Open Journal of Obstetrics and Gynecology, 2013, 3, 51-60 OJOG
http://dx.doi.org/10.4236/ojog.2013.39A007 Published Online November 2013 (http://www.scirp.org/journal/ojog/)
Ex Utero intrapartum treatment (EXIT)
Srinivas Pentyala1,2,3,4*, Aleef Rahman1,4, Pooja Mysore1, Sahana Pentyala1, Kyle Urbanczyk1,
Thomas Tumillo1, John Muller1, Yimei Miao2, Sardar Khan2
1Department of Anesthesiology, Stony Brook Medical Center, Stony Brook, USA
2Department of Urology, Stony Brook Medical Center, Stony Brook, USA
3Department of Health Sciences, Stony Brook Medical Center, Stony Brook, USA
4Department of Physiology & Biophysics, Stony Brook Medical Center, Stony Brook, USA
Received 25 September 2013; revised 22 October 2013; accepted 30 October 2013
Copyright © 2013 Srinivas Pentyala et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
The anes t hes ia ex u t er o intrapartum treatment (EXIT)
procedure is a specialized surgical procedure used to
deliver babies who have airway compression due to
cystic adenomatoid malformation, bronchopulmon-
ary sequestration, cervical teratomas, or other con-
genital conditions. EXIT is erroneously known as a
routine cesarean section (CS), but is rather an exten-
sion of CS with discernible differences. The proce-
dure creates an opening in the anesthetized abdomen
of the mother and uterus. Once EXIT is complete, the
remainder of the CS proceeds. EXIT is much more
complex than a routine CS, as it requires coordina-
tion between the mother and a multidisciplinary team
of surgical and neonatal personnel. This review high-
lights current anesthetic concepts during the EXIT
procedure.
Keywords: Caesarean Section; Airway; Vaginal Birth;
Anesthesia; Ex Utero Intrapartum Treatment; EXIT
1. INTRODUCTION
As scheduled cesarean sections (CS) become safer, there
has been a movement to perform CS upon maternal re-
quest [1,2]. Vaginal birth after caesarean (VBAC) is not
associated with increased risk of maternal or neonatal
mortality and has contributed to the increase in CS pro-
cedures in recent years [3-7]. However, a mother may
refuse to undergo a CS in most countries. In the CS pro-
cedure, laparotomy occurs through a surgical incision
made in the abdomen followed by a similar hysterotomy
for the uterus. A hysterectomy consists of a CS followed
by the removal of the uterus. There are several ways to
perform CS. The traditional method involves a midline
longitudinal incision. However, it is rarely performed to-
day, as it is more prone to complications. Instead, the
lower uterine segment section (USS) is used through a
transverse cut just above the edge of the bladder, which
results in fewer complications. USS may be done in
cases of extreme blood loss or when the placenta is in-
separable from the uterus. Repeat CS can occur and is
typically performed through the old scar. Regional anes-
thesia is frequently delivered and general anesthesia is
reserved for high risk cases or emergencies. However,
the overall risks of general anesthesia for mother and
baby are still extremely small. Recent studies did not link
epidural anesthesia with any type of labor failure leading
to CS, but the general medical practice is to use labor
induction drugs after anesthesia to counteract sedative
effects [8]. In terms of proper ex utero intrapartum treat-
ment (EXIT) procedure, the infant is delivered attached
to the umbilical cord and the placenta, while a surgeon
establishes the airway to allow the infant to breathe.
Once EXIT comes to completion, the umbilical cord can
be clamped and the infant is delivered. The remainder of
the CS proceeds, as EXIT requires coordination between
the mother and specialists operation. The difficulty lies
in preserving enough blood flow through the umbilical
cord and protecting the placenta to avoid contractions of
the uterus.
The basic principles of EXIT were developed for the
initial purpose of reverse tracheal occlusion of the infant,
especially for cases of severe congenital diaphragmatic
hernia (CDH). EXIT provides the advantage of uteropla-
cental gas exchange but on placental support. Through
the early development of EXIT, additional principles
were gathered, which have improved outcomes, most no-
tably in cases of airway obstruction. The prodroms of
EXIT have expanded and now include giant fetal neck
masses, lung or mediastinal tumors, congenital high air-
way obstruction syndrome, and EXIT to extracorporeal
*Corresponding author.

