It is an extraordinary story of a little baby who underwent aunique procedure even before she was born. A couple hailing from Warangal were devasted when they came to know that their unborn baby has a huge neck mass on a routine pregnancy scan. They were told that it could be life threatening and were advised to undergo abortion. However, the couple did not give up and wanted to find any chance of survival for the baby. Their search brought them to Hyderabad, where they consulted a team of doctors at Rainbow Children’s Hospital, Banjara Hills, a leading multi-specialty pediatric and obstetrics and gynecology hospital.
Rainbow Children’s Hospital at Banjara hills is an established Quaternary Children’s Care in the country andmanages complex and challenging cases needing advanced therapies like ECMO, Transplants in Children including Liver, Kidney and Bone Marrow, complex surgeries including neuro surgeries, and advance perinatal care. Round the clock availability of consultants in multiple pediatric specialties like neonatologists, pediatric ENT specialists, Pediatric surgeons, Pediatric anesthetists along with the obstetricians under one roof is the backbone of the hospital group in successfully dealing this kind of complex cases.
Team consisting of Fetal Medicine Specialist Dr Gayathri& Dr Sravanthi, Obstetrician Dr Shruthi, Chief Anesthetist Dr Subramanyam& Dr Geetha, ENT Surgeon Dr PVLN Murthy, Pediatric Surgeon Dr Harish Jayaram, Director- NICU services, Dr Dinesh Kumar Chirla and Neonatologist Dr Vijayanand and team have together dealt this case successfully.
Dr Sravanthi, the Fetal Medicine specialist at Rainbow Children’s Hospital explained to the couple, “there was indeed a huge mass obstructing the breathing tube and food pipe of the baby and that for any chance of the baby’s survival, they would need to perform a very unique and rare procedure called EXIT (Exutero Intrapartum Treatment) at the time of delivery”
Whilestill in the mother’s womb, babygets their oxygen supply from the mother’s blood via the placenta. After delivery, babies needto be able breath on their own. But in the presence of an obstruction of the breathing tube due to the large neck mass andbreathing is not possible after birth and will causebrain damage due to lack of oxygen supply. It is here that the EXIT procedure plays a vital role. Its aim is to deliver the baby partially and keep the blood and oxygen flow from the placenta going, allowing the experts to establish breathing for the baby through a special tube before completing the delivery.
The couple consented to undergo EXIT procedure so as to give the best chance of survival to their unborn baby. A series of discussions took place among various specialists includingFoetalMedicine consultants, Obstetricians, Anaesthetists, ENT surgeons and Paediatricsurgeons and Neonatologists. As the procedure needs a lot of co-ordination among various teams, the team also conducted a mock drill to anticipate, plan and prepare for any possible complication.
At 37 weeks of pregnancy, the mother underwent caesarean section and “EXIT” was undertaken. The team of 25 Doctors from all specialties attended the delivery and were ready to help the baby and the mother. Just Before delivery, fetal medicine team performed cyst reduction to decrease size of the massto facilitate delivery of the baby. The team of anesthetists provided special anesthesia to the mother to allow the placental blood supply to the baby.
Dr Subramanyam, Chief anesthetist said “Exposure of the chest and rest of the body to the air would have hastened separation of the placenta. Therefore, special drugs were used to keep the uterus relaxed to delay separation of the placenta from the mother’s womb till the baby could breathe at 11 minutes, as well as maintaining the mother’s blood pressure. Fluid was also infused into the womb to maintain the pressure inside and prevent placental separation”.
Dr Shruthi, Senior Obstetrician said, “It was a unique experience of delivering the baby’s head, but not rest of the body holding for 11 mins and monitoring fetal well being by fetal umbilical cord pulsation till airway is established.”
It was difficult to establish the airway in-spite of special equipment called video laryngoscope and bronchoscopy as the breathing pipe was pushed tooneside because of huge neck mass. The ENT Surgeon performedtracheostomy (insertion of special tube through wind pipe) while baby was still connected to placenta in mother’s womb. The baby,while critical during the delivery, was born and could breathepost-delivery thanks to the EXIT procedure and the special breathing tube.
Dr Murthy, Pediatric ENT surgeon shared his experience saying, “it was challenging to get the Tracheostomy done in a baby whose head was delivered and had a big neck mass and still connected to mother’s womb in short time. Once we got the tube in airway, further assessment and stabilization was done by the neonatal team.”
Once Stabilized baby shifted to NICU and requiredfurther intensive care on high level ventilator support. Dr Harish, Pediatric Surgeon who has successfully removed the neck mass weighing 600 grams and measuring 8x6x7cm was removed following 4hrs of long surgery. Dr. Harish, sharing his experience and expressed, “it was a major surgical challenge to remove such a big neck mass on such a small baby, where many vital vessels and nerves are there”.
Dr Vijayanand, Senior Consultant Neonatologist,sharing the experience explained, “It was a unique case where the treatment was initiated even before baby was born. She neededventilatory support for 50 days including advanced high frequency ventilation. There were several challenges during 12weeks stay in NICU. Becauseof 24/7 excellent medicaland nursing care we were able to successfully discharge the baby. It was very rewarding to see the baby who is five months old, breathing on her own and growing well.”
Dr Dinesh Chirla, Director, ICU said, “Never give up attitude of our team helped in saving such a challenging cases. The excellent team work, coordination and dedication of the doctors and nursing helps Rainbow in managing such challenging cases in past. This was the first time when we had Fetal medicine specialist, Obstetrician, Anesthetist, Pediatric surgeon, ENT surgeon and Neonatologist all attending delivery in coordinated and planned way and saving such challenging case. This is possible only because of multi-disciplinary approach and Teamwork.”
Dr Ramesh Kancharla, The Chairman and Managing Director of Rainbow Children’s Hospital said, “Every life is precious, and a determined effort from team of doctors would be able to save the most challenging cases. Rainbow’s team of expert specialists could achieve this because of efficient, effective and well-coordinated care. Further,our vision is to establish several such Quaternary Children’s Hospitals across India.”
This exemplary case demonstrated that best outcomes are still possible even in such a rare, complex case. Team Rainbow is proud and happy to share this success story of helping a couple and their dream to become parents.
For More Information: Dr Dinesh Kumar Chirla: 98497-90003 DrVijayanand:98661-57271