Post on 16-Jul-2015
Anesthetic Considerations for
Uncommon Obstetrical
Procedures
The PUBS and EXIT Procedures
Adam Flowe CRNA MSN
Interim Chief CRNA Duke University Medical Center
April 11th 2015
NCANA District 1amp2 meeting -- Winston-Salem
None
Financial disclosures
1) Please know that this presentation today is meant
entirely to be informativehellip and only that
1) The content presented here is in no way intended to
pass judgment on any mother or child who should
need these procedures
1) The content presented here is in no way intended to
credit or discredit any religious or cultural belief
Personal disclosures
1) You will be able to identify the key features
of the PUBS procedure and its anesthetic
considerations
1) You will be able to identify the key features
of the EXIT procedure and its anesthetic
considerations
Primary Objectives
Secondary Objective
You will think about cultural popular and
historical concepts and images and their
relationship to scientific advances
ldquoThe past is never dead
Itrsquos not even pastrdquo
-William Faulkner 1951
Science Fiction
ldquoScience fiction guesses at sciences before
they are sprung out of the brows of thinking
[wo]menhellip then we try to guess at how
mankind will react to these machines how use
them how grow with them how be destroyed
by themhelliprdquo
Ray Bradbury 1974
Science fiction
ldquoAny sufficiently advanced technology is
indistinguishable from magicrdquo
-Arthur C
Clarke 1974
So which came first
Hmmm
ldquoThe Jetsonsrdquo Hanna-Barbera 1963 Apple
April 2015
Part 1 -- the PUBS
The PUBS procedure
Percutaneous Umbilical Blood Sampling
-also called cordocentesis
-can be done purely as a
diagnostic
-but more interesting when done
therapeutically
PUBS -- What is it
It is using sonography to guide a needle into
the umbilical vessels to sample for genetic
assays or for other blood tests (ie hematocrit)
For this presentation the focus is on the
therapeutic PUBS used for the treatment of
maternal-fetal Rh-incompatibility
Brief background
1) Fetal-maternal Rh incompatibility occurs when the Rh-
mother forms antibodies to her Rh+ fetus (another
damnable behavior of the father)
1) The motherrsquos antibodies will then attack the antigenic
fetal blood
1) This is a problematic situation that typically affects
subsequent pregnancies
More background (USNLM and NIH 1995 and 2013)
4) Maternal antibodies attack fetal blood cells
potentially resulting in a fetus with
hemolytic anemia
hyperbilirubinemia
IUGR
possible neurologic impairment
and frequent IUFD ()
Treatment options (Berry 2013)
1) Exchange Transfusion (after delivery)
2) Apheresis (maternal vs pediatric)
3) RhoGAM injections (immunoglobulins)
1)the therapeutic PUBS
The candidate
Therapeutic PUBS treatment is indicated for
1 an Rh- non-primigravida mother
2 whose fetus is showing signs of IUGR
3 with the fetus having attained an
developmental age of viability (25 wks)
The candidate (continued)
Historical features include
1) A prior pregnancy with an Rh+ father
a) or other Rh+ blood exposure
2) Often poor peri-natal care (missed receiving RhoGam)
1) Often history of multiple lossesstillbirths
The PUBS Gestalt
Performed in the OR with anesthesia and
surgical teams present
Preparation is made for a possible c-section
Ultrasound (+- technician) is brought to OR
Irradiated red blood cells are brought to OR
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
None
Financial disclosures
1) Please know that this presentation today is meant
entirely to be informativehellip and only that
1) The content presented here is in no way intended to
pass judgment on any mother or child who should
need these procedures
1) The content presented here is in no way intended to
credit or discredit any religious or cultural belief
Personal disclosures
1) You will be able to identify the key features
of the PUBS procedure and its anesthetic
considerations
1) You will be able to identify the key features
of the EXIT procedure and its anesthetic
considerations
Primary Objectives
Secondary Objective
You will think about cultural popular and
historical concepts and images and their
relationship to scientific advances
ldquoThe past is never dead
Itrsquos not even pastrdquo
-William Faulkner 1951
Science Fiction
ldquoScience fiction guesses at sciences before
they are sprung out of the brows of thinking
[wo]menhellip then we try to guess at how
mankind will react to these machines how use
them how grow with them how be destroyed
by themhelliprdquo
Ray Bradbury 1974
Science fiction
ldquoAny sufficiently advanced technology is
indistinguishable from magicrdquo
-Arthur C
Clarke 1974
So which came first
Hmmm
ldquoThe Jetsonsrdquo Hanna-Barbera 1963 Apple
April 2015
Part 1 -- the PUBS
The PUBS procedure
Percutaneous Umbilical Blood Sampling
-also called cordocentesis
-can be done purely as a
diagnostic
-but more interesting when done
therapeutically
PUBS -- What is it
It is using sonography to guide a needle into
the umbilical vessels to sample for genetic
assays or for other blood tests (ie hematocrit)
For this presentation the focus is on the
therapeutic PUBS used for the treatment of
maternal-fetal Rh-incompatibility
Brief background
1) Fetal-maternal Rh incompatibility occurs when the Rh-
mother forms antibodies to her Rh+ fetus (another
damnable behavior of the father)
1) The motherrsquos antibodies will then attack the antigenic
fetal blood
1) This is a problematic situation that typically affects
subsequent pregnancies
More background (USNLM and NIH 1995 and 2013)
4) Maternal antibodies attack fetal blood cells
potentially resulting in a fetus with
hemolytic anemia
hyperbilirubinemia
IUGR
possible neurologic impairment
and frequent IUFD ()
Treatment options (Berry 2013)
1) Exchange Transfusion (after delivery)
2) Apheresis (maternal vs pediatric)
3) RhoGAM injections (immunoglobulins)
1)the therapeutic PUBS
The candidate
Therapeutic PUBS treatment is indicated for
1 an Rh- non-primigravida mother
2 whose fetus is showing signs of IUGR
3 with the fetus having attained an
developmental age of viability (25 wks)
The candidate (continued)
Historical features include
1) A prior pregnancy with an Rh+ father
a) or other Rh+ blood exposure
2) Often poor peri-natal care (missed receiving RhoGam)
1) Often history of multiple lossesstillbirths
The PUBS Gestalt
Performed in the OR with anesthesia and
surgical teams present
Preparation is made for a possible c-section
Ultrasound (+- technician) is brought to OR
Irradiated red blood cells are brought to OR
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