S. Pentyala et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 51-60 52
membrane oxygenation (ECMO) [9].
The EXIT procedure encompasses situations in which
obstruction is already anticipated. Not only is EXIT use-
ful in CDH with intrauterine tracheal occlusion, but ad-
ditional indicators have been proposed. Reports of cases,
which utilized the EXIT procedure, varied, but stress the
importance of combining fetal ultrasound (US) and mag-
netic resonance imaging (fMRI) in the characterization
of cervical masses and usefulness in programming the
procedure with a multidisciplinary team. For instance,
anesthesia of the mother can be induced with thiopental,
succinylcholine, and fentanyl followed with intubation,
and maintained with isoflurane and nitrous oxide [10].
Any abdominal midline incision should be followed with
a low transverse incision of the uterus. Immediate laryn-
goscopy is a main indicator of an administered tracheo-
stomy. Surfactant can be given after ventilation to facili-
tate compliant delivery [11]. After reducing the concen-
tration of anesthetic, administration of oxytocin can help
with uterine contractility establishment and avoidance of
uterine atony in the postoperative period.
Case reports indicated the procedure of EXIT to
ECMO for a fetus with CDH and cardiac defect, con-
genital high airway obstruction syndrome, resection of
congenital cystic adenomatoid malformation of the lung
on uteroplacental bypass, unilateral pulmonary agenesis,
and thoracoomphalopagus conjoined twins. The average
duration of uteroplacental bypass was 14.7-min to 30.3-
min, during which hemodynamic instability is not re-
corded by fetal heart rate, pulse oximeter, or fetal echo-
cardiography, except in rare cases. Blood loss through
the mother is on average 574.1-mL to 848.3-mL [12]. In
selected groups of infants with CDH, tracheal occlusion
is still recommended to obstruct the normal flow of lung
fluid and to stimulate lung expansion and growth. The
solution is to arrange delivery to allow the occlusion to
be removed and the airway secured, if the uterus is to be
kept relaxed and the uteroplacental blood flow intact.
The technique of tracheal occlusion remains under study
in clinical trials [13].
Recent treatment of CDH suggests onset within 24 hrs
of life and has likewise been a main concern. However,
the use of modalities is dependent on the situation of
each institution. Permissive hypercapnea respiration aims
to avoid barotraumas in aspiration and has reportedly
improved outcomes [14]. In terms of EXIT to ECMO,
infants usually pass ventilation trials, but require ECMO
within 48-hr before delivery. The overall survival mo-
rality of EXIT to ECMO is suggested to be around 64%
[15]. With the assumption of severe CDH, EXIT to
ECMO is associated with infants expected to have a poor
prognosis under conventional techniques. In addition, it
is reported through EXIT that postpartum wound com-
plications are increased to around 15% with no effect on
the rate of endometritis. In addition, there is no differ-
ence in hematocrit level change or postpartum hospital
stay [16]. The presence of large fetal neck masses is one
of the causes of airway obstructions. The relationship of
the neck mass to airway structures can be established
with US and fMRI. The EXIT procedure can be helpful
in such cases and to obtain a fetal airway [17-19]. In par-
ticular cases of life-threatening fetal neck masses (con-
sider CVR values between 2.1 and 4.5 at maximum size
or between 1.9 and 3.6 near term) [20], EXIT with the
course of diagnostic accuracy of imaging results, intra-
operative complications and outcomes, can lead to poly-
hydramnios as a symptom. The possibility of wedging of
the lungs is almost always a sign of detectible hyperex-
tension. In addition, the chance of the trachea pulled up
into the neck may lead to the underestimation of the site
of tracheostomy. The occurrence of polyhydramnios is
noted as a result of esophageal compression [9].
