BACKGROUND: EXIT procedure is a rare technique consisting of fetal partial externalization from uterine cavity during delivery that maintains uteroplacental circulation while managing life-threatening conditions. The anesthetic management is different from that of conventional caesarean section. We present a case of a pregnant woman, whose fetus was prenatally diagnosed with a cervical lymphangioma.

CASE REPORT: A female patient, 37 years old, primipara, 37 weeks pregnancy, ASA II, was listed to elective caesarean section with EXIT procedure by a multidisciplinary team including anesthesiologists, obstetricians, neonatologists, pediatric surgeons and pneumologists, otolaryngologists and nurses.
Prior to the surgery, rocuronium, fentanyl and atropine were prepared for intramuscular fetal administration if necessary.
An arterial line for continuous arterial pressure monitoring and two peripheral intravenous lines were placed before induction. Aspiration and antibiotic prophylaxis were made and remifentanil perfusion was initiated. Endotracheal intubation was done after propofol and rocuronium administration by a rapid sequence induction. General anesthesia was maintained with sevoflurane and remifentanil.
After uterine incision, fetal head, trunk and upper limbs were delivered and he was intubated with a 3.5mm uncuffed tracheal tube by a neonatologist at the second attempt. Once the fetal airway was assured and the positive-pressure ventilation was satisfactory the umbilical cord was divided and the neonate was fully delivered. Additional resuscitative efforts were not required. The time from uterine incision to cord clamp was about 4 minutes. Apgar score was 9/10. Operation time was 55 minutes. Both mother and neonate tolerated the EXIT procedure well.

DISCUSSION: EXIT procedure allows ensuring fetal airway patency prior to delivery when there is an airway obstruction due to congenital malformations. A multidisciplinary team with a proper plan is essential to the success of this technique. Anesthesia differs substantially from the required for a conventional caesarean section. A general anesthesia using high concentrations of halogenated agents to get a deep uterine relaxation, uteroplacental circulation preservation and fetal immobility is the recommended technique. Another way to obtain an appropriate uterine relaxation is done by nitroglycerin administration. General anesthesia take advantage to fetal anesthesia and immobility.
Once the fetus airway is safe and the cord clamped, halogenated levels should be immediately lowered and oxytocin perfusion initiated to control uterine relaxation that is associated with bleeding risk.

01 / Ex-Utero Intrapartum Treatment (EXIT) procedure – A challeng to the Anesthesiologist