An uncommon surgical procedure, called “EXIT,” enables emergency removal of the fetus from its mother’s uterus, while remaining attached to the umbilical cord and placenta. Only a few such procedures have been performed in Israel, most of them at Rambam Health Care Campus. “The procedure enables delaying the birth and buying additional time in order to treat the fetus before the staff is forced to separate it from the placenta,” explains one of Rambam’s senior gynecologists.
Trusting in the expertise and experience of Rambam’s Professor Dove and the Mrs. Edith Katz Maternal and Fetal Unit, 28-year-old Hadas Metzger agreed to an uncommon but life-saving surgery on her unborn child. Suffering from a medical condition that endangered its ability to breathe after birth, the fetus was removed from its mother’s womb by what is known as the EXIT surgical procedure. During the operation, an incision was made in the mother’s womb through which the unborn baby’s head and arms were lifted, though it remained attached to the umbilical cord and placenta, which served as a respiratory support system. The multidisciplinary surgical team could then treat the unborn baby’s medical problem within the very short and limited window of opportunity available to them.
Rambam reported that the successful operation requires great skill and experience. The surgery is performed by a multidisciplinary team of gynecologists; ear, nose, and throat specialists; anesthesiologists; and nurses. It is a relatively rare surgical procedure, performed in cases when there is concern about the unborn baby’s ability to breathe on its own after leaving the uterus. It is customary to perform such surgical procedures when the medical problem can be corrected with a quick operation.
During pregnancy, instead of breathing on its own, the fetus gets its oxygen and other critical nutrients from the mother’s placenta. Hence, the goal of the experienced medical team is to treat the fetus’s critical medical condition so that it can stably transition from the placental circulation to newborn circulation (involving the lungs and heart). After birth, the newborn is then transferred to the neonatal intensive care unit for further care and supervision until it stabilizes and can be discharged home.
Dr. Dana Vitner, senior gynecologist and Director of the Maternal-Fetal Medicine (MFM) Outpatient Clinics at Rambam, explains: “This method enables performing complex medical procedures on fetuses with respiratory problems, before they are separated from the umbilical cord and breathing spontaneously. This intervention makes it possible to delay the birth and buy more time, allowing the fetus to be treated before the medical team has to detach it from the placenta. The EXIT procedure, in all its complexity, enables us to save babies that in the past might not have survived delivery.”
“I was certain that I would not easily give up on this pregnancy”
Hadas Metzger underwent all the usual screening tests during her pregnancy. She found out about her fetus’s medical problem during the 14-week ultrasound scan, and recounts the moment when she realized she had to undergo the complex surgery: “I was very relieved to know there was something that could be done to help my baby breathe and that he would not have to suffer after he was born. It is a super complex and rare operation, but I felt that I was in good hands. Luckily, I was right.”
Metzger, an occupational therapist concluded; “As an occupational therapist, I encounter a wide range of people with different disabilities. I was certain that I would not easily give up on this pregnancy, and when I learned that there was something that could be done to prevent my baby from suffering after birth, I chose to continue on. Of course, now that the surgery is behind me, I am very happy with the decision.”