1) Please know that this presentation today is meant
entirely to be informativehellip and only that
1) The content presented here is in no way intended to
pass judgment on any mother or child who should
need these procedures
1) The content presented here is in no way intended to
credit or discredit any religious or cultural belief
Personal disclosures
1) You will be able to identify the key features
of the PUBS procedure and its anesthetic
considerations
1) You will be able to identify the key features
of the EXIT procedure and its anesthetic
considerations
Primary Objectives
Secondary Objective
You will think about cultural popular and
historical concepts and images and their
relationship to scientific advances
ldquoThe past is never dead
Itrsquos not even pastrdquo
-William Faulkner 1951
Science Fiction
ldquoScience fiction guesses at sciences before
they are sprung out of the brows of thinking
[wo]menhellip then we try to guess at how
mankind will react to these machines how use
them how grow with them how be destroyed
by themhelliprdquo
Ray Bradbury 1974
Science fiction
ldquoAny sufficiently advanced technology is
indistinguishable from magicrdquo
-Arthur C
Clarke 1974
So which came first
Hmmm
ldquoThe Jetsonsrdquo Hanna-Barbera 1963 Apple
April 2015
Part 1 -- the PUBS
The PUBS procedure
Percutaneous Umbilical Blood Sampling
-also called cordocentesis
-can be done purely as a
diagnostic
-but more interesting when done
therapeutically
PUBS -- What is it
It is using sonography to guide a needle into
the umbilical vessels to sample for genetic
assays or for other blood tests (ie hematocrit)
For this presentation the focus is on the
therapeutic PUBS used for the treatment of
maternal-fetal Rh-incompatibility
Brief background
1) Fetal-maternal Rh incompatibility occurs when the Rh-
mother forms antibodies to her Rh+ fetus (another
damnable behavior of the father)
1) The motherrsquos antibodies will then attack the antigenic
fetal blood
1) This is a problematic situation that typically affects
subsequent pregnancies
More background (USNLM and NIH 1995 and 2013)
4) Maternal antibodies attack fetal blood cells
potentially resulting in a fetus with
hemolytic anemia
hyperbilirubinemia
IUGR
possible neurologic impairment
and frequent IUFD ()
Treatment options (Berry 2013)
1) Exchange Transfusion (after delivery)
2) Apheresis (maternal vs pediatric)
3) RhoGAM injections (immunoglobulins)
1)the therapeutic PUBS
The candidate
Therapeutic PUBS treatment is indicated for
1 an Rh- non-primigravida mother
2 whose fetus is showing signs of IUGR
3 with the fetus having attained an
developmental age of viability (25 wks)
The candidate (continued)
Historical features include
1) A prior pregnancy with an Rh+ father
a) or other Rh+ blood exposure
2) Often poor peri-natal care (missed receiving RhoGam)
1) Often history of multiple lossesstillbirths
The PUBS Gestalt
Performed in the OR with anesthesia and
surgical teams present
Preparation is made for a possible c-section
Ultrasound (+- technician) is brought to OR
Irradiated red blood cells are brought to OR
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
1) You will be able to identify the key features
of the PUBS procedure and its anesthetic
considerations
1) You will be able to identify the key features
of the EXIT procedure and its anesthetic
considerations
Primary Objectives
Secondary Objective
You will think about cultural popular and
historical concepts and images and their
relationship to scientific advances
ldquoThe past is never dead
Itrsquos not even pastrdquo
-William Faulkner 1951
Science Fiction
ldquoScience fiction guesses at sciences before
they are sprung out of the brows of thinking
[wo]menhellip then we try to guess at how
mankind will react to these machines how use
them how grow with them how be destroyed
by themhelliprdquo
Ray Bradbury 1974
Science fiction
ldquoAny sufficiently advanced technology is
indistinguishable from magicrdquo
-Arthur C
Clarke 1974
So which came first
Hmmm
ldquoThe Jetsonsrdquo Hanna-Barbera 1963 Apple
April 2015
Part 1 -- the PUBS
The PUBS procedure
Percutaneous Umbilical Blood Sampling
-also called cordocentesis
-can be done purely as a
diagnostic
-but more interesting when done
therapeutically
PUBS -- What is it
It is using sonography to guide a needle into
the umbilical vessels to sample for genetic
assays or for other blood tests (ie hematocrit)
For this presentation the focus is on the
therapeutic PUBS used for the treatment of
maternal-fetal Rh-incompatibility
Brief background
1) Fetal-maternal Rh incompatibility occurs when the Rh-
mother forms antibodies to her Rh+ fetus (another
damnable behavior of the father)
1) The motherrsquos antibodies will then attack the antigenic
fetal blood
1) This is a problematic situation that typically affects
subsequent pregnancies
More background (USNLM and NIH 1995 and 2013)
4) Maternal antibodies attack fetal blood cells
potentially resulting in a fetus with
hemolytic anemia
hyperbilirubinemia
IUGR
possible neurologic impairment
and frequent IUFD ()
Treatment options (Berry 2013)
1) Exchange Transfusion (after delivery)
2) Apheresis (maternal vs pediatric)
3) RhoGAM injections (immunoglobulins)
1)the therapeutic PUBS
The candidate
Therapeutic PUBS treatment is indicated for
1 an Rh- non-primigravida mother
2 whose fetus is showing signs of IUGR
3 with the fetus having attained an
developmental age of viability (25 wks)
The candidate (continued)
Historical features include
1) A prior pregnancy with an Rh+ father
a) or other Rh+ blood exposure
2) Often poor peri-natal care (missed receiving RhoGam)
1) Often history of multiple lossesstillbirths
The PUBS Gestalt
Performed in the OR with anesthesia and
surgical teams present
Preparation is made for a possible c-section
Ultrasound (+- technician) is brought to OR
Irradiated red blood cells are brought to OR
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Secondary Objective
You will think about cultural popular and
historical concepts and images and their
relationship to scientific advances
ldquoThe past is never dead
Itrsquos not even pastrdquo
-William Faulkner 1951
Science Fiction
ldquoScience fiction guesses at sciences before
they are sprung out of the brows of thinking
[wo]menhellip then we try to guess at how
mankind will react to these machines how use
them how grow with them how be destroyed
by themhelliprdquo
Ray Bradbury 1974
Science fiction
ldquoAny sufficiently advanced technology is
indistinguishable from magicrdquo
-Arthur C
Clarke 1974
So which came first
Hmmm
ldquoThe Jetsonsrdquo Hanna-Barbera 1963 Apple
April 2015
