Super Bowl Grand Rounds (3/6/2024)

Good morning. I wonder with the, wow, I was going to say it's closed the door because of that security alarm, but like magic it went off. Good morning. Welcome to Super Bowl Grand Rounds. This is a relatively new series that we have brought in. We've had a tremendous enthusiastic response to prior presentations and we're so we're going to continue in this pattern. Unlike regular grand rounds in our various departments, this is all inclusive and not only for the audience of which there's many, many, many who attend in person and on Zoom, but also we have a lot of speakers. So instead of spending a lot of time reviewing people's CVs and talking about their history and their value to ran in medical school and all that, we do very brief interest. And we have a lot of introduction and sort of self-interventions because if we introduced all these agust people here, we would be at the end of the hour and have learned nothing except about their personal history. Today, first of all, we had a last minute change. You all received the announcement for this. It was going to be all fetal for an hour and it still is going to be all fetal, but we very much expressed our condolences to Darren Orbok, who was going to leave the second half of his Darren loss, a family member yesterday and had to go to New Jersey. So we will, the case he was going to feature is just extraordinary and we'll get a chance for you all to see that at another time. But it does allow time for this group of speakers to talk to us more about the cases they had. So as a very brief introduction, what we look at in these super bowls are kind of wild cases showing each other what we do. We got some great cases already lined up for October. We're doing this twice a year. This one's a little different in that we're going to feature an entirely new field. And I've said this to many people who participated as many, many people in the audience to look at have gotten involved in this is actually not a new field. It's a new field of Boston Children's Hospital. And that's a little bit backwards of usual. We're usually the place that is innovating that is forging new pathways that is developing new fields. So much of the history of pediatric medicine began at this institution. In this case, although we've had a longstanding fetal assessment, fetal counseling center, we used to call the advanced fetal care center, the best imaging counseling coaching of care in the world. In terms of fetal surgery, actually intervening in a uterus, there was massive innovation here that happened in the cardiac world a couple of decades ago. And that is still the world leading effort. But in terms of the other things that have been done around the country, around the world, we're actually a little late to the party. And when as an institution, our leadership decided that we should, it was now time to do this. It was proven that there was value to families for this and that there is progress to be made going forward where we should innovate, where we should take our vast clinical expertise and our scientific base and advance to feel forward a few years ago, kind of during a pandemic, the hospital leadership said to Gary Fleischer and I, find the best people, make it happen, no limitations. In order to do that, we had to bring in an entirely specialty that doesn't exist because we're at Children's Hospital and we don't have obstetricians in our hospital, although we work incredibly closely with our adult affiliated hospitals in the neighborhood. So we're going to see the beginning of what was a soft launch, like we didn't announce to the world that we were doing field surgery at Boston Children's Hospital. In fact, an announcement to the obstetric and MFM community community in New England only went out a couple of weeks ago. We've been doing this for almost a year now with the intervention, but two years can make it happen. So you're going to see what I would say is the beginning because there's a lot more coming in the next six months in terms of what we're going to do. But I think you're going to have a great display of the enormous effort that's going to buy so many people to make this a reality of Boston Children's Hospital. So this will be led very briefly by our chief of the new division of maternal fetal medicine and surgery and director of the Maternal Field Care Center. Otherwise, a shamshia saw us, although he prefers to go by Shammy. So as patients call him, Dr. Shammy, or because of Dr. Shammy, or because of Shammy. So that's not a cocos and that's his preferred name. I'm not going to read his background other than he was born, raised, educated, initially trained in Iran and has come to the states and has had more fellowships than you can count. Was leading one of the busiest and most advanced fetal intervention centers of Texas Children's Hospital. And we were fortunate to attract him here to take us and the field to a new level. We were also fortunate that he was able to bring his mostly recently trained fetal fellow. I'll crispen here with him. He has led this effort and you're going to see an amazing team of people who have jumped on the train with him. So with no further ado, Shammy. And I think everybody should do some selves as you'd like to. Thank