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Dr. Prashant Jain

Dr. Prashant Jain

Sr. Consultant
Paediatric Surgery
BLK Centre of Neonatal,
Paediatric & Adolescent
Medicine
BLK Super Speciality
Hospital, New Delhi



Safe Exit

A life saved by performing a challenging Exit
procedure

A new born baby with a large neck mass blocking his airways was able to have a safe access and new lease of life owning to a rare and diffi cult procedure called Extra Uterine Intra Partum Treatment (EXIT) performed by the Paediatric Surgery and Neonatology team of BLK Super Speciality Hospital.

THE CASE

A 29-year old lady, 30 weeks pregnant from Bihar was diagnosed on antenatal ultrasound scan to have a large neck mass in foetus. The patient was referred to BLK Super Speciality Hospital for further management. The patient was further evaluated and a foetal MRI was done which was suggestive of large neck mass of an approximate size of 10 x 9 cm. The infant’s airways could not be visualized as the giant cervical mass was compressing it.

The infant’s normal exit from the womb would have been life threatening as the wind pipe was blocked due to the giant neck mass, obstructing the oxygen passage despite its abundant presence. The odds were stacked against his survival, as his wind pipe had to be decongested by intubation while he was still in the uterus, keeping the umbilical circulation intact throughout the intervention.

THE PROCEDURE

A multidisciplinary team comprising Paediatricians, Neonatologists, Paediatric Anaesthesiologists, Obstetricians, Paediatric Cardiologist, Paediatric Pulmonologist, Paediatric ENT specialists and dedicated nursing staff and other operating room personnel was formed to perform this rare and critical procedure.

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A special caesarean section was performed, only the head and shoulder of baby were delivered out of uterus and intubation was done. Intubation procedure was swiftly done within a record time of 1 minute 32 seconds. Every step during the caesarean and after delivery operation of Giant Cervical Lymphangioma was performed with precision and the end result was quite satisfying as the baby was breathing safely. The case also required a special C-section to keep the foeto-placental circulation intact. This can only be made possible under general anaesthesia with uterine relaxants. But again this carries a high risk of maternal bleeding. After the successful windpipe procedure and delivery of the new born, the non-cancerous Tumour in the neck was also operated. Intubation was also done away with as his windpipe was decongested thoroughly.

THE RESULT

The baby and mother were well post operation and recuperated without any complication. The mother and baby duo got discharged after a few post-operative days.

DISCUSSION

When the baby is in womb, mother breathes for him through the umbilical cord. But once out of the womb, the baby needs to breathe for himself as all babies do. It would have been fatal for the baby had he exited without going through the ‘EXIT’ procedure. Securing airway after the child is delivered could have been diffi cult because of distorted anatomy of neck and the intubation time cannot exceed more than 25- 30 seconds to prevent brain hypoxia. So EXIT procedure was the only option left with the doctors wherein they could have comparatively more time to perform the intubation procedure.

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