Part 1 -- the PUBS
The PUBS procedure
Percutaneous Umbilical Blood Sampling
-also called cordocentesis
-can be done purely as a
diagnostic
-but more interesting when done
therapeutically
PUBS -- What is it
It is using sonography to guide a needle into
the umbilical vessels to sample for genetic
assays or for other blood tests (ie hematocrit)
For this presentation the focus is on the
therapeutic PUBS used for the treatment of
maternal-fetal Rh-incompatibility
Brief background
1) Fetal-maternal Rh incompatibility occurs when the Rh-
mother forms antibodies to her Rh+ fetus (another
damnable behavior of the father)
1) The motherrsquos antibodies will then attack the antigenic
fetal blood
1) This is a problematic situation that typically affects
subsequent pregnancies
More background (USNLM and NIH 1995 and 2013)
4) Maternal antibodies attack fetal blood cells
potentially resulting in a fetus with
hemolytic anemia
hyperbilirubinemia
IUGR
possible neurologic impairment
and frequent IUFD ()
Treatment options (Berry 2013)
1) Exchange Transfusion (after delivery)
2) Apheresis (maternal vs pediatric)
3) RhoGAM injections (immunoglobulins)
1)the therapeutic PUBS
The candidate
Therapeutic PUBS treatment is indicated for
1 an Rh- non-primigravida mother
2 whose fetus is showing signs of IUGR
3 with the fetus having attained an
developmental age of viability (25 wks)
The candidate (continued)
Historical features include
1) A prior pregnancy with an Rh+ father
a) or other Rh+ blood exposure
2) Often poor peri-natal care (missed receiving RhoGam)
1) Often history of multiple lossesstillbirths
The PUBS Gestalt
Performed in the OR with anesthesia and
surgical teams present
Preparation is made for a possible c-section
Ultrasound (+- technician) is brought to OR
Irradiated red blood cells are brought to OR
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
ldquoThe past is never dead
Itrsquos not even pastrdquo
-William Faulkner 1951
Science Fiction
ldquoScience fiction guesses at sciences before
they are sprung out of the brows of thinking
[wo]menhellip then we try to guess at how
mankind will react to these machines how use
them how grow with them how be destroyed
by themhelliprdquo
Ray Bradbury 1974
Science fiction
ldquoAny sufficiently advanced technology is
indistinguishable from magicrdquo
-Arthur C
Clarke 1974
So which came first
Hmmm
ldquoThe Jetsonsrdquo Hanna-Barbera 1963 Apple
April 2015
Part 1 -- the PUBS
The PUBS procedure
Percutaneous Umbilical Blood Sampling
-also called cordocentesis
-can be done purely as a
diagnostic
-but more interesting when done
therapeutically
PUBS -- What is it
It is using sonography to guide a needle into
the umbilical vessels to sample for genetic
assays or for other blood tests (ie hematocrit)
For this presentation the focus is on the
therapeutic PUBS used for the treatment of
maternal-fetal Rh-incompatibility
Brief background
1) Fetal-maternal Rh incompatibility occurs when the Rh-
mother forms antibodies to her Rh+ fetus (another
damnable behavior of the father)
1) The motherrsquos antibodies will then attack the antigenic
fetal blood
1) This is a problematic situation that typically affects
subsequent pregnancies
More background (USNLM and NIH 1995 and 2013)
4) Maternal antibodies attack fetal blood cells
potentially resulting in a fetus with
hemolytic anemia
hyperbilirubinemia
IUGR
possible neurologic impairment
and frequent IUFD ()
Treatment options (Berry 2013)
1) Exchange Transfusion (after delivery)
2) Apheresis (maternal vs pediatric)
3) RhoGAM injections (immunoglobulins)
1)the therapeutic PUBS
The candidate
Therapeutic PUBS treatment is indicated for
1 an Rh- non-primigravida mother
2 whose fetus is showing signs of IUGR
3 with the fetus having attained an
developmental age of viability (25 wks)
The candidate (continued)
Historical features include
1) A prior pregnancy with an Rh+ father
a) or other Rh+ blood exposure
2) Often poor peri-natal care (missed receiving RhoGam)
1) Often history of multiple lossesstillbirths
The PUBS Gestalt
Performed in the OR with anesthesia and
surgical teams present
Preparation is made for a possible c-section
Ultrasound (+- technician) is brought to OR
Irradiated red blood cells are brought to OR
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Science Fiction
ldquoScience fiction guesses at sciences before
they are sprung out of the brows of thinking
[wo]menhellip then we try to guess at how
mankind will react to these machines how use
them how grow with them how be destroyed
by themhelliprdquo
Ray Bradbury 1974
Science fiction
ldquoAny sufficiently advanced technology is
indistinguishable from magicrdquo
-Arthur C
Clarke 1974
So which came first
Hmmm
ldquoThe Jetsonsrdquo Hanna-Barbera 1963 Apple
April 2015
Part 1 -- the PUBS
The PUBS procedure
Percutaneous Umbilical Blood Sampling
-also called cordocentesis
-can be done purely as a
diagnostic
-but more interesting when done
therapeutically
PUBS -- What is it
It is using sonography to guide a needle into
the umbilical vessels to sample for genetic
assays or for other blood tests (ie hematocrit)
For this presentation the focus is on the
therapeutic PUBS used for the treatment of
maternal-fetal Rh-incompatibility
Brief background
1) Fetal-maternal Rh incompatibility occurs when the Rh-
mother forms antibodies to her Rh+ fetus (another
damnable behavior of the father)
1) The motherrsquos antibodies will then attack the antigenic
fetal blood
1) This is a problematic situation that typically affects
subsequent pregnancies
More background (USNLM and NIH 1995 and 2013)
4) Maternal antibodies attack fetal blood cells
potentially resulting in a fetus with
hemolytic anemia
hyperbilirubinemia
IUGR
possible neurologic impairment
and frequent IUFD ()
Treatment options (Berry 2013)
1) Exchange Transfusion (after delivery)
2) Apheresis (maternal vs pediatric)
3) RhoGAM injections (immunoglobulins)
1)the therapeutic PUBS
The candidate
Therapeutic PUBS treatment is indicated for
1 an Rh- non-primigravida mother
2 whose fetus is showing signs of IUGR
3 with the fetus having attained an
developmental age of viability (25 wks)
The candidate (continued)
Historical features include
1) A prior pregnancy with an Rh+ father
a) or other Rh+ blood exposure
2) Often poor peri-natal care (missed receiving RhoGam)
1) Often history of multiple lossesstillbirths
The PUBS Gestalt
Performed in the OR with anesthesia and
surgical teams present
Preparation is made for a possible c-section
Ultrasound (+- technician) is brought to OR
Irradiated red blood cells are brought to OR
