The Ex-Utero Intrapartum Treatment (EXIT) Procedure: A Narrative Review.

Michele Gaffuri^1,2Genny Raffaeli^2,3Elena Emilia Bullejos Garcia^4*Giuseppe Perugino⁵Ottavio Cassardo⁵Nicola Persico^2,6Mariarosa Colnaghi³Felipe Garrido⁷Eduardo Villamor⁸Irene Cetin^2,5Monica Fumagalli^2,3Lorenzo Pignataro^1,2Giacomo Cavallaro^3*

• ¹Department of Otolaryngology and Head and Neck Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
• ²Department of Clinical Sciences and Community Health, Dipartimento di Eccellenza 2023-2027, Università degli Studi di Milano, Milan, Italy
• ³Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
• ⁴Pediatric Anesthesia and Resuscitation Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
• ⁵Department of Obstetrics and Gynecology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico,, Milan, Italy
• ⁶Prenatal Diagnosis and Fetal Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
• ⁷Neonatal Intensive Care Unit, Clínica Universidad de Navarra, Madrid, Spain
• ⁸Division of Neonatology, MosaKids Children’s Hospital, Maastricht University Medical Center (MUMC+), Research Institute for Oncology and Reproduction (GROW), Maastricht University, Maastricht, Netherlands

The “Ex Utero Intrapartum Treatment” (EXIT) procedure is a specialized surgical technique used during cesarean delivery to perform life-saving fetal interventions while maintaining placental circulation. By preserving feto-placental gas exchange, EXIT enables the treatment of severe conditions such as predictable severe breathing difficulties at birth. EXIT’s origins date back to removing tracheal occlusion devices used for congenital diaphragmatic hernias. It has since expanded to treat conditions such as congenital high airway obstruction syndrome and airway compression by masses. Despite the risks of adverse maternal and fetal events, it shows high perinatal survival rates. The success of EXIT depends on an accurate prenatal diagnosis through fetal ultrasound and magnetic resonance imaging. Anesthetic management differs from standard cesarean sections, balancing the need for uterine relaxation and avoiding maternal-fetal risks. Inhaled anesthetics are preferred, although recent studies suggest the potential of neuraxial anesthesia combined with tocolytics. Although the EXIT procedure can be performed safely in specialized centers, it does carry risks for both the mother and the fetus. Neonatal mortality and complications vary depending on indications and postnatal management. Research and clinical practice must advance to improve safety and efficacy.