Airway Management for the Unborn Patient by Dr. Corey Iqbal, Chief, Section of Fetal Surgery, Children's Mercy Kansas City, Assistant Professor of Surgery, UMKC
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This document provides an overview of EXIT (ex-utero intrapartum treatment) procedures, which allow for fetal airway management during planned cesarean delivery while maintaining placental circulation. The key points are: 1) EXIT procedures allow time to secure the fetal airway for conditions threatening postnatal respiratory failure like neck masses or CDH before placental circulation is stopped. This maintains oxygenation until definitive airway control can be established. 2) Indications for EXIT include any fetal anomaly where cardiopulmonary collapse is expected immediately after birth, such as large neck masses, CDH, or certain congenital heart or lung lesions. 3) The procedure involves a low transverse uterine incision with
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Ante partum haemorrhage
This document discusses antepartum haemorrhage (APH), which is bleeding from the vagina during pregnancy between 24 weeks of gestation and term. It defines APH and provides information on its importance, common causes such as placenta praevia and placental abruption, associated risks, diagnostic evaluation, potential complications, and management approach, which involves admission to the hospital for resuscitation and treatment of the underlying cause of bleeding. Timely management is important to reduce risks of maternal and fetal morbidity and mortality.
9. obstetrical hemorrhage
This document presents a case study of obstetrical hemorrhage involving placenta previa. It summarizes the patient's history, including previous cesarean deliveries, and current presentation with vaginal bleeding. Ultrasound revealed the placenta was located at the cervical os. The resident discusses management of placenta previa, including expectant care and risk factors for hemorrhage. Complications like placenta accrete syndrome are also reviewed, where the placenta invades the uterine wall, increasing bleeding risks.
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This document discusses congenital diaphragmatic hernia (CDH), a birth defect where organs protrude into the chest cavity due to a hole in the diaphragm. It covers the embryology, pathophysiology, diagnosis, and management of CDH. Surgical repair is the only treatment, but stabilization of the patient's respiratory and general status is needed first. Extracorporeal membrane oxygenation (ECMO) has improved survival for CDH. Long-term follow up is also important due to potential complications. A regional anesthesia method without opioids allowed early operating room extubation for CDH repair in one study.
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Respiratory distress in paediatric surgery can have many causes, including both upper and lower airway obstruction as well as general causes like pneumonia. Signs include increased respiratory rate, use of accessory muscles, and noisy breathing. Investigations depend on available facilities but often include chest x-ray, blood tests, and imaging. Treatment involves supportive care like supplemental oxygen and treating the underlying cause. Some specific conditions that can cause respiratory distress are laryngomalacia, tracheomalacia, congenital diaphragmatic hernia, congenital cystic adenomatoid malformation, congenital lobar emphysema, and pneumothorax.
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This document summarizes several common surgical disorders that can occur in newborns, including fetal surgical disorders like polyhydramnios and oligohydramnios, as well as postnatal disorders involving the respiratory, gastrointestinal, and genitourinary systems. Key conditions discussed include esophageal atresia, tracheoesophageal fistula, diaphragmatic hernia, anorectal malformations, and necrotizing enterocolitis. Diagnostic approaches and management strategies are provided for each condition.
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Abortion is a leading cause of maternal mortality, accounting for 13% of maternal deaths worldwide and 32% in Ethiopia. Complications from unsafe abortion, which is defined as procedures done without proper skills or in unsanitary conditions, can cause severe infections and hemorrhaging. Post-abortion care aims to treat complications from both spontaneous and induced abortions, provide contraceptive services to prevent future unintended pregnancies, and offer counseling and referrals for other health needs. Recurrent spontaneous abortion, defined as 3 or more consecutive early pregnancy losses, can have causes such as chromosomal abnormalities, uterine anomalies, or immunological factors.
Obstetric Hemorrhage- PPH
This document discusses obstetrical hemorrhage from placenta previa and placenta accrete syndrome. It begins with an introduction and overview of placenta previa, including risk factors, clinical features, diagnosis and management. It then discusses placenta accrete syndrome in more detail, including pathogenesis, risk factors, ultrasound and MRI findings for diagnosis, and recommendations for management. The recommendations are that placental accrete syndrome should be ruled out using Doppler ultrasound in this patient, and preparations should be made for potential hysterectomy due to the high risk.
Antenatal and post natal management of congenital diaphragmatic
1) Congenital diaphragmatic hernia results from a developmental defect in utero that causes abdominal organs to protrude into the chest cavity, compressing lung development.
2) Prenatal diagnosis is now possible using ultrasound and MRI, allowing for monitoring and in some cases experimental fetal surgery.
3) After birth, infants receive respiratory support, treatments for pulmonary hypertension if needed, and surgery to repair the diaphragmatic defect when stable, with an overall survival rate now of 70-90% though long term outcomes vary.