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Science fiction
ldquoAny sufficiently advanced technology is
indistinguishable from magicrdquo
-Arthur C
Clarke 1974
So which came first
Hmmm
ldquoThe Jetsonsrdquo Hanna-Barbera 1963 Apple
April 2015
Part 1 -- the PUBS
The PUBS procedure
Percutaneous Umbilical Blood Sampling
-also called cordocentesis
-can be done purely as a
diagnostic
-but more interesting when done
therapeutically
PUBS -- What is it
It is using sonography to guide a needle into
the umbilical vessels to sample for genetic
assays or for other blood tests (ie hematocrit)
For this presentation the focus is on the
therapeutic PUBS used for the treatment of
maternal-fetal Rh-incompatibility
Brief background
1) Fetal-maternal Rh incompatibility occurs when the Rh-
mother forms antibodies to her Rh+ fetus (another
damnable behavior of the father)
1) The motherrsquos antibodies will then attack the antigenic
fetal blood
1) This is a problematic situation that typically affects
subsequent pregnancies
More background (USNLM and NIH 1995 and 2013)
4) Maternal antibodies attack fetal blood cells
potentially resulting in a fetus with
hemolytic anemia
hyperbilirubinemia
IUGR
possible neurologic impairment
and frequent IUFD ()
Treatment options (Berry 2013)
1) Exchange Transfusion (after delivery)
2) Apheresis (maternal vs pediatric)
3) RhoGAM injections (immunoglobulins)
1)the therapeutic PUBS
The candidate
Therapeutic PUBS treatment is indicated for
1 an Rh- non-primigravida mother
2 whose fetus is showing signs of IUGR
3 with the fetus having attained an
developmental age of viability (25 wks)
The candidate (continued)
Historical features include
1) A prior pregnancy with an Rh+ father
a) or other Rh+ blood exposure
2) Often poor peri-natal care (missed receiving RhoGam)
1) Often history of multiple lossesstillbirths
The PUBS Gestalt
Performed in the OR with anesthesia and
surgical teams present
Preparation is made for a possible c-section
Ultrasound (+- technician) is brought to OR
Irradiated red blood cells are brought to OR
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
So which came first
Hmmm
ldquoThe Jetsonsrdquo Hanna-Barbera 1963 Apple
April 2015
Part 1 -- the PUBS
The PUBS procedure
Percutaneous Umbilical Blood Sampling
-also called cordocentesis
-can be done purely as a
diagnostic
-but more interesting when done
therapeutically
PUBS -- What is it
It is using sonography to guide a needle into
the umbilical vessels to sample for genetic
assays or for other blood tests (ie hematocrit)
For this presentation the focus is on the
therapeutic PUBS used for the treatment of
maternal-fetal Rh-incompatibility
Brief background
1) Fetal-maternal Rh incompatibility occurs when the Rh-
mother forms antibodies to her Rh+ fetus (another
damnable behavior of the father)
1) The motherrsquos antibodies will then attack the antigenic
fetal blood
1) This is a problematic situation that typically affects
subsequent pregnancies
More background (USNLM and NIH 1995 and 2013)
4) Maternal antibodies attack fetal blood cells
potentially resulting in a fetus with
hemolytic anemia
hyperbilirubinemia
IUGR
possible neurologic impairment
and frequent IUFD ()
Treatment options (Berry 2013)
1) Exchange Transfusion (after delivery)
2) Apheresis (maternal vs pediatric)
3) RhoGAM injections (immunoglobulins)
1)the therapeutic PUBS
The candidate
Therapeutic PUBS treatment is indicated for
1 an Rh- non-primigravida mother
2 whose fetus is showing signs of IUGR
3 with the fetus having attained an
developmental age of viability (25 wks)
The candidate (continued)
Historical features include
1) A prior pregnancy with an Rh+ father
a) or other Rh+ blood exposure
2) Often poor peri-natal care (missed receiving RhoGam)
1) Often history of multiple lossesstillbirths
The PUBS Gestalt
Performed in the OR with anesthesia and
surgical teams present
Preparation is made for a possible c-section
Ultrasound (+- technician) is brought to OR
Irradiated red blood cells are brought to OR
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Hmmm
ldquoThe Jetsonsrdquo Hanna-Barbera 1963 Apple
April 2015
Part 1 -- the PUBS
The PUBS procedure
Percutaneous Umbilical Blood Sampling
-also called cordocentesis
-can be done purely as a
diagnostic
-but more interesting when done
therapeutically
PUBS -- What is it
It is using sonography to guide a needle into
the umbilical vessels to sample for genetic
assays or for other blood tests (ie hematocrit)
For this presentation the focus is on the
therapeutic PUBS used for the treatment of
maternal-fetal Rh-incompatibility
Brief background
1) Fetal-maternal Rh incompatibility occurs when the Rh-
mother forms antibodies to her Rh+ fetus (another
damnable behavior of the father)
1) The motherrsquos antibodies will then attack the antigenic
fetal blood
1) This is a problematic situation that typically affects
subsequent pregnancies
More background (USNLM and NIH 1995 and 2013)
4) Maternal antibodies attack fetal blood cells
potentially resulting in a fetus with
hemolytic anemia
hyperbilirubinemia
IUGR
possible neurologic impairment
and frequent IUFD ()
Treatment options (Berry 2013)
1) Exchange Transfusion (after delivery)
2) Apheresis (maternal vs pediatric)
3) RhoGAM injections (immunoglobulins)
1)the therapeutic PUBS
The candidate
Therapeutic PUBS treatment is indicated for
1 an Rh- non-primigravida mother
2 whose fetus is showing signs of IUGR
3 with the fetus having attained an
developmental age of viability (25 wks)
The candidate (continued)
Historical features include
1) A prior pregnancy with an Rh+ father
a) or other Rh+ blood exposure
2) Often poor peri-natal care (missed receiving RhoGam)
1) Often history of multiple lossesstillbirths
The PUBS Gestalt
Performed in the OR with anesthesia and
surgical teams present
Preparation is made for a possible c-section
Ultrasound (+- technician) is brought to OR
Irradiated red blood cells are brought to OR
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Part 1 -- the PUBS
The PUBS procedure
Percutaneous Umbilical Blood Sampling
-also called cordocentesis
-can be done purely as a
diagnostic
-but more interesting when done
therapeutically
PUBS -- What is it
It is using sonography to guide a needle into
the umbilical vessels to sample for genetic
assays or for other blood tests (ie hematocrit)
For this presentation the focus is on the
therapeutic PUBS used for the treatment of
maternal-fetal Rh-incompatibility
Brief background
1) Fetal-maternal Rh incompatibility occurs when the Rh-
mother forms antibodies to her Rh+ fetus (another
damnable behavior of the father)
