Background: Prenatal imaging allows the early diagnostic of some neonatal malformations. Therefore, surgeries have been performed in fetuses either intrauterus or just before fetal extraction during delivery. The ex-utero intrapartum treatment (EXIT) procedure is an uncommon intervention to secure the fetal airway while placental blood circulation is maintained to prevent fetal hypoxemia and organ injuries with subsequent delivery. The purpose of this case report is to discuss the use of goal-directed fluid therapy (GDT) in an EXIT procedure to maintain adequate placental perfusion during the maternal  anesthesia, wich has to be profound, since extreme uterine and muscular relaxation are primordial to facilitate the fetal extraction.
Case report: An EXIT procedure was performed in a 42 years old patient, G3P1A1, ASA physical status II, at 32 weeks of gestation. The obstetric ultrasound suggested polyhydramnios and a cervical mass that could obliterate the fetal airway. The mother was monitored with invasive arterial pressure, ECG, end-tidal CO2  and pulse oximetry. Cardiac index and SVV were obtained by using the FloTracTM (Edwards Lifesciences)  system. General anesthesia was induced with fentanyl, propofol and rocuronium and maintained with sevoflurane (to promote uterine relaxation) and remifentanil until fetal cephalic portion was exposed. Throughout the procedure, IV fluid administration was guided by the stroke volume variation (SVV>10%), cardiac index (CI>2,5 l/min/m2) and mean arterial pressure (MAP>70 mmHg). Fetal oral-tracheal intubation was successful within the first minute and was followed by total delivery of the child. From this moment, sevoflurane was shifted to propofol and the cesarean section was terminated. The patient was extubated uneventfully, and the child was operated three days later, with total remotion of the cervical tumor, and no further complications.
Discussion: EXIT procedures have been indicated to reduce the rate of fetal morbidity and mortality and to prevent fetal asphyxia when major cervical tumors are diagnosed prenatally. Maternal general and profound anesthesia can lead to hypotension and uteroplacental hypoperfusion, which may induce fetal cardiovascular insufficiency. The GDT contributes to an assertive fluid therapy to maintain adequate cardiac output and systolic volume variation, therefore, reducing the use of vasopressors, which could also decrease the placental perfusion.


04 / Anesthetic management with goal-directed fluid therapy (GDT) for an ex-utero intrapartum treatment (EXIT) procedure: a case report