you, Saf. Good morning, everybody. Let's start at the outline of today talking. I just go quickly around the maternal fetal care center overview. And we most focus on the first case as a Nectar trauma and the team will be described of what happened to the patient. And then I'll also go very briefly about two and two transfusions syndrome for a monocore unique diameter to twins. This is one of the most common cases in fetal surgery that we perform so far at Boston Children. Regarding the overview, you know, as you can see, we started a March of last year, exactly March 1st. In the past year, we've done more than 50 cases and through those 50 cases, as you can see, the majority of cases is coming down to the laser application of plasticine tonostomoses for twin to in transfusions syndrome. And these are monocore unique diameter to twins. That means you know, put all those numbers together, more than 80% of our patients population for intervention so far is complex monocore unique diameter to twins. With that said, you know, if you counted, you know, in the first year, we saw a lot more than, you know, 40, that means we perform more than 40 cases in the Boston Children. We saw more than 150 cases. That means, you know, we concur the majority of the Northeastern is 90% of the all cases in the North just now coming to the Boston Children. With that said, let's start off from first case, Ali please come. And then each one of the, you know, presenters please introduce yourself. Good morning everyone. My name is Ali Javinani. I'm the post-like research fellow at MFCCR. Our first case is the fetal patient with neck, third trauma undergoing exit procedure. Our patient is 27 year old, assistant herself identified woman G2P0 with prior history of spontaneous abortion at the age of 21 requiring a dilatient extraction. The past medical history of a significant for a BSD repair at the age of 10 month at the same hospital at Boston Children's and the current pregnancy was conceived as an in vitro fertilization with first cycle embryo transfer. The pregnancy was initially complicated with a diet control gestation diabetes and a neck mass was noted at 27 weeks and 6 days and a fetal ultrasound with the primary OB which was suspicious for the fetal goiter. The fetal echo at that time was normal. The patient was referred to MFCCR 28 weeks and first seen here at 29 week and one day. This fall prenatal imaging, Dr. D.V.A. what did you see? Everyone hear me through the mic? Awesome. Good morning. I'm Ryan Didier. I'm one of the co-directors of the fetal imaging section in radiology and we're very fortunate here to have a long history of excellent imaging, particularly with fetal MRI. Probably the most advanced, I think, in the nation through our collaboration with Siemens. Also on our first initial ultrasound, 28 weeks, sorry, 29 weeks and one day, often very difficult to image these babies this far along and ingestation. It'll have a shadowing from the osteostructures. We always start with ultrasound but find MRI to become incredibly helpful. You can see the blue arrow showing the spine on the right side of the image and you can see this very large exophatic mass arising from the neck. It's really just like right under the chin. You can see both solid components and cystic components. You go to MRI. You can see that, thanks. You can see with the yellow arrows, you can actually see that arrow a little bit better. Where's the white arrow is showing the mass inferiorly on this fetus? If you look at the image on the right, I think what's most important, the size of the mass is important. The characteristics are important. This for us is very consistent with a teratoma, just based on its imaging characteristics. Everyone else on the team wants to know what's going on with the airway and how difficult is this going to be to manage the patient. I've put yellow arrows on the airway by MRI. You can see it well. Sometimes you can see it well with ultrasound if you have a cooperative baby and is in the right position and mom's body habit is supportive of that. MRI really showcases that T2 hyperintense airway is shifted to the right. It's narrowed but it's not collapsed. This is our first one. We did a follow up on the second one as well to just re-show the airway later in gestation to show that it remains peentant, it's narrowed and shifted while the mass continues to grow kind of expected for a teratoma. I think this sort of imaging analysis can be very, very helpful for the team in helping them prepare for the delivery. Thank you very much. The patient was assigned to primary nurse and social worker and the genetic and new synthesis performed which was perfecting normal. The multidisciplinary appointments with MFM's with surgery surgeons, ENT, specialties and no-nataloges was scheduled before the surgery and the exit procedure was planned based off all the comments and from the consensus that we have from all the teams. Andrew Smith, what did you do for the OR planning? Good morning everyone. I'm Andrew Smith from the main operating room and here to talk about a lot of the nursing coordination that goes into planning these cases. Communication is key. There are so many different disciplines and I'm going to forget to mention some of them so I