1) The motherrsquos antibodies will then attack the antigenic
fetal blood
1) This is a problematic situation that typically affects
subsequent pregnancies
More background (USNLM and NIH 1995 and 2013)
4) Maternal antibodies attack fetal blood cells
potentially resulting in a fetus with
hemolytic anemia
hyperbilirubinemia
IUGR
possible neurologic impairment
and frequent IUFD ()
Treatment options (Berry 2013)
1) Exchange Transfusion (after delivery)
2) Apheresis (maternal vs pediatric)
3) RhoGAM injections (immunoglobulins)
1)the therapeutic PUBS
The candidate
Therapeutic PUBS treatment is indicated for
1 an Rh- non-primigravida mother
2 whose fetus is showing signs of IUGR
3 with the fetus having attained an
developmental age of viability (25 wks)
The candidate (continued)
Historical features include
1) A prior pregnancy with an Rh+ father
a) or other Rh+ blood exposure
2) Often poor peri-natal care (missed receiving RhoGam)
1) Often history of multiple lossesstillbirths
The PUBS Gestalt
Performed in the OR with anesthesia and
surgical teams present
Preparation is made for a possible c-section
Ultrasound (+- technician) is brought to OR
Irradiated red blood cells are brought to OR
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
The PUBS procedure
Percutaneous Umbilical Blood Sampling
-also called cordocentesis
-can be done purely as a
diagnostic
-but more interesting when done
therapeutically
PUBS -- What is it
It is using sonography to guide a needle into
the umbilical vessels to sample for genetic
assays or for other blood tests (ie hematocrit)
For this presentation the focus is on the
therapeutic PUBS used for the treatment of
maternal-fetal Rh-incompatibility
Brief background
1) Fetal-maternal Rh incompatibility occurs when the Rh-
mother forms antibodies to her Rh+ fetus (another
damnable behavior of the father)
1) The motherrsquos antibodies will then attack the antigenic
fetal blood
1) This is a problematic situation that typically affects
subsequent pregnancies
More background (USNLM and NIH 1995 and 2013)
4) Maternal antibodies attack fetal blood cells
potentially resulting in a fetus with
hemolytic anemia
hyperbilirubinemia
IUGR
possible neurologic impairment
and frequent IUFD ()
Treatment options (Berry 2013)
1) Exchange Transfusion (after delivery)
2) Apheresis (maternal vs pediatric)
3) RhoGAM injections (immunoglobulins)
1)the therapeutic PUBS
The candidate
Therapeutic PUBS treatment is indicated for
1 an Rh- non-primigravida mother
2 whose fetus is showing signs of IUGR
3 with the fetus having attained an
developmental age of viability (25 wks)
The candidate (continued)
Historical features include
1) A prior pregnancy with an Rh+ father
a) or other Rh+ blood exposure
2) Often poor peri-natal care (missed receiving RhoGam)
1) Often history of multiple lossesstillbirths
The PUBS Gestalt
Performed in the OR with anesthesia and
surgical teams present
Preparation is made for a possible c-section
Ultrasound (+- technician) is brought to OR
Irradiated red blood cells are brought to OR
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
PUBS -- What is it
It is using sonography to guide a needle into
the umbilical vessels to sample for genetic
assays or for other blood tests (ie hematocrit)
For this presentation the focus is on the
therapeutic PUBS used for the treatment of
maternal-fetal Rh-incompatibility
Brief background
1) Fetal-maternal Rh incompatibility occurs when the Rh-
mother forms antibodies to her Rh+ fetus (another
damnable behavior of the father)
1) The motherrsquos antibodies will then attack the antigenic
fetal blood
1) This is a problematic situation that typically affects
subsequent pregnancies
More background (USNLM and NIH 1995 and 2013)
4) Maternal antibodies attack fetal blood cells
potentially resulting in a fetus with
hemolytic anemia
hyperbilirubinemia
IUGR
possible neurologic impairment
and frequent IUFD ()
Treatment options (Berry 2013)
1) Exchange Transfusion (after delivery)
2) Apheresis (maternal vs pediatric)
3) RhoGAM injections (immunoglobulins)
1)the therapeutic PUBS
The candidate
Therapeutic PUBS treatment is indicated for
1 an Rh- non-primigravida mother
2 whose fetus is showing signs of IUGR
3 with the fetus having attained an
developmental age of viability (25 wks)
The candidate (continued)
Historical features include
1) A prior pregnancy with an Rh+ father
a) or other Rh+ blood exposure
2) Often poor peri-natal care (missed receiving RhoGam)
1) Often history of multiple lossesstillbirths
The PUBS Gestalt
Performed in the OR with anesthesia and
surgical teams present
Preparation is made for a possible c-section
Ultrasound (+- technician) is brought to OR
Irradiated red blood cells are brought to OR
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Brief background
1) Fetal-maternal Rh incompatibility occurs when the Rh-
mother forms antibodies to her Rh+ fetus (another
damnable behavior of the father)
1) The motherrsquos antibodies will then attack the antigenic
fetal blood
1) This is a problematic situation that typically affects
subsequent pregnancies
More background (USNLM and NIH 1995 and 2013)
4) Maternal antibodies attack fetal blood cells
potentially resulting in a fetus with
hemolytic anemia
hyperbilirubinemia
IUGR
possible neurologic impairment
and frequent IUFD ()
Treatment options (Berry 2013)
1) Exchange Transfusion (after delivery)
2) Apheresis (maternal vs pediatric)
3) RhoGAM injections (immunoglobulins)
1)the therapeutic PUBS
The candidate
Therapeutic PUBS treatment is indicated for
1 an Rh- non-primigravida mother
2 whose fetus is showing signs of IUGR
3 with the fetus having attained an
developmental age of viability (25 wks)
The candidate (continued)
Historical features include
1) A prior pregnancy with an Rh+ father
a) or other Rh+ blood exposure
2) Often poor peri-natal care (missed receiving RhoGam)
1) Often history of multiple lossesstillbirths
The PUBS Gestalt
Performed in the OR with anesthesia and
surgical teams present
Preparation is made for a possible c-section
Ultrasound (+- technician) is brought to OR
Irradiated red blood cells are brought to OR
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
More background (USNLM and NIH 1995 and 2013)
4) Maternal antibodies attack fetal blood cells
potentially resulting in a fetus with
hemolytic anemia
hyperbilirubinemia
IUGR
possible neurologic impairment
and frequent IUFD ()
Treatment options (Berry 2013)
1) Exchange Transfusion (after delivery)
2) Apheresis (maternal vs pediatric)
3) RhoGAM injections (immunoglobulins)
1)the therapeutic PUBS
The candidate