Fetal fMRI provides the most accurate diagnosis in
most cases while ultrasonography can be used as an al-
ternative [21]. It is evident for neck areas, especially the
upper respiratory tract, that EXIT procedure can be indi-
cated in selected cases and include exposure and temporary
obstruction of the trachea to reduce the viscera and pre-
vent pulmonary hypoplasia in CDH, prenatal tracheot-
omy in laryngeal atresia, and intranatal establishment of
an airway in airway-obstructing embryonic tumors [21,
22]. It is necessary to utilize fMRI for evaluation of fetal
neck masses prior to operation through the EXIT. With
diagnosis either through fMRI, US, spin-echo, fast gra-
dient-echo, or half-fourier single shot turbo spin-echo,
the sequences were able to demonstrate fetal airway rela-
tive to the mass. In addition, the sequences were able to
give a precise definition of the mass because of larger
scopes of view, which would otherwise be obtained with
only fMRI as opposed to US. The fast gradient-echo se-
quence is known to provide the most definition of a mass
due to its decreased motion artifacts.
However, fMRI brings the most essential information
about the anatomy of the fetal neck masses and the adja-
cent airways prior to selection for the EXIT procedure
[23]. In general, fetal neck masses can present a major
challenge with subsequent risks of hypoxia, brain injury,
and death. A multidisciplinary approach combined with
accurate imaging sequences is the main precedent of a
successful outcome [24]. The EXIT procedure provides
up to 1-hr of good uteroplacental support and is still a
choice to secure an airway in a large neck mass [21].
Labor after CS is associated with a greater perinatal risk
than CS without labor. A factor like prior VBAC is asso-
ciated with a high rate of successful labor compared with
patients without VBAC. For instance, US measurement
of the lower uterine segment thickness is around 3.5-mm
and is followed with a negative predictive value for uter-

S. Pentyala et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 51-60 53
ine defect risks [7]. In comparison with planned repeat
low-transverse CS, VBAC is not shown to increase the
risk of maternal or neonatal mortality [4]. In a study,
which examined the infant risk associated with VBAC
through examination of depressed Apgar score, the Ap-
gar scores within 5-min suggested only insignificant dif-
ferences between patients who delivered VBAC and
those patients who delivered vaginally without CS. In-
fants in the VBAC group were more likely to have an
umbilical arterial pH of no more than 7.1. VBAC poses a
low level of risk to the infant, but the potential damage in
fetal acidemia is unknown [6]. In addition, there is an
insignificant difference in uterine rupture or bladder in-
jury and with VBAC, a risk for composite adverse ma-
ternal outcome or transfusion is generally lower.
Among almost all VBAC, risk for overall major ma-
ternal morbidities and maternal fever is relatively low, so
that physicians can make a favorable benefit-risk ratio
explicit when counseling [3]. In looking at whether or
not women were able to exercise informed choices to
explore decisions about the method of delivery and how
the choices are interpreted following the birth, expected
mothers must have access to non-biased information in
order to engage in a collaborative understanding with
midwives and obstetricians. For women, psychological
and social implications about VBAC may trump any
physical concerns [1].
2. IMAGING AND DIANOSTICS
Antenatal ultrasound is commonly used to detect and
surgically correct fetal masses, which requires intrapar-
tum surgical intervention to save the fetus from future
harm during full time birth. Specific anesthetic concepts
are needed for ensuring umbilical perfusion [25]. If the
diagnosis is accurately made through image sequencing,
the EXIT procedure may be life-saving [26-29]. The
most important concern of the anesthesiologist is the us-
age of deep volatile anesthesia for a prolonged period of
time in combination with any necessary intravenous in-
fusions. The hemodynamical stability of the mother is
the main goal. Normal blood gas values in the umbilical
artery means gas exchange is not negatively affected
during EXIT [30]. Epidural anesthesia with monitoring
allows surgery to take place without complications [31].