apologize. But when we are alerted of these cases from the MFCC, we immediately spring into action working with all of our different colleagues from the fetal surgery team, ORL, pediatric surgery, ultrasound, respiratory care, breathing and this patient was going to be going on ECMO. The NICU is present as it was a going to be a live birth. We then communicate with all of those different areas from the perioperative care coordination clinic or the PCCC. Periop is involved. We coordinate with our colleagues from either the Brigham or the BI as they will come and help us with the postoperative care and then we plan for the mom to go to the pack you. Some of our learnings from this case next slide please. We always double check and triple check our equipment and work very collaboratively with our sterile processing department. There's lots of different instrumentation that has to be brought in not only for the fetal intervention. But the surgery on the baby afterwards, we prepare for everything. Are we going to go on ECMO? Are we going to do a bronch? Are we going to do a tracheostomy? And we always have backups of everything and make sure that we have all of our soft goods. We actually changed up our practice a little bit with this care or this case particularly. We used to when we did these in the ORL 16 and 17, we would just go across the sub sterile and sub sterile area and it was very easy. We've been performing these in our hail building now and we actually learned from a couple of these that would be easier to go directly across the hall instead of through the sub sterile. So we made that change. Some of the other things that we do is that we really plan for traffic through the ORLs and that area. We use extra personnel to make sure that random folks aren't just walking through to make sure that we have a very direct path once the baby is delivered to get to the next operating room. And then something else that we did is that our general surgery team then actually wore their roles on their chest so that everyone who exactly who was going to be in the ORL and what they were going to do. This is just a kind of a very brief layout of what the actual ORL looked like with the different teams being positioned throughout the ORL. Thank you so much for that. We're going to start with the flow that Wayne New Shelley had in the ORL. Our first name, Offsetz Reconnaissance Dezialogy Dr. Safer. Everybody hear me? Hi everyone, I'm Sebastian. I'm one of the OB anesthesiologists here. I'm going to talk about some of the maternal considerations. One of the main pillars of this type of procedure is to maintain the placental support of the neonate, which could be just a couple of minutes if everything goes well. Or it could mean that we need to support the neonate through the placenta for 30, 60, 90 minutes potentially. And so what you really need is profound uterine relaxation because you don't want the uterus to contract. You don't want the placenta to start to separate. So the way that we can achieve that is that if mom is under general anesthesia, which most of the time she is, is we can use our inhalation anesthetics, which cause you in relaxation. The patients can be very deep, sometimes more than to Mac. Some other adjuncts that we can use are nitroglycerin or remyphen tonal nitroglycerin as a smooth muscle relaxant relaxes the uterus. It's also heavily metabolized by the placenta. And so it doesn't cause hemodynamic changes in the neonate. Mifatinals also another nice adjunct that can cause some uterine relaxation, abdominal or relaxation for mom. And then it does cross the placenta. And so it can be an adjunct for the fetal anesthesia as well. Similarly, it's really important to maintain mom's map because you need to maintain flow through the uterine arteries. The placenta doesn't have auto regulation. So maintaining mom's blood pressure, even at 10 to 20 percent within baseline may not be enough for these cases. So you really need to maintain that flow. These cases is really important to consider the surgical complexity as well as the placenta location. So I know Sammy will get into this, but the placenta in this case was anterior. And so the histrothermia, the incision in the uterus was going to have to be posterior. And so the uterus was going to have to be exteriorized pretty significantly to make an incision on the posterior part of the uterus. And so that's more complex. And then from my standpoint, my concern was whether or not the uterine vessels were going to be chained in whether we were going to be able to maintain flow through the placenta. Of course, we want to maintain normal maternal physiology, the normal respiratory alkalosis that happens in pregnancy, for example, as well as making sure that the gravity uterus doesn't compress the IVC and that we decrease our preload. Some other considerations are certainly risks to mom. You know, we have to think about her comorbidities. This patient had a history of a VSD repair, but still had some mild RV dysfunction, some mild pulmonary stenosis, and some moderate trachuspid regurg. And so we would need to consider the hemodynamic changes with mom at the time of delivery with the fluid shifts that come with that. She's going to have a laparadomy in this case. It was mid-line