Therapeutic PUBS treatment is indicated for
1 an Rh- non-primigravida mother
2 whose fetus is showing signs of IUGR
3 with the fetus having attained an
developmental age of viability (25 wks)
The candidate (continued)
Historical features include
1) A prior pregnancy with an Rh+ father
a) or other Rh+ blood exposure
2) Often poor peri-natal care (missed receiving RhoGam)
1) Often history of multiple lossesstillbirths
The PUBS Gestalt
Performed in the OR with anesthesia and
surgical teams present
Preparation is made for a possible c-section
Ultrasound (+- technician) is brought to OR
Irradiated red blood cells are brought to OR
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Treatment options (Berry 2013)
1) Exchange Transfusion (after delivery)
2) Apheresis (maternal vs pediatric)
3) RhoGAM injections (immunoglobulins)
1)the therapeutic PUBS
The candidate
Therapeutic PUBS treatment is indicated for
1 an Rh- non-primigravida mother
2 whose fetus is showing signs of IUGR
3 with the fetus having attained an
developmental age of viability (25 wks)
The candidate (continued)
Historical features include
1) A prior pregnancy with an Rh+ father
a) or other Rh+ blood exposure
2) Often poor peri-natal care (missed receiving RhoGam)
1) Often history of multiple lossesstillbirths
The PUBS Gestalt
Performed in the OR with anesthesia and
surgical teams present
Preparation is made for a possible c-section
Ultrasound (+- technician) is brought to OR
Irradiated red blood cells are brought to OR
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
The candidate
Therapeutic PUBS treatment is indicated for
1 an Rh- non-primigravida mother
2 whose fetus is showing signs of IUGR
3 with the fetus having attained an
developmental age of viability (25 wks)
The candidate (continued)
Historical features include
1) A prior pregnancy with an Rh+ father
a) or other Rh+ blood exposure
2) Often poor peri-natal care (missed receiving RhoGam)
1) Often history of multiple lossesstillbirths
The PUBS Gestalt
Performed in the OR with anesthesia and
surgical teams present
Preparation is made for a possible c-section
Ultrasound (+- technician) is brought to OR
Irradiated red blood cells are brought to OR
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
The candidate (continued)
Historical features include
1) A prior pregnancy with an Rh+ father
a) or other Rh+ blood exposure
2) Often poor peri-natal care (missed receiving RhoGam)
1) Often history of multiple lossesstillbirths
The PUBS Gestalt
Performed in the OR with anesthesia and
surgical teams present
Preparation is made for a possible c-section
Ultrasound (+- technician) is brought to OR
Irradiated red blood cells are brought to OR
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
The PUBS Gestalt
Performed in the OR with anesthesia and
surgical teams present
Preparation is made for a possible c-section
Ultrasound (+- technician) is brought to OR
Irradiated red blood cells are brought to OR
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
The therapeutic PUBS
The mother is prepared as if for surgery
but hopefully will only receive an
amniocentesis-type event
An epidural is placed and dosed to ascertain if
acceptable for surgical conditions
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
The therapeutic PUBS
The mother is prepped and draped
Ultrasound is used with sterile cove to assess
the baby
An amniocentesis needle is introduced
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
The Therapeutic PUBS
Typically at this point the baby is paralyzed
with IM injection of paralytic
The proceduralist then cannulates the umbilical
vein and draws out 1-3 ml sample to assess
hematocrit
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
PARALYZED
Remember the fetus is on ldquoplacental bypassrdquo
The proceduralist injects the fetal rump or leghellip
trying to avoid head and vitals
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
PARALYZED
Pancuronium vecuronium and rocuronium
have all been used
The anesthetist prepares a non-dilute solution
and delivers it to sterile cup on surgical field
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Paralytic comparison (Reynolds et al 1996)
Paralytic Dosing IM Pros Cons
Vecuronium 1 mgkg Bradycardia
Pancuronium 1 mgkg Increased
fetal HR
Benzyl
alcohol
Rocuronium 1 mgkg Long-lasting
small volumes
Small volumes needed best dosing unclearhellip
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Why paralyze
The moving fetus is a problem
1) Needle is easily decannulated
2) Increased potential for injury with
unexpected movement
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Why paralyze
Procedure is challenging
if the placenta is
posteriorly implanted
The Fetus is in the way
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Anterior vs
Posterior
Placentation
What is good for a PUBS
is less desirable for a
C-Section
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Fetal transfusion
The event proceeds as follows
1 Serial withdrawal of blood samples (1-3ml)
2 Assessment of hematocrit
3 Administration of PRBCs
4 Reassessment of hematocrit and repeat
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Fetal transfusion
1 Blood administration tubing will be passed off sterile
field to anesthetist
1 Irradiated PRBC should be sent through fluid warmer
without dilution by saline (avoid excessive volumes)
1 Blood will be given in small aliquots dictated by
proceduralist and hematocrit-driven algorithm
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Why irradiated blood
1 Irradiation eliminates donor antibodies (and is a standard precaution
in fetal neonatal certain immunocompromisedcancer patients) (Chestnutt 2014)
1 Should be made available before procedure begins
1 Request small divided amounts be prepared (due to
potential for intra-procedure expiration)
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Pull up a chair
The procedure may last 3-8 hourshellip
depending on technical difficulty andor need
for transfusion
(At this point challenge patient to best 3-out-of-5 at Risk
OR offer to read New York Times aloud OR discuss
World Cup of Cricket highlights)
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
What could go wrong
1 Emergency c-section -- fetal distress andor
procedural injury (single umbilical artery)
1 Failure to cannulate -- failed procedure
1 Maternal discomfort -- bruised back andor
psychosocial stress
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Anesthetic Concerns -- Review
1 Need for epidural (tested and then hopefully not used)
1 Need for paralytics (prepared and delivered to sterile
