title: Obstetric hemorrhage during an EXIT procedure for severe fetal airway obstruction.
abstract: OBJECTIVE
  To report a case of massive obstetric hemorrhage occurring during Cesarean delivery for an ex utero intrapartum treatment (EXIT) procedure. Methods to optimize the anesthetic, obstetric, and perinatal management are discussed.
  
  
  METHODS
  A healthy parturient underwent an urgent EXIT procedure at 32 weeks gestation for a giant fetal neck mass. During the intraoperative period, severe intraoperative hemorrhage occurred from the site of the uterine incision. No evidence of placental bleeding, premature placental separation, or inadequate uterine relaxation was observed during the perioperative period. Placement of a uterine stapling device was unsuccessful in achieving adequate surgical hemostasis. Initial attempts with laryngoscopy and rigid bronchoscopy to secure the fetal airway on placental support were unsuccessful, and early termination of placental support was deemed necessary due to the severity of maternal blood loss. After full delivery of the neonate and termination of placental support, neonatal ventilation with bag-mask ventilation was achieved and successful endotracheal intubation occurred during repeat bronchoscopy.
  
  
  CONCLUSIONS
  The risk of obstetric hemorrhage due to uterine relaxation and inadequate surgical hemostasis in patients undergoing EXIT procedures is poorly reported. To reduce adverse maternal and neonatal outcomes, the premature termination of placental support during EXIT procedures may be required in the setting of severe obstetric hemorrhage.
authors.affiliation: Department of Anesthesia (MC:5640), Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA. ajbut@stanford.edu
authors.forename: Alexander
authors.initials: A
authors.lastname: Butwick
authors.forename: Pedram
authors.initials: P
authors.lastname: Aleshi
authors.forename: Imad
authors.initials: I
authors.lastname: Yamout
mesh_terms: D000328:Adult; D000402:Airway Obstruction / Q000209:etiology / Q000601:surgery*; D000768:Anesthesia, General / Q000379:methods; D000773:Anesthesia, Obstetrical / Q000379:methods*; D016063:Blood Loss, Surgical; D002585:Cesarean Section / Q000009:adverse effects*; D005260:Female; D005315:Fetal Diseases / Q000209:etiology / Q000601:surgery*; D005865:Gestational Age; D006258:Head and Neck Neoplasms / Q000151:congenital / Q000601:surgery; D006801:Humans; D007231:Infant, Newborn; D007442:Intubation, Intratracheal / Q000379:methods; D011247:Pregnancy; D013724:Teratoma / Q000151:congenital / Q000601:surgery; D016896:Treatment Outcome