Pulmonary-Disease-Part-1.pptx
C. CDH is more commonly found on the left side (around 85% of cases are left-sided).
Capillary alveolar dysplasia, bronchopulmonary sequestration, and chylothorax do not have a strong side predominance. Around half of bronchopulmonary sequestrations are left-sided, but they can occur on either side. Capillary alveolar dysplasia and chylothorax also occur bilaterally or on either side without a clear predominance.
So the developmental lung condition that is most strongly left-sided is congenital diaphragmatic hernia.
Meconium aspiration syndrome
Meconium aspiration syndrome is a common cause of respiratory failure in term and post-term infants caused by inhalation of meconium-stained amniotic fluid before, during, or after birth. It can range from mild respiratory issues to severe forms that can lead to death. Risk factors include fetal distress, umbilical cord compression, post-term birth, and breech presentation. Clinically, affected infants may experience tachypnea, retractions, grunting, and decreased breath sounds. Chest x-rays can show infiltrates, atelectasis, and pneumothorax. Management involves respiratory support, antibiotics, surfactant therapy, and measures to maintain temperature and oxygen levels.
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Airway Management for the Unborn Patient by Dr. Corey Iqbal, Chief, Section of Fetal Surgery, Children's Mercy Kansas City, Assistant Professor of Surgery, UMKC
- 1. Airway Management for the Unborn Patient Corey W. Iqbal, MD, FAAP
- 2. Objectives • What is an EXIT procedure • Indications • Procedural considerations – Preoperative – Intraoperative – Postoperative
- 3. • Not that important Fetal Airway
- 6. History of Fetal Surgery • Michael R. Harrison – 1981 “Father of Fetal Surgery” • Bladder Obstruction • CDH Pulmonary Hypoplasia
- 7. CDH • 70% survival – Pulm hypoplasia – Pulm HTN
- 8. CHAOS
- 10. OOPS!!! • Operation On Placental Support • Ex-utero Intra-partum Therapy (EXIT)
- 11. NOT A CESAREAN SECTION EXIT • Placental Circulation – Placenta as bypass pump • Uterine atony – Deep general anesthesia – Tocolytics • Hemorrhage risk* Cesarean • Uterine contraction • No placental circulation • Regional anesthesia • “Slash & Dash”
- 12. Indications • Any anomaly where cardiopulmonary collapse off placental/fetal circulation – Airway • Fetal neck mass • CHAOS • Micrognathia – Thoracic lesions • Lung lesions • CDH – Congenital heart disease – SCT
- 13. EXIT-to-??? • EXIT-to-airway – Oral endotracheal – Trachesotomy • EXIT-to-resection • EXIT-to-ECMO
- 14. Fetal Considerations – Pain – fetal cocktail – Monitoring • US • Pulse Oximetry • Temperature – Venous access
- 15. Maternal Considerations • DVT risk • Position – right side up • Epidural • DEEP general anesthesia – Uterine atony • Tocolytics – Nitroglycerin – Terbutaline • Hemorrhage risk
- 16. Preoperative • Patient selection • Fetal Neck Mass – Obtain MRI – repeat between 30-34 weeks – TEDI score >12 – Teratoma – Polyhydramnios Cass et al. JPS. 2012;47:46-50
- 17. Fetal Neck Mass • Survival without EXIT – 0-20% • Survival with EXIT – 83% • ALL EXITs – UCSF survival 71% Iqbal et al. In Submission
- 18. Fetal Neck Mass • 36 year old
- 19. Fetal MRI
- 20. Aerodigestive Compression Deviated Trachea Small Stomach
- 21. Intraoperative • Low transverse incision to expose uterus • Placental mapping by ultrasound • Hysterotomy • Tocolytics – Nitro – Terbutaline
- 22. Intraoperative
- 23. Intraoperative • Fetal cocktail – Fentanyl + rocuronium • Pulse oximetry – HR – SpO2 • Temp probe • +/-Fetal IV access – Pressors: epi, atropine – Fluid resuscitation
- 24. Intraoperative
- 25. Other Indications • CDH – Boston data does not support – EXIT-to-ECMO: 33% vs 50% survival • Lung lesions – 100% survival; discharge at 10 days – 71% survival without EXIT Buchmiller et al. JPS. 2012;47:1053-1057 Lee et al. JPS. 2013;48:138-144
- 26. Other Indications • Congenital Heart Disease – HLHS with in tact septum – Delivery in OR with immediate cath • Other neoplasms – SCT – Little data to support
- 28. Delivery • Secure airway – paralytics on board • Clamp chord and deliver – Obtain chord blood gas • Anesthesia – Reduce inhalation – Administer pitocin • Now becomes a Cesarean
- 29. Crowd Control
- 30. Postoperative • Mom C-sxn – Pain control – ADAT – 4 days • Baby – Work-up – Definitive treatment
- 31. Other Scenarios • CHAOS – Fetoscopy
- 33. Questions