field for administration by proceduralist)
1 Need for fetal transfusion (warmed undiluted irradiated
blood)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
The Gestalt The Archetype
The Cultural Legacy
A contained besieged being receives life-
sustaining aid from withoutabove
A seemingly-doomed being is immersed in a
hostile environment that requires intervention to
survive
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Popular images Yes
Warner Brothers
Roadshow Entertainment 1999
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
X-Men Origins Wolverine 20th Century Fox 2009
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
The Empire Strikes Back
20th Century Fox
Lucasfilm 1980
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Alien
20th Century Fox
Brandywine Productions
1979
The Sigourney is
more important
than the destination
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Historic iterations
Moses
in his basket
unattributed
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Noahrsquos Ark
Sainte Chappelle
Paris
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Odysseus Arnold Bocklin 1896
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Perseus and his mother
set adrift to die
Arthur Rackham
1903
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Romulus and Remus
The Childhood of Rome
Louise Lamprey
Little Brown and Co
1920
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
The Capitoline Wolf
Piazza Campidoglio
5th century BCE
Rome
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
The Intervention
Deus ex Machina or
ldquoMachine of the Godsrdquo
Image from Greek Urn
possibly Medea
3rd century BCE
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Deus ex Machina
in ancient theatre
a crane was used
to introduce
the godly intervention
(as coming from above)
from Google images
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
A constant theme
The Wizard of Oz
MGM
1939
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Ingrained
ET the Extra-Terrestrial
Universal Pictures
1982
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Commonplace
Toy Story 3
DisneyPixar
2010
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
The Claaww
Toy Story 3
DisneyPixar
2010
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
An extraordinary intervention (from above) that rescues the innocent
from a hostile and doomed scenario
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Part 2 -- the EXIT
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Ex Utero Intrapartum Treatment
So in essence out of the uterus but during the
birthhellip
It is a fetal procedure performed
during c-section
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
The EXIT procedure Gestalt
What is it
A c-section is startedhellip
The fetus is half-deliveredhellip
An intervention takes placehellip
Delivery is then completed
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Half-delivered
The hallmark feature
for fetal safety with
the EXIT is that
placental perfusion
is maintained during
the intervention
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Who is the EXIT for
The Fetus has a condition that is incompatible
with separation from mother (birth) that is
treatable with a direct ldquofairly shortrdquo intervention
1 Airway establishmentcreation
2 Airway mass resection
3 ECMO bridge
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Who needs
an EXIT
Most common type is
ldquothe EXIT-to-airwayrdquo
(Garcia 2011)
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Also for floppy or stiff babies
In addition to the airway and cardiac concerns
listed beforehellip
Multiple case reports for Arthrogryposis (Benonis
Habib 2009 Fink 2011)
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Arthrogryposis
(Holloway 2010)
(Jeanty 1999)
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
This is really what it looks like
Obstetrical team
Surgical team
Pediatric team
Anesthesia (x1-2)
Nursing
and auxiliary staff
No chairs
this time
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
And this
(Filipchuk 2009)
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
No large retrospective study
but there are multiple case reports
The best is an excellent overview from this
Anesthesiology June 2011hellip
ldquoCase Scenario Anesthesia for
Maternal-Fetal Surgery The EXIT procedurerdquo
by Garcia et al
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Anesthetic Considerations
1 Maternal anesthesia
1 Fetal anesthesia
1 Uterine relaxation
1 Prolonged hysterotomy
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Maternal Anesthesia
The EXIT is a deluxe c-section eventhellip
So most of us would select a regional
anesthetichellip out of concern for maternal
safetyhellip
Due to time concerns a CSE is advisable (George et al 2007)
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Maternal Anesthesia
A review of case studies shows that
many centers have elected for GETA
Their rationale is for the next two anesthetic
concerns fetal anesthesia and uterine
relaxation (Marwan 2006)
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Fetal Anesthesia
All reports showed some attention to fetal
anesthesiahellip
Two basic approaches described for
anesthesia delivery
1 Delivered directly to the fetus
2 Delivered via the maternal
anesthetic
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Fetal Anesthesia
Some procedures have involved establishing IV
access on the partly-delivered fetus
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Fetal Anesthesia
More commonly anesthesia is delivered via the
mother
General anesthetics readily cross the placental
membrane and enter fetal circulation
(typically high MACs are used)hellip
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Fetal Anesthesia
In the case of regional anesthesia narcotic
infusions have been given to the mother and
titrated to maintain maternal respiratory effort
and consciousness
Remifentanil (05-2 mcgkgmin) has been used for
its rapid titratability and metabolism (Fink 2011)
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Uterine Relaxation
Surgeons (both obstetrical and pediatric)
require a greater than normal uterine relaxation
for positioning and interventional access
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Uterine relaxation
1 Gas anesthetics have a dose-dependent
uterine relaxant effect (Yoo 2006)hellip resulting in
use of high MACs and likely need for
vasopressors
1 Regional cases have used nitroglycerin
boluses and infusions to accomplish the
relaxation (Clark et al 2004)