vertical. And so there's postoperative pain issues to consider. She's at risk for bleeding. So we're giving medications to cause leaders to relax, post delivery. We need to reverse that because we want good uterine tone to decrease bleeding. There's also the potential for abruption. And OB, there's the higher risk of having a difficult airway for these patients. And they can get some laryngeal edema. Additionally, OB patients have higher oxygen consumption as well as diminished reserve. There's also potential aspiration risk, higher risk for pulmonary edema. And then considerations for future pregnancies. There's a higher risk of having invasive placentation, or for having a uterine rupture because of the incision on the uterus. This is a recent systematic review looking at the types of maternal anesthesia for exit procedures. And the vast majority are performed under general anesthesia because you need that really profound uterine relaxation. 4% in this review were done under combined spinal epidural for straightforward cases. And then so for this patient, our plan because of the surgical complexity of having to do a posterior histrodomy and what was going to be to do general anesthesia with a preoperative combined spinal epidural. The combined spinal epidural would give some postoperative under axial opioid for pain management. And then there was some consideration with having that epidural component that if the baby wasn't doing well that we could either optimize mom's pain control in the recovery area or potentially when the fascia was closed, we could wake mom up toward the end of the procedure so there should be able to see the baby if the baby wasn't doing well. And ended up that the epidural was challenging so we converted to a spinal. So we did a spinal and we gave interethycho opioids for postoperative pain control. So she had GA, we did two peripheral IVs as well as an arterial line for uterine perfusion. We used Norepine phynelephrine and then for uterine relaxation we had our inhalation anesthetic as well as nitroglycerin. Under the arrow you can see our part of the anesthetic. So the red triangles are the blood pressure and the green circles are the heart rate. And so you can see that we were able to maintain our hemodynamics and our uterine placental perfusion. Post delivery when the baby is delivered we turn down the inhalation anesthetic to less some point five Mac to try to get some uterine tone. We convert to a purple fall infusion because that doesn't affect uterine tone and then we start oxytocin and monitor bleeding. And then the lung did very well from our standpoint for this procedure. Thank you so much for that. As we mentioned the patient had an anterior placenta, so the exiled procedure was a little bit different. We need to have an uterine exposure and Dr. Sam are going to explain the uterine exposure to an histrothomy technique. Moija was pretty easy when you have such an excellent team. So the patient was on a deep general anesthesia as mentioned before the placenta was completely anterior. Therefore we couldn't do any kind of incision from the anterior aspect of placenta with uterus. We need to definitely go to the back of the uterus. As you see we exerise the uterus first and this is a big uterus, 36-week years are pretty big. The first step that we need to do is we need to map the placenta that means we definitely need to find out where is the edge of the placenta. The reason is when you want to make the incision definitely you don't and we can't do the incision through the placenta and we almost need to be about at least about 5 cm away from placenta. The reason is we want to prevent any kind of placenta absorption spatially because the patient in a deep general anesthesia the uterus is very relaxed and if you get to the end of the absorption then it's separation of the placenta from uterine wall the patient can start having a very heavy bleeding. But with that we make that kind of mapping and the next step is trying to put our stitch. The technique that we use on putting on a stitch is for the exit procedures usually I try to do the box stitch. As you can see is the ultrasound guided, we put a needle, we make sure that we are not getting any of the fetus parts. We anchor the aminetic membrane to the uterine wall and that's also helpful when we make the incision those aminetic membrane will not separate from the uterine wall and doesn't cause any kind of placenta separation. As you can see you completely put a four box around each other like a box. The reason is you make a very nice evascular space in the middle. When you have that kind of evascular space in the middle then we start with the bow, we start opening the uterus. The uterus is a very you know, the vascular organ spatially during the pregnancy because as you can see here you know there is no bleeding from the uterine wall. We get an inside an aminetic sac, we make some opening space. The staple that I use here is GI stapler. Again it's very common and everybody can find those GI stapler. The baby head was worth it. Therefore what we did is we avert the baby, the head is up now and the baby is looking to the seal because you know for working on an airway definitely the baby needs to look upward. Very nicely easily you know the baby you