In numerous ways anesthetic considerations for EXIT
procedures are identical to considerations for non-ob-
stetric surgery during pregnancy, including concerns for
the mother, avoidance of teratogenic drugs and asphyxia,
and prevention of preterm labor. Anesthetic considera-
tions also depend on the location of the placenta and dis-
tinct from maternal surgery for the EXIT procedure, and
the infant is not considered for anesthetic interference
[32]. Instead, the infant can be the primary patient along
with the mother and complications can be effectively
recognized, predicted, and avoided by monitoring. Moni-
toring is crucial for assessing the response to corrective
maneuvers [33,34]. Occasionally, the bellows may pop-
off the valve, even if the gas flow is turned off. This can
be due to the ventilator entering the breathing circuit
through leaks in the bellows. Therefore, testing the integ-
rity of the bellows is suggested to avoid complications
[35].
3. METHODOLOGY OF ANESTHESIA
In addition to the usual considerations of anesthesia in
obstetrics, the special considerations for the EXIT pro-
cedure can be summarized to fetoplacental circulation
through profound uterine relaxation and airway manipu-
lations and controls [36]. As part of a planned EXIT pro-
cedure, a multidisciplinary team (obstetric and surgical
personnel) to care for the mother, and neonatal surgical
personnel to care for the infant, are equally needed [37].
All cases require the specialist airway skills of the pedi-
atric anesthetist. As part of a multidisciplinary team in-
volved in EXIT, the anesthetist may be suddenly called
upon to secure a compromised airway when no antenatal
diagnosis has been made. Still after elective surgical ex-
cision, airway compromise may occur and require inter-
vention. There are several concerns to be addressed in all
the postpartum, surgery, and postoperative stages, and
the understanding of the techniques employed to over-
come the potential difficulties are key [38]. In specific to
the anesthetist, extracorporeal membrane oxygenation
(ECMO) has in the past been found to significantly boost
survival rates in infants with respiratory collapse cases,
but there has been a decrease in the use of ECMO. In-
stead, the methods of high frequency oscillatory ventila-
tion (HFOV), inhaled nitric oxide (iNO), and surfactant
therapy are used [39-41]. The instances of ECMO utili-
zation found within the past decades are likely obsolete
and unmet for instances today. Moreover, data supports
the increasing trend of HFOV, iNO, and surfactant over
ECMO [42]. Recent case studies of the anesthetic man-
agement in high-risk EXIT cases are presented in Table
1.
4. METHODOLOGY OF FETAL
SURGERY
There is a misconception that the EXIT procedure is the
same as a CS, but the goals of the EXIT and CS differ.
For instance, CS intents to maximize the uterine to pre-
vent postpartum hemorrhage and minimize transplacental
diffusion to avoid neonatal depression. Whereas, EXIT
aims to achieve a state of uterine hypotonia to maintain
uteroplacental gas exchange, preserve uterine volume,
maintain maternal blood pressure, and avoid cardiac de-
pression through the appropriated level of anesthesia [9].

S. Pentyala et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 51-60 54
Table 1. Applications of anesthetics & drug dosages in recent EXIT case studies.
