Exit procedure - Twins!

Gillian Newman, Eugenie Heitmiller

Research output: Chapter in Book/Report/Conference proceedingChapter


The case A 44-year-old, gravida 4 para 0120 woman with gestational hypertension and a dichorionic, diamniotic twin pregnancy was referred to our center at 21 weeks' 5 days' gestation for congenital high airway obstruction syndrome (CHAOS) in Twin B; diagnosis was confirmed by ultrasound. After multidisciplinary consultation and discussion with the patient, all parties agreed that the ex utero intrapartum treatment (EXIT) procedure was the best option. Weekly sonograms confirmed that fetal hydrops did not develop. Fetal magnetic resonance imaging (MRI) was performed to better delineate Twin B's fetal anatomy. Before delivery, a multidisciplinary planning session was held that included physician and nursing teams from maternal and fetal medicine, pediatric otolaryngology, neonatology, and anesthesiology (pediatric and obstetric). Two days before the procedure, the team conducted a walk-through in the operating room (OR). The patient was admitted to the hospital at 36 weeks' gestation. Ultrasound showed a vertex position for the normal Twin A and a superior, anterior breech for the affected Twin B. The surgical plan thus included intraoperative sonogram and intra-abdominal/extrauterine version of Twin B to allow for the delivery of Twin A before the EXIT procedure was per formed on Twin B. Delivery was planned for 3 days after admission. Before the patient's arrival to the OR, a team briefing took place, during which all personnel identified themselves and their roles. The case plan was reviewed; equipment, drug supplies, and blood availability were verified. The patient was brought into the OR and placed in the supine, left uterine displacement position. Standard monitors and external fetal monitors were applied, and the patient was preoxygenated prior to a rapid sequence induction with 100 mg lidocaine, 200 mg propofol, and 120 mg succinylcholine and was easily intubated.

Original languageEnglish (US)
Title of host publicationCore Clinical Competencies in Anesthesiology
Subtitle of host publicationA Case-Based Approach
PublisherCambridge University Press
Number of pages6
ISBN (Electronic)9780511730092
ISBN (Print)9780521144131
StatePublished - Jan 1 2010

ASJC Scopus subject areas

  • General Medicine


Dive into the research topics of 'Exit procedure - Twins!'. Together they form a unique fingerprint.

Cite this