visualize vocal cords, under bronchoscopic guidance airway was secured by the team, after the airway was secured, the baby was delivered and then the cord was cut.
The Baby needed ventilator support for 2 days. In the meanwhile baby’s blood drawn for thyroid function tests and oral thyroid hormone replacement started. With that the swollen gland started shrinking well, the baby was taken off the endotracheal tube and ventilation on day 3. Baby was able to breath easily without difficulty.
The neonatal team from Dr. Mehta’s Hospitals was Dr Lakshmi, Dr Jayanthi, Dr Thirunavukarasu, Dr. Balamurugane.
The obstetric team from Seethapathy Hospital Dr Sowmya Balakrishnan, Dr. Uma Ram, Dr Vasanthi Vidyasagar and Fetal medicine Specialist Dr S Suresh and Dr Sudarshan Suresh from Mediscan.