The maternal-fetal anesthetic considerations of ex utero intrapartum treatment (EXIT) procedure: Experience from a tertiary referral center and literature review

The ex utero intrapartum treatment (EXIT) procedure is a specialized surgical technique designed to safely establish cardiopulmonary support by maintaining placental circulation during cesarean delivery. It is most commonly indicated for fetuses with compromised airways caused by cervical masses, congenital high airway obstruction syndrome (CHAOS), or tracheal occlusion. Additional indications include resection of thoracic abnormalities, extracorporeal membrane oxygenation (ECMO) cannulation, management of conjoined twins, and resuscitation of extremely low birth-weight neonates. The primary purpose of the EXIT procedure is to provide critical time to secure the fetal airway and stabilize cardiopulmonary function before complete delivery. Unlike conventional cesarean delivery, it involves maintaining adequate uteroplacental perfusion to sustain fetal oxygenation through profound uterine relaxation. Anesthetic management during cesarean section concomitant with the EXIT procedure is more complex and challenging than standard cesarean deliveries. The benefits and risks for both mothers and neonates must be simultaneously considered. In this review, we shared our institutional experience with two EXIT procedures successfully performed at a tertiary referral center and review the current literature focusing on anesthetic techniques and considerations. Maternal and neonatal outcomes were also summarized. Our results highlighted the value of the EXIT procedure as a life-saving intervention for neonatal airway compromise, with favorable maternal and neonatal outcomes.