The Children's Hospital of Philadelphia
What Families and Physicians Should Know About Teratomas — Delivery

Mark P. Johnson, MD: Sometimes potential risks to the baby are so great that it necessitates, kind of, a team approach to delivery.

N. Scott Adzick, MD: Two adjacent operating rooms -- one operating room for the mother and the obstetrical team with a number of obstetricians, advanced practice nurses, anesthesiologists, and so forth. And then the adjacent operating room where the pediatric surgeon, the neonatologist, appropriate neonatal surgical nurses, advanced practice nurses, are ready to resuscitate the baby and, if need be, if there's an issue with the tumor such as a rupture, to deal with it on an emergent basis. So when we make the diagnosis of sacrococcygeal teratoma, planned cesarean delivery is recommended with the team there to resuscitate the newborn, if that's required.

Alan W. Flake, MD: It's underappreciated how large these tumors are, and how difficult they are to deal with through standard sorts of hysterotomies, or incisions in the uterus.

Mark P. Johnson, MD: Sometimes the masses are so big that we -- the only option we have for delivery is to do a cesarean section where we make a classical-type incision, which is the vertical up and down incision, that provides us with more room to deliver the baby and the very, very large mass.

Alan W. Flake, MD: We'll sometimes open a uterus over its entire length to deliver one of these teratomas and that prevents rupture at the time of delivery, which can also be a lethal event.

N. Scott Adzick, MD: The goal is to do a smooth delivery with an intact tumor, a stable baby, and then transfer the baby to the intensive care nursery --

Mark P. Johnson, MD: -- where the baby can stabilize going from fetal life to newborn life and become a much better surgical patient.

Alan W. Flake, MD: Deliveries for cervical teratoma are a special circumstance. If you can imagine a tumor that's really this size and bending the fetal head backward, it compresses the airway.

N. Scott Adzick, MD: In some circumstances it is impossible despite laryngoscopy, bronchoscopy to get an endotracheal tube through the mouth beyond the teratoma because the airway is frequently crushed by the teratoma.

Mark P. Johnson, MD: And that's a scenario where we might talk about an EXIT delivery.

Alan W. Flake, MD: The EXIT procedure is a procedure that's developed to allow us time to place an airway on a fetus.

Mark P. Johnson, MD: It's really a huge team effort with anesthesiologists and surgeons and obstetricians and fetal echocardiography support to make sure that the baby is very, very stable and everybody plays a little bit different role.

N. Scott Adzick, MD: The fetal head, the teratoma in the neck, the arms are delivered out of the uterus. The bottom half of the fetus stays in the uterus and the fetus is still hooked up to the placenta via the umbilical cord to maintain that maternal-placental-fetal circulation, basically heart-lung bypass for the fetus, if you will.

Alan W. Flake, MD: The placenta normally provides oxygenation for the fetus and, as long as the placenta is receiving blood flow, then the fetus is fine.

N. Scott Adzick, MD: So the EXIT approach is a way to convert what could be an emergency or catastrophe into a controlled situation in which airway control can be obtained.

Alan W. Flake, MD: And then once that airway's established, we can divide the umbilical cord and take the baby to an adjacent operating room and actually remove the tumor under controlled circumstances.

N. Scott Adzick, MD: We have experience with more than 70 EXIT procedures, the largest experience in the world, and many of those cases were for cervical teratomas.

Alan W. Flake, MD: The same can be said for mediastinal teratomas. If you can imagine a tumor inside the chest that's taking up space, compressing adjacent structures away from it, it can compress the intrathoracic or the airway within the chest cavity. And that's really the same sort of a situation.

Mark P. Johnson, MD: In those cases when we look at delivery, we have to plan delivery to get the mass out. And that's another scenario where an EXIT delivery would be appropriate in many cases.

Alan W. Flake, MD: We actually open the fetal chest and relieve the compression of the tumor and then we're able to establish an airway. Most of the time we actually go ahead and remove the mediastinal teratoma during the EXIT procedure so it's all done on maternal bypass, if you will.