can see you know on a uterine edge there is no bleeding at all and now we expose the baby to our anesthetic. Dr. Raffer the first step ever man. Sure sure. Yes. Thank you Ali. Thank you Ali. First let me you know I really want to thank also Shami and acknowledges leadership and collaboration throughout all of those things. And I want to specific also ask Ali for thank Ali for putting all the slides even working last night until 10 o'clock sending emails to him. I can't get this one. So in general from the role of the oral for airway intervention really falls into two categories. Giant neck masses which are ideal in plastic, malformation or in in this case terotomo or what we call chaos congenital high airway obstruction which is usually the cases that we are dealing with in case of laranjal at regional. So those are the main indication for oral to be involved at the time of the delivery or at the time of the exit for airway intervention. So as you have seen the MRI findings, you know these are two one side to your left and one coronal imaging showing the large neck mass the terotomo. I have to just mention one thing typically in the medical field when we make a decision for treatment plan is really based on three things. We do a history sign symptoms. We do a physical exam look for you know the lesion, the firmness, location, vocal chord check and then we do some imaging chest X-rays CT scan and MRI and based on those three entities we make a treatment plan. As far as I know this is the only field that we make a treatment plan based on one entity on that image. I have to tell you within the past two and years that I have been involved with the advances in the imaging is amazing. The only reason we can do this is because of the advances of the imaging because I cannot examine the fetus we call the airway status and I don't know if there is any striders and feeding difficulty. So basically we are designing a treatment plan based on imaging and our OB team that will affect actually two individuals mom and their child. So the question that we are always asking is do we really need to do exit or do we can be intervened and in my mind I have tried to make it very simple and that's the paradigm that I think when I speak with the family. If there is any airway obstructions or concern based on the imaging then if there are no issues then the case is close we don't intervene. But if there is any concern the question is is the concern valid enough severe enough that we should do an exit and if you don't need to an exit as you can see in the paradigm the recommendation would you are going to do a normal delivery do we need to do C section and work in which location that delivery should take place. Can they do it back home in a remote institution that have no other facilities or should they come to Boston Children's or Brigham or BI to do that. If you are going to do an exit and the three questions need to be answered can we integrate the patient do we need to talk about tracheostomy and if the case is really severe should we have echo in the room. So that's a simple paradigm that I think about and I think that would be an easy way to convert that with the family. So I'm going to I showed I showed this imaging as far as I know this is the first case ever done at this institution for an exit that has been an Ontario placenta. I've never done this before I've never seen it and I believe this was the first case. So we had a lot of conversation with Shamia about the delivery. I know it's hard to tell but on the picture I don't know if you can see this. So this is this is obviously mom's belly the uterus that was delivered all sorts on that Shamia showed you the incision. The reason I wanted to show you this in every other case when we do the intubation the head is delivered toward mom's feet because the incision on the uterus is an anterior and it's low. So it's much easier the baby's head comes toward us toward the feet. In this case it was the reverse the head the baby's head is delivered to mom's head and it's actually sitting on the chest. So the way to interpret was a little bit more challenging. I'm going to show you the video that I put together to me. I'm sorry. So these are more imaging. Here is the head is being delivered. I was asked to make some point about what is what methods should be used to to intubate this patient. There are many controversies. A lot of people use endoscope imaging, Lyrengoscope to intubate. For me I think the critical thing is not to make a hard intuition harder by causing bleeding. So I personally prefer to just use the small Lyrengoscope to take a look first just to see what's happening. I usually use a flexible suction soft suction to clear whatever fluid and usually there's a lot of fluid in the mouth just to get a sense of where if I can see the larynx then I use a laryngeal suction which is firmer and I can cause some bleeding with it to suction the airway and then gently into it. With intubation I really think of it as threading the needle. We can't really push hard. Based on those imaging that I showed you for about 37 weeks that trachea has been compressed by teratoma and it becomes very malactic. Those cartilage are not formed. So when this endotracheal tube with the style that goes through it