[Anesthesia for ex utero intrapartum treatment of fetus with prenatal diagnosis of cervical hygroma: case report].

BACKGROUND AND OBJECTIVES Ex utero intrapartum treatment (EXIT) is a procedure performed during Cesarean section with preservation of fetal-placental circulation, which allows the safe handling of fetal airways with risk of airways obstruction. This report aimed at describing a case of anesthesia for EXIT in a fetus with cervical cystic hygroma. CASE REPORT Female patient, 22 years old, 37 weeks gestation without anesthetic background, physical status ASA I, submitted to EXIT for airway handling and tracheal intubation of fetus at risk for airway obstruction. Procedure was performed under general anesthesia associated to continuous epidural anesthesia. Patient was premedicated with intravenous metoclopramide (10 mg) and ranitidine (50 mg). Epidural 0.25% bupivacaine with epinephrine (30 mg) associated to fentanyl (100 mg) was administered, followed by cephalic catheter for postoperative analgesia. Uterus was displaced to the left. Anesthesia was induced in rapid sequence with fentanyl, propofol and rocuronium and was maintained with isoflurane in 2.5 at 3% in O2 and N2O (50%). After hysterotomy, fetus was partially released assuring uterus-placental circulation, followed by fetal laryngoscopy and tracheal intubation. Then fetus was totally released with umbilical cord clamping, administration of oxytocin (20 UI) in continuous infusion, followed by intravenous methyl-ergonovine (0.2 mg). Maternal systolic pressure was maintained above 100 mmHg during the procedure with bolus ephedrine (5 mg) and crystalloids (3000 mL). Isoflurane concentration was gradually decreased during uterine closure. At surgery completion neuromuscular block was reversed and morphine (2 mg) was injected through the epidural catheter for postoperative analgesia. CONCLUSIONS Major recommendations for EXIT are maternal-fetal safety, uterine relaxation to maintain uterine volume and uterus-placental circulation, and fetal immobility to help airway handling.