UNC maternal-fetal medicine leads team in EXIT delivery

A baby was delivered at UNC Hospitals on Thursday, Nov. 12, via an EXIT (ex utero intrapartum fetal treatment) procedure. A rare occurrence anywhere, it was the third EXIT procedure performed at UNC Hospitals since 2003.

For one baby delivered at UNC on Thursday (Nov. 12, 2009), its entrance into the world was made through an EXIT, an ex utero intrapartum fetal treatment procedure.

A rare occurrence anywhere, it was the third EXIT performed at UNC since Nancy Chescheir, M.D., performed the first in 2003. EXIT is a specialized fetal intervention procedure employed most commonly when problems during pregnancy may obstruct the fetus’s airway. In such cases, if the baby were delivered without the intervention, it could  be at risk for a loss of oxygen, says Bill Goodnight, M.D., assistant professor in the Department of Obstetrics and Gynecology who led a team of more than a dozen physicians and nurses in the procedure.

In EXIT, surgeons perform a specialized C-section while the mom is under general anesthesia in which the baby is partially delivered – head first, then a shoulder and an arm – leaving the baby attached to the placenta by the umbilical cord. The placenta continues to provide oxygen to the baby while the newborn’s airway is established.

In the procedure Thursday, “we had the baby on placental circulation for about 15 minutes,” Goodnight says. The team completed intubation and confirmed the airway with endoscopy then finished delivering the baby with no complications. “The baby went off to the nursery and the mom’s doing well.” The family chooses to remain anonymous.

At 28 weeks gestation a mass was detected on the baby’s neck, and Drs. Goodnight and Ashley Hickman, M.D., a senior fellow in obstetrics and gynecology, started thinking about the need  for delivery via EXIT. The mass continued to grow, and about a month ago a fetal MRI showed that the growth had begun to deviate the trachea, and was possibly affecting the fetus’s ability to swallow, so Goodnight began planning the EXIT.

Goodnight and Hickman are part of the Center for Maternal & Infant Health, which meets weekly with colleagues from other disciplines to review and coordinate care for babies with anomalies.

“Our goal is to provide all services available for the sickest babies in North Carolina. The collective expertise of this group allows us to do that, while coordinating care with a woman’s local doctor,” says Goodnight, who graduated from the UNC School of Medicine and completed a fellowship in maternal fetal medicine at the Medical University of South Carolina before returning to UNC last year.

“At UNC, we take our mission to the people of North Carolina very seriously,” says Daniel Clarke-Pearson, M.D., chairman of obstetrics and gynecology. “We are fortunate to have a collection of extremely skilled and caring physicians, in our department and across the hospital, that enables us to meet our mission.”

Kathleen Smith, M.D., and Adriene Ray, M.D., from adult anesthesiology had an especially crucial role, Goodnight says, because the mother had to be under general anesthesia while keeping the uterus relaxed and blood flow to the placenta normal.

Nate Nonoy, M.D., and Michael Danekas, M.D., from pediatric anesthesiology intubated the baby. Others on the team included George Retsch-Bogart, M.D., and Kathy Adobe from pediatric pulmonology; Cyril Engmann, M.D., and Lynne Harrington Johnson, M.D. from neonatal-perinatal medicine; and Amelia Drake in otolaryngology.

Over the next few days doctors will carefully keep watch over the baby and determine the best way to remove the growth.