Fetal
disease
state
Procedure
used
Pre-op drugs
relative reported
dosages
Induction
anesthestics and
reported dosages
Anesthestic
maintanence with
relative reported
dosages
Opiods and
neuromuscular
blockers/fetal
anesthesia
Uterine
relaxation Reference
Congenital
high
airway
obstruction
syndrome
(chaos)
in twin
gestation
1) EXIT
2) Laryngoscopy
for neonate
intubation
3) Tracheostomy
Pre-oxygenated
Rapid Sequence
Induction (RSI):
1) Lidocaine (100
mg)
2) Propofol (200
mg)
3) Succinylcholine
(120 mg)
Operational closing:
1) Midazolam (5 mg)
2) Propofol (100 mg)
3) Hydromorphone (1.2 mg)
4) Ondansetron (4 mg)
5) Neostigimine/
glycopyrolate
(3 mg/0.6 mg )
In additional to maternal
anesthesia fetus was given:
6) Single injection directly
into infant:
Fentanyl (5 mcg/kg )
Atropine (0.2 mg/kg )
Rocuronium (1.5 mg/kg )
Vecuronium*
*Dosage not
reported
1) Desflurane*
2) Nitroglycerin
infusion*
*Dosages not
reported
[44]
Cervical
tumor
of the neck
1) Cervical
tumor
resection
2) Tracheostomy
3) EXIT
1) Intravenous
metoclopramide
(10 mg)
2) Ranitidine
(50 mg)
Rapid Sequence
Induction (RSI):
1) Fentanyl (250
μg)
2) Propofol (150
mg)
3) Succinylcholine
(50 mg)
2% Isoflurane with
expired fraction of 1.4%
in 100% oxygen
Fentanyl (100 μg)
Atracurium (30
mg) for muscle
relaxation
During procedure,
uterine relaxation
due to 2% isoflurane
was satisfactory and
it was, therefore, not
necessary to use
additional tocolytic
agents
[65]
Large oral
tumor
1) Tracheostomy
2) Laryngoscopy
for neonate
intubation
3) EXIT
Morphine for
analgesia
(100 μg)
Rapid sequence
induction (RSI):
1) Fentanyl (150
μg)
2) Propofol (150
mg)
3) Succinylcholine
(100 mg)
2.5% isoflurane,
oxygen at 100%
additional fentanyl
(200 μg)
Atracurium (25
mg) for muscle
relaxation
During the
procedure, uterine
relaxation was
satisfactory and it
was, therefore, not
necessary to use
additional tocolytic
agents
[65]
Cesarean
section
of a twin
gestation,
one had
a large
2) EXIT
epignathus
1) Tracheostomy **Not reported
Rapid sequence
induction:
1) Propofol
2) Suxamethonium
**Dosages not
reported
3% sevoflurane in
100% oxygen
**Not reported **Not reported [66]
Cystic
hygroma/
teratoma
1) Tracheostomy
2) Cystic
hygroma
resection
3) EXIT
**Not reported
Rapid sequence
induction (RSI)
with cricoid
pressure:
1) Fentanyl (100
μg)
2) Sodium
thiopental (370
mg)
3) Succinylcholine
(120 mg)
2.0% sevoflurane in
100% oxygen
1) Subcutaneous
terbutaline
(40 μg)
2) Nitroglycerine
drip was on
standby
3) Rocuronium
(20 mg) IV
boluses to
maintain no
more than 1 to 2
twitches during
train-of-four
monitoring
Subcutaneous
terbutaline
(40 μg ) was
administered, and a
nitroglycerine drip
was on standby
[67]

S. Pentyala et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 51-60 55
Continued
Micrognathia
glossoptosi,
abnormal ears
with
preauricular
tags, and
ventricular
septal defect
*Newborn died
of sepsis and
cardiac failure
one month later*
1) Tracheostomy
2) EXIT
Intravenous (IV)
metoclopramide
(10 mg)
Rapid sequence