it can easily perforate the trachea which I have done here at this institution. So once the intubate then I'm confirming the location of the endotracheal tube then the baby was delivered. And this is the video that Ali sent me late last night. So you can see the whole process that I told you. This is again the head of the baby is toward mom's head. There's the endotracheal. The larynxal scope is going in and then that's a plastic tube that I told you the suction to clear the main secretion in the oral cavity. You can see the neck mass. I believe it's the chanis hand that is pulling the teratoma away from the airway to help me find localize the larynx. And that's the laryngeal suction I told it's just to get a better sense of the laryngeal inlet and find the clear secretion from the airway so I can really see the vocal cord. These larynx are very, very small. So you just want to be sure in the tracheaal tube with a very small style that I'm sort of trying to thread it as you can see on my finger. And I shouldn't push it because again, it's easily can be perforated trachea. For those of you who remember Dr. Kim from anesthesia, he would tell me on a critical airway, I would wait until the patient wakes up three times before I take the endotracheal tube. For 25 years I heard that from him. I do the same thing here. I check three times, be sure I put it in the right place before the baby comes in. And that voice is always in my head. And I think after that the baby is delivered. I think that's the end of it. Okay, thank you. I just want to mention that the small tube here that you can see is for the amni-infusion during the procedure to maintain the amni-influid inside the uterus. The next thing to be because the uterus, the astronomy, was performed using the GI's typeplers after delivery of the baby. The next step is the removal of the staplers from the myometrium and Dr. Kim. This part is pretty easy in a way off. Because we use the GI's typeplers, you know, definitely very meticulously. We need to go around the uterus, make sure we remove all of those tape where we put the closure uterus. As you can see, we set by step, we trim the edge and then we put the T-clams. And then we did closure uterus in tree layer. With that said, also during the exit as you can see, we did put a probe on the baby part and we monitored it, you know, part of the function for the entire pregnancy. Okay. And now the baby is delivered, transferred to the other room and the pediatric anesthesiology doctor, which is great. Good morning, everyone. My name is Linda Bielich. I think I know most even in the room here today. My part of this is going to be more shifting to the management of the baby after delivery. So as we're learning in a fetus with a large anterior neck mass that both distorts anatomy and potentially compresses the airway structures, the exit procedure is considered the standard approach to secure a safe secure airway needed by providing the airway on placental support and in turn avoid perinatal demise or serious hypoxic injury to the newborn baby. So the exit procedure is characterized by a histurotomy followed by partial delivery of the fetal head and sometimes the upper torso while fetal placental blow is preserved. During the exit, obviously monitoring of the baby is very limited because we only have access to the head and the upper torso. But fetal heart rate is monitored using ultrasound guidance that will confirm fetal well being until the time of complete delivery. So considerable preoperative preparation by a dedicated multidisciplinary team is needed days to weeks prior to the plan day of the intervention. From the pediatric anesthesia standpoint, we must do a thorough review of the maternal, medical and pregnancy history since the mother's health obviously affects the fetal, the baby's health. We do a formal review with the rest of the team of the most recent fetal ultrasound MRI and echo that will give us some idea as to the predicted difficulty with airway management and the fetus's general health. So a recent ultrasound is also important to give us an idea of the estimated fetal weight of the baby, which will be needed down the road for the administration of medications to the baby after delivery. The center location as we learned is extremely important is also determined by ultrasound and it will determine the surgical, uterine incision as well as have the fetal head will present to the ORL team upon delivery. The meeting meetings are also vitally important to discuss strategy. So we all need to be on the same page. If intubation fails, what are the next options for airway intervention? So depending on the size and location of the mass, do we need to do a potentially partial or total resection of the mass? Is the placement of a tracheostomy even an option? And as a last resort, can the baby be placed on ECMO? So getting back to our case. So for any ex procedure, two adjacent operating rooms must be available. One is for the mother and one is for the baby. And an attempt to avoid significant hypothermia after delivery and the newborn, the room temperature and the baby operating room is warmed. And we have a plentiful supply of warm towels to dry the baby once the arrival and the pediatric OR. So thankfully, in this