b'COORDINATING EXIT PROCEDURES:HOW 30+ PROVIDERS WORK TOGETHERTO HELP MOTHERS AND BABIES THRIVE.When an expectant mother went in for a prenatal ultrasound at 32 weeks gestation, a large neck mass was identified to be compressing the babys trachea. The imaging was referred to the ex-utero intrapartum treatment (EXIT) team at Childrens Health that determined that an EXIT procedure addressing the airway obstruction prior to delivery was appropriate. An EXIT is a complicated procedure, says Sushmita Yallapragada, M.D., MSc, FAAP, Medical Director of the FETAL Center at Childrens Health and Assistant Professor of Pediatrics atUT Southwestern. The team must simultaneously manage multiple health considerations for the mother and the baby.MULTIDISCIPLINARY EVALUATION OFEXIT PROCEDURE CANDIDATES.Dr. David Schindel prepares for ex-utero intrapartum treatment (EXIT) At Childrens Health and Parkland Health, the first step toward a successful EXIT is aat Childrens Medical Center Dallas, a program he created in 2007.multidisciplinary team meeting with 30+ physicians and medical staff, including maternal fetal medicine specialists, surgeons and neonatologists. The team evaluates whether the baby is anEXIT PROCEDURE IN UNDER 30 MINUTES.appropriate candidate, while weighing medical considerations that might also complicate the mothers well-being or threaten her future fertility. Early in the morning, the OB anesthesia team placed the mother under general anesthesia. The anesthesiologist had to sedate the mother to relax her uterus. The degree of uterine relaxation The meeting gives everyone a chance to ask questions and offer input, says Patricia Santiago- had to be enough to prevent the uterus from contracting and prematurely delivering the Muoz, M.D., a high-risk pregnancy specialist and Associate Professor at UT Southwestern.placenta during the EXIT.Dr. Santiago-Muoz and Dr. Yallapragada evaluated a case alongside David Schindel, M.D., EXITAt 7:42 a.m., the team delivered the baby girls head and shoulders, keeping her lower body Team Director, Fetal Co-Director, pediatric surgeon at Childrens Health and Associate Professorwithin the uterus. The fetus receives oxygenated blood via the umbilical cord using the at UT Southwestern.mothers uteroplacental circulation, which Dr. Schindel refers to as the worlds mostIn this case, the mother had safely delivered two previous babies and was otherwise healthy.efficient heart-lung machine ever devised. Despite the airway obstruction, advanced prenatal imaging suggested the fetus lungs wereThe babys neck mass was mobile enough that we could move it off the airway, allowing an developing appropriately.endotracheal tube to be passed beyond it, Dr. Schindel says. TEAMWORK IS KEY. After three comprehensive exams, Dr. Santiago-Muoz clamped the cord and fully delivered An EXIT potentially combines multiple procedures,the baby at 8:03 a.m. including intubation, tracheostomy, neck mass resection,Our neonatal resuscitation team stabilized the infant and put in IV lines prior to transferring her chest tube placement, central line placement andto the Childrens Health NICU for additional imaging and surgical repair, Dr. Yallapragada says. thoracotomy, into a single procedure.A HEALTHY OUTCOME.Theres a significant amount of equipment and personnel that need to be managed and organized so everythingsThe mothers recovery was smooth. The babys tumor was completely resected 48 hoursready at a moments notice, Dr. Schindel says. And theafter birth at Childrens Health by Dr. Schindel, and she was home breathing and feeding team needs to be prepared to work together seamlesslynormally just two weeks later. Pathologists determined the mass to be an immature teratoma. in a variety of potential situations. For the EXIT to work, every provider needs to be at the top of their game, Dr. Yallapragada For this EXIT case, Dr. Schindel guided the team throughsays. Expert imaging, precise coordination from multiple specialists and subspecialists, and three simulated procedures, during which every teamsupportive care for mom as we prepared for delivery led to a truly successful outcome. member was in the operating room to rehearse even the smallest details. THE UMBILICAL CORD/PLACENTA IS THE WORLDSMOST EFFICIENT HEART-LUNG MACHINE EVER DEVISED. Dr. David Schindel'