induction:
1) Propofol
(200 mg)
2) Remifentanil (20
μg)
3) Rocuronium
(50 mg)
1) Combination of nitrous
oxide (N2O)/oxygen
0.6/0.4 and remifentanil
infusion (1.0 mg of
remifentanil diluted in 50
mL of 0.9% NaCl) titrated
by syringe pump up to 0.8
μg/kg/min
2) Repeated 1.0 mg boluses of
midazolam (total 5 mg for
the procedure) were used
to potentiate the hypnotic
and amnestic effects of the
remifentanil/N2O
combination
3) In addition to maternal
anesthesia, fetus was given
Fentanyl (30 μg)
In additional to
maternal
anesthesia
fetus was given:
intramuscular
injection of
rocuronium
(3.0 mg)
Nitroglycerin
(NTG) infusion
was started after
induction of
anesthesia at
0.06 μg/kg/min
and increased to
0.3 μg/kg/min
[68]
Cervical
teratoma 1) Tracheostomy
2) EXIT Pre-oxygenated
Rapid sequence
induction (RSI):
propofol or
thiopental, fentanyl,
and succinylcholine
or rocuronium
**Dosages not reported
Sevoflurane*
*Dosage not reported
**Not reported
Initial
sevoflurane
was gradually
increased to
5.5%
[69]
Large
goitre 1) Tracheostomy
2) EXIT
**Not reported
Spinal-epidural (CSE)
L3-L4:
1) Bupivacaine (12
mg)
2) Fentanyl (15 μg)
3) Morphine (150 μg)
Intrathecally
Remifentanil initiated at
0.15 μg·kg−1·min−1
No muscle
relaxation or
anaesthesia
was required
for the fetus
i.v. bolus of
Nitroglycerine
(50 μg)
followed by
an infusion
at 50 μg·min−1
[70]
Severe
arthrogryposis
1) Tracheostomy
2) EXIT
**Not reported
Spinal-epidural (CSE)
L3-L4:
1) Bupivacaine (12
mg)
2) Fentanyl (15 μg)
3) Morphine (150 μg)
Intrathecally
Remifentanil infusion
initiated at 0.1
μg·kg−1·min−1 and
titrated up to 0.15
μg·kg−1·min−1
No
neuromuscular
b
locking agents
or analgesic
adjuncts were
needed
A nitroglycerin
bolus of 100
ug i.v. followed
by an infusion
of 50 - 100
μg·min−1
[70]
Arthrogryposis
with
temporoman-
dibular joint
involvement
and a hyper
extended neck
1) Tracheostomy
2) EXIT
**Not reported
Spinal-epidural (CSE)
L3-L4:
1) Bupivacaine (12
mg)
2) Fentanyl (15 μg)
3) Morphine (150 μg)
Intrathecally
Remifentanil infusion
was also started at that
time at 0.10 μg·kg−1·min−1
and titrated up
to 0.2 μg·kg−1·min−1
No
neuromuscular
b
locking agents
or analgesic
adjuncts were
needed
Nitroglycerin
infusion was
initiated
(100 μg·min−1)
[70]
Anterior neck
mass and
polyhydramnios
1) Teratoma
resection from
neck
2) Tracheostomy
3) EXIT
**Not reported
Rapid sequence
induction (RSI)
1) Thiopental sodium
(3 mg/kg)
2) Succinylcholine
(1.5 mg/kg)
1) Sevoflurane 2 - 3 vol%
2) Nitrous oxide in oxygen
(50-50) combined with
3) Dose of Remifentanil
(0.1 - 0.5 μg/min/kg) and
rocuronium (50 mg total)
**Not reported
Two boluses
of intravenous
Nitroglycerine
(30 μg),
followed by
an infusion at
0.5 - 1
μg/kg/min
[71]
Massive
obstetric
hemorrhage/
polyhydramnios
and a fetal
cervical
teratoma
1) Tracheostomy
2) EXIT
1)Pre-oxygenated
2) Oral nifedipine
(20 mg every 4
hr)
3) Subcutaneous
terbutaline (0.25
mg)
Rapid sequence
induction
Propofol (180 mg)
succinylcholine
(100 mg)
fentanyl 100 μg i.v.