case, Dr. Robara was successfully able to intubate our patient on the first attempt using the store's Lerangascope. The baby was fully delivered and carried immediately into the adjacent operating room. So had intubation proved to be impossible with this exit, the team must have backup plans in place. So in the other room, we're prepared for any situation. So we have different sized masks, LMAs and dethracial tubes by Robtoxcope and Vidioloringa scopes available. The baby OR also equipped with a tracheostomy and bronchoscopy setup with appropriately sized tracheostomy tubes. Our ECMO team was notified and was available if all measures to secure the field airway had failed. In addition, we need to plan for a regular case with anesthetic medications, resuscitation meds, fluids, blood, IVs to the surgical procedure if we indicated. So after arrival into our OR, the correct intitrachial tube position is confirmed with bi-robbed visualization, the presence of entitled CO2, the oscillation of brylateral breast sounds, and an improvement in oxygenation with ventilation. The baby's intitrachial tube always needs to be suctioned many, many times to remove the excess amniotic fluid, which will also improve ventilation for the baby. As with any case, we treat this as a normal anesthetic with the placement of standard ASA monitors, which of course include pulse asymmetry, EKG and non-invasive blood pressure, was able to place a peripheral IV soon after arrival in the OR, and a NICU staff was able to place on billable catheters. Once we were reassured that the intitrachial tube is in the correct place in the trachea, and the baby could oxygenate and ventilate well. We proceeded to a general anesthetic, which included syvoplorane, rockerone, and ventinol. The baby also did require several fluid boluses for a little bit of high-potension after delivery. Prior to transfer up to the NICU, a test x-ray was obtained to document intitrachial tube placement above the carina. Our baby was then transported uneventfully to the NICU, both sedated and paralyzed. This was a huge team effort by multiple services in our hospital. Many of us are standing up here on the podium, and I see a lot of you also in the audience, and I wanted to thank you for making this day. Very calm, collegial, and provide exceptional care to this mother and her baby. Thank you. Thank you so much. I would like to thank two individuals, Dr. Terry Butch, Miller from the pediatric surgery team. Unfortunately, she was not able to be in person here, but I know she's on the Zoom. Thank you so much for all the effort that you've done for this case. And also, Dr. Phil Plyby from the neonatology team. He helped and this case particularly, and also the same for the presentations. And now Dr. Morrison from the neonatology team about the NICU care organization. Thank you. Good morning. I'm Terny Morrison, one of the neonatologists here at Boston Children's. And with the assistance of Philly, the two of us are both present for this exit delivery. So the neonatology role in an exit delivery includes sort of providing an additional layer of continuity for this family who has a fetus, who is undergoing an exit procedure. So this begins early, prenatally during the pregnancy, coordinating with MFM and offering neonatal consultation to the family. And then of course, our presence at the delivery for the exit procedure, really collaborating with the pediatric anesthesia team to ensure that neonatal recetation occurs according to an RP guidelines. And then of course, following admission to our NICU overseeing and helping to coordinate the multidisciplinary care of the infant and then seeing this family and infant through all the way through hospital discharge and beyond. So more specifically regarding our pre-delivery responsibilities, like I had mentioned, Dr. Levy had performed a neonatal consultation with the family in the Boston Children's MFCC. And the role of this was really to discuss what is life like in the NICU. Many families like to know or have us predict as best as we can, sort of the overall duration of their neonatal hospitalization. So we try to provide sort of the best informed prediction of this time frame. Also what the care will look like, what feeding might look like, what respiratory support might look like and how we would intend to wean that respiratory support throughout the hospitalization. The NICU specifically Dr. Levy and I were involved in multiple multidisciplinary pre-planning meetings ahead of the actual exit procedure. Regarding delivery room participation, our role was really initiating and coordinating with pediatric anesthesia neonatal recetation to make sure that everything aligned with our peak guidelines. We provided input in terms of optimizing thermal regulation for the infant as well as assigning APCAR scores following delivery. One of our neonatal nurse practitioners was able to obtain access with a central umbilical VDIS catheter in this particular instance given that the baby was overall quite stable. We did defer placement of a UAC and this was done later in the NICU. Another role for the neonutologist in this case was I was able to DL the airway after Dr. Robar had intubated and after the baby had been stabilized but before transporting the infant from