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Prolonged hysterotomy
The uterus is not closed promptly
The parturient is already at a greater risk for DIC PE
coagulopathy (Chestnutt 2009)
There is concern increased blood loss (documented) and
risk of amniotic fluid embolism (undemonstrated) (Marwan 2006)
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Prolonged hysterotomy
Be prepared to transfusehellip
TampSTampC (possibly will need for
fetus too)
Good IV access
+- arterial line
+- cardiac output monitor (non-
invasive)
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
ldquoEXIT strategyrdquo
General vs Regional rarr Unclear (Gaiser et al 1997)
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
QUESTIONS
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
The Gestalt The Archetype
The Cultural Legacy A vulnerable being must straddle two worlds (planes of existence) in order to
overcome a test of survival
A being-within-a-being must be brought forth (and altered with violence) in
order to be released
A being (perhaps a monster (in the teratogenic sense of the word)) must be
physicallyartificially altered before heshe is ready to survivebecome
independent
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Popular images Indeed
Alien
20th Century Fox
Brandywine Productions
1979
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Popular images Yep
Total Recall
Carolco Pictures
1990
ldquoKuatordquo
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Have these images had influence
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
On scientists I donrsquot know
(SNL April 2007)
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Popular images
Spaceballs
BrooksfilmsMSM
1987
(original title =
ldquoPlanet Moronrdquo)
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Everyday You bet
The Hangover
Warner
Brothers
2009
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Existence on multiple planes
Star Trek 1966
Superman1978
Thriller 1982
Company of Wolves
1984
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Religious multi-dimensionality
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Some Word Origins
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Teratogens Teratogenicity
A agent that leads to malformation of the fetus
(of vital importance to the anesthetist)
From the Greekhellip
teras (monster) + genein (making) (OED 2015)
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Monsters What Careful nowhellip
Monster from the Latin monstrum -- to show or
warn (as in demonstrate)
The word took off in history hinging on its sense
of showing as in being distinctive disruptive or
disastrous
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Monsters Rude
The 3rd definition for Monster in the OED
ldquoa fetus neonate or individual with a gross congenital malformation usually of
a degree incompatible with life Cf MONSTROSITY n 1a (Now rare because of its
pejorative associations)rdquo (OED 2015)
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Monster What century are you from
1752 W SMELLIE Treat Midwifery I 122 When two children are distinct they are called
twins and monsters when they are joined together
1840 E A POE 1002nd Tale in Wks (1864) I 141 The term lsquomonsterrsquo is equally applicable to
small abnormal things and to great
1897 T C ALLBUTT et al Syst Med IV 528 It [sc congenital absence of spleen] has been
noted in monsters
1968 Brit Jrnl Plastic Surg 21 411 As the child was thought to be a mentally defective
monster unlikely to survive infancy he was kept in the local hospital for 16 months
1996 European Jrnl Obstetr amp Gynecol 65 245 (title) An acardiac acephalic monster
following in-utero anti-epileptic drug exposure
(OED 2015)
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
A doomed being (a monster) is altered to
survive
As it turns out there are many stories of
a doomed (with a time limit)
being-within-a-being
who receives an intervention
and is savedhellip
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Fiona takes
ldquotrue loversquos
formrdquo
Shrek
Dreamworks
2001
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
The frog prince
Frog receiving
monstrous treatment
Arthur Rackham
1913
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
Love as an
intervertion
Beauty and the Beast
Disney
1991
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
A being-within-a-being (a monster) receives a critical
intervention to survive
University of Wisconsin YouTube Channel 2009
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
References
Benonis JG Habib AS Ex utero intrapartum treatment procedure in a patient with arthrogryposis multiplex congenita using
continuous spinal anesthesia and intravenous nitroglycerin for uterine relaxation Int J Obstet Anesth 2008 Jan 2317(1)53-6 Epub 2007
Apr 23
Berry SM Stone J Norton ME Johnson D Berghella V Fetal blood sampling Am J Obstet Gynecol 2013 Sep209(3)170-80
Chestnut HD Wong C Chestnuts Obstetric Anesthesia Principles and Practice Saunders 5th edition 2014
Clark KD Visconi CMLowell J Chien EK Nitroglycerin for uterine relaxation to establish a fetal airway Obstet Gynecol 2004 103 1113-5
Fink RJ Allen TK Habib AS Case series remifentanil for fetal immobilization and analgesic during the EXIT procedure under combined spinal-
epidural anesthesia Br J Anesth 2011 106 851-8
Gaiser HR Cheek TG Kurth CD Anesthetic management of cesarean delivery complicated by EXIT treatment of fetus Anesth Analg 1997 84
1150-3
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7
References
George Rb Melnick AH Ros EC Habib AS Case series comn=bined spinal epidural anetehsia for caesarean delivery and exut procedure
Can J Anesth 2007 54 218-22
Holloway S Second trimester detection of arthrogryposis multiplex congenita with two-dimensional ultrasound Ultrasound February 2010
vol 18 1 pp 25-27
Marwan A The EXIT procedure principles pitfalls and progress Semin Pediatr Surg 2006 15 107-15
Reynolds LM1 Lau M Brown R Luks A Fisher DM Intramuscular rocuronium in infants and children Dose-ranging and tracheal
intubating conditions Anesthesiology 1996 Aug85(2)231-9
Steiner EA1 Judd WJ Oberman HA Hayashi RH Nugent C Percutaneous umbilical blood sampling and umbilical vein transfusions
Rapid serologic differentiation of fetal blood from maternal bloodTransfusion 1990 Feb30(2)104-8
Yoo K Lee JC Yoon MH et al The effects of volatile anesthetics on spontaneous contractions of isolated pregnant uterine muscle a
comparison among sevoflurane desflurane isoflurane and halothane Anesth Analg 2006 103 443-7