with cricoid pressure
Sevoflurane (1.5% - 2%)
was administered with
50% oxygen and 50%
nitrous oxide
Intermittent
boluses of
vecuronium
Intravenous
Nitroglycerin
(200 μg)
[72]

S. Pentyala et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 51-60 56
Continued
Tumoral mass on
the anterior neck
(cervical
teratoma)
1) Hysterotomy
2) Tracheostomy
3) EXIT
1) Intravenous
metoclopramide
(10 mg)
2) Ranitidine (50 mg)
Rapid sequence induction:
oxygenation with
100% under mask
1) Intravenous fentanyl
(250 µg)
2) Propofol (140 mg)
Isoflurane in 2.5%
concentration at 3%
through gauged
vaporizer and
administered in
mixture of O2 and
N2O (50%)
Rocuronium
(50 mg)
**Not
reported [73]
Cavernous
lymphangioma
large septate mass
protruding into
the hypopharynx
and the distal
portion of the
nasopharynx
1) Tracheostomy
2) EXIT
**None reported
1) Thiopental (300 mg )
2) Succinylcholine (100 mg)
3) Fentanyl (50 ug )
0.4% - 2.5%
sevoflurane in
100% oxygen
**None
Reported
Magnesium
sulfate*
*Dosage not
reported
[74]
Severe
micrognathia
and
polyhydramnios
1) Tracheostomy
2) EXIT
**None reported
Rapid sequence induction:
general anesthesia
(with cricoid pressure)
1) Propofol, (150 mg)
2) Succinylcholine (100 mg)
1) 5% sevoflurane
2) 50% nitrous oxide
& oxygen
3) Fentanyl (300 mcg)
Vecuronium
(5 mg)
Nitroglycerin
infusion
(30 mcg/min)
[75]
In terms of preoperative considerations, the physiology
of pregnancy contributes to a variety of risks. The mother
is at risk for aspiration pneumonitis due to decreased
pressure of the lower esophageal sphincter, the increased
pressure of the gravid uterus on the stomach, and gastric
acid production. In addition, the cardiovascular system
takes a decrease in preload during supine positioning,
and there is an expanded blood volume, lower hematocrit,
and increased peripheral venous capacity. The pulmonary
function likewise is affected through alterations in func-
tional residual capacity, suggesting the increased chance
of hypoxia. The anesthetics are used mainly to decrease
myometrial tone intraoperatively, and there is an inhala-
tion anesthetic regime administered. The first stage in-
volves anesthesia maintenance at 0.5-MAC of desflurane,
isoflurane or sevoflurane in oxygen, which is decreased
to 0.2-MAC before maternal incision, then increased
before hysterotomy when needed [43]. The second stage
prevents uterine atony and excessive maternal bleeding
through measures including decreased anesthetic to 0.5-
MAC, followed by 20-U oxytocin in 500-mL saline and
10-U bolus in 1000-mL drip [9]. Before incision, a cock-
tail of fentanyl, atropine, and vecuronium is administered
intramuscularly to provide for postoperative care [44].
5. EXIT INDICATIONS FROM KNOWN
CONDITIONS
Several conditions are likely suitable for the usage of
EXIT. In rare cases if diagnosed in utero, EXIT can be
performed for amniotic band syndrome (ABS), if the
congenital disorder starts to cause entrapment of fetal
parts. However, unless to save a limb considered in seri-
ous danger of amputation or deformity, EXIT is typically
not considered until identifiable vital organs or the um-
bilical cord are directly affected. Cervical teratomas (CT)
are difficult tumors with high mortality and morbidity.
Though most tumors are benign, CT must be dealt with
through timely antenatal diagnosis and care must be
taken to avoid upper airway obstruction. EXIT is cited
through sources to one part of a structured approach to
the treatment of CT [28,38,45].
Along with EXIT, fMRI for evaluation of giant fetal
mass must be used as fMRI provides the essential infor-
mation prior to selection for the EXIT [21,23,24]. En-
cephaloceles known to be abnormalities in the pediatric
age group can likewise be treated. For the otolaryngolo-
gist, encephaloceles will mostly be encountered adjacent
to the brain and in the nasopharynx, which might de-
velop through mastoid surgery, trauma, or infections [46].
However, it is rare for encephaloceles to occur congeni-
tally, but nonetheless, instances are found in the mastoid.
It is relatively more common for fronto-ethmoidal en-
cephaloceles to be found in about 1 in 10 of all encepha-
loceles [47]. The infant presented with cystic mediastinal
mass or enlarged echogenic lungs can be treated with
bronchoscopic evaluation during EXIT [15,48,49]. The
presence of CDH in infants with liver herniation into the
chest show prenatal repair with unsuccessful outcomes.
In understanding the pathophysiology of CDH and its
repair, the normal egress of fetal lung fluid enlarge the
lungs and reduces herniated viscera, leading to improved
pulmonary function. The development of methods to
temporarily occlude the fetal trachea allows growth of
the lungs and reverse obstruction, unplugging the trachea
at the time of birth. Signs of improvements in the lungs
in utero, with reversal of pulmonary hypoplasia, is docu-

S. Pentyala et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 51-60 57
mented after birth and temporary occlusion of the trachea
accelerates growth of the lungs and ameliorates the pul-
monary hypoplasia associated with CDH [50].
Cases of syringomyelia with coexisting hydrocephalus
establish a pathogenic relationship between several con-
ditions. It is reported that hydrocephalus can aggravate
conditions through the hydraulic pressure effect [51,52].
Myelomeningocele is a congenital occurrence in the
backbone and spinal canal and is a type of spina bifida
associated with the lack of dietary folate or neural tube
defects. Detection of neural tube defects can usually be
done during pregnancy by AFP screening or detailed US,
among other imaging [53-55]. Intrauterine surgery for
myelomeningocele has also been performed and the
safety and efficacy is currently being investigated. The
incidence of spina bifida can be decreased significantly
with dietary folate within three months of pregnancy.
Sacrococcygeal teratoma (SCT) is a tumor located at the
base of the coccyx. Specifically, SCT is a type of tera-
toma neoplasm belonging to a class of nonseminomatous
germ cell tumor and is a result of abnormal development
of pluripotent cells. SCT are idiopathic in terms of
whether the condition is congenital and the pluripotent
cell seem unimportant in the body [56,57]. Recent case
reports should however be noted for other indications for
the use of EXIT (Table 1).
6. FUTURE AND IMPROVEMENTS OF
EXIT PROCEDURE
There are several rules for the future success and expan-
sion of the EXIT procedure. In the short-term, the most
important rule is accountability. The EXIT procedure has
been concluded as an optimal strategy for delivery in
multiple cases. In order for the EXIT procedure to be-
come permanently established, patients must be random-
ized in clinical trials when applicable to demonstrate the
benefits. In the long-term, it is predicted that the EXIT
procedure, as now practiced, will be entirely eliminated.
The uterine incisions with attendant risk and morbidity
will likely be deduced or entirely minimized for less in-
vasive procedures using superior imaging, instruments,
and technological innovations and advances. In the same
area, the developed method will likely be required to
correct the specific defects with discrete interventions
[58]. The randomized trails would need to be validated
through outcome-based research [59,60]. Due to the rar-
ity of anomalies or high mortality, it had been impracti-
cal or unethical to perform clinical trials, but it has be-
come imperative that EXIT can be subjected to the scru-
tiny of randomized trails as found in fetoscopic laser
separation cases and fetoscopic tracheal occlusion for
diaphragmatic hernia. In addition, though present time
fetoscopy is considered minimally invasive, there is con-
sideration for treatment associated morbidity with mini-
mal procedures [61,62]. Though procedures are currently
performed fetoscopically, progress has been slow [63].
Ultimately, fetal imaging is the realization of immediate
ultra-high resolution imaging in all aspects [58]. The pro-
cession of US and fMRI technologies seems most prom-
ising and the most modern is the high Tesla fMRI tech-
nologies, which achieves 25-µm resolution and provides
internal and external anatomy [64]. Additionally, it has
been suggested that Near-Infrared Spectroscopy (NIRS)
can be used in the monitoring of fetal health during the
EXIT procedure considering the advantageous ability of
measuring hemoglobin oxygen saturation and umbilical
venous oxygenation [44].
7. SUMMARY
While EXIT procedure is being used, advances have
been made in both the neonatal and uteroplacental as-
pects surrounding CS. The methodology of EXIT from
preoperative to postoperative care has improved drasti-
cally with the additional influx of information from re-
cent research. It is now definitely known that the benefits
of the procedure are formulated through accuracies in
imagining diagnostics and accommodations to the needs
of the mother through the multidisciplinary team of spe-
cialists, surgeons, and other personnel. With several con-
ditions mentioned about the EXIT procedure, steps to
avoid complications are known, and imperfections in the
art are noted. The direction of the EXIT procedure will
allow attendant risk and morbidity to be deduced, and
methods will correct defects. As further information be-
comes accessible, the psychosocial concerns of women
about CS and EXIT procedure will likewise be addressed,
assuming CS can occur with the link of anesthesia in
terms of proper EXIT procedure.
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