the OR to the NICU just to gain further information about this particular patient's airway anatomy and in this case the airway was a relatively easy view but was shifted or deviated towards the right. We also helped assist with ventilator call management alongside pediatric anesthesia and the respiratory therapy teams and then as is the case in all deliveries once the baby was stable our team provided vitamin K. I am injection as well as a rhythmic and ophthalmic ointment. And I think a really key role was identification ahead of the entire case of a member of our team who was going to be able to communicate with the partner in this case the father of the baby who was in an adjacent care area while the mother was still in the OR and the baby was still being stabilized. And then lastly our team helped to transport this infant safely from the OR up to the NICU and insured a handoff to the accepting physician in the NICU. Thank you. Thank you so much and after the stabilization of the baby in the NICU we had a team of the doctors. For this part I am presenting this on behalf of myself and Terry Bocchumler who is my partner who is directing this. She is out of town attending I believe a board exam for terminal surgery so what I am presenting is behalf of both of us. So as far as the reception of these tumors you know I am not going to get into the technical aspect but just give you more of a global thinking that goes through our head. Obviously as Dr. Morrison mentioned when the baby is delivered at the time of exit and intuitive the question is is the baby safe enough from an airway perspective to postpone the reception or is it critical enough that we may lose the airway during the transfer or in the middle of the night and we may have an issue and whether the reception should be done right after the exit. The ideal situation is to postpone the surgery for at least 24 hours that the baby settled on about doing an exam by all the group in the NICU just to be sure we are not missing anything. Repeat the postnatal MRI which are these MRI just to get a better sense of the tumor location or the vital structure and then do the resection. And as Dr. Morrison said the decision to delay the surgery is surely not should not be based on one individual. We were able to innovate at the time of the delivery but the question is what if the baby and the tracheal tube comes out at 2 o'clock in the morning when the patient is in the NICU. So I usually collaborate and Dr. Morrison came in looked at the airway. I will actually have the fellow who is on call with us take a look at the airway and it will be really an entirely team decision whether this air baby is safe to be transferred to the NICU and stay overnight go to the MRI get the imaging come back 24 hour to do this surgery. So that's what the decision was made. So from a resection obviously anesthesia consideration this is a small baby one day old 37 week one day old that doesn't have much blood to lose. So cardiac status pulmonary status blood volume needs to be considered. We should have a consideration with endocrine evaluation. The end post of these these teratomas come from the thyroid class. So sometimes when we resect them they were we were dealing with hypothyroidism there may be a question of calcium involved. So those things need to be discussed and prepared with the endocrine consult. Airways that has need to be discussed at the time of the resection vocal cord function. I think we have to the my last check if we have about 11 of these teratomas that has been resected here. Majority of those come from the left side. Majority of them lose their vocal cord on the left side because it's impossible to find it. These tumors comes from the thyroid and the recurrent ligand nerve is inherent between the tumor. So when you resect it they're actually resecting the tumor. So vocal cord issue then that we are dealing with feeding status post resection or we dealing with aspiration because of the vocal cord issue and are we thinking about NG2. And also, I'll talk about this as far as I know we have had one case in the past two decades of this teratoma that has been malignant. Majority of them are benign but we have had one malignant case. So that's also need to discuss upfront with the family and think about consultation of the nerve harbor afterwards. So these are this is at the time of the surgery when the patient has come in. This is the incision that you see on the neck. It's an anterior incision that was resected the tumor. And oh these are this. Thank you for putting this together. So that I think that imaging to your left I believe is like maybe one week out with an NG2 and then the imaging on the right with me is actually last week in the clinic this patient came into see me. Now I have to say the vocal cord functions are okay and Terry and I would like to get the credit for that. But it has nothing to do with us. It was an act of God because we really could I could not find a red bottle there but for whatever it's worked. So we were fortunate. Thank you very much and the last step is the pathology report. Yes, thank you. Yes, truly an incredible reception of the tumor. It's a very good size. As you can see. On cut surfaces it's kind of yellowish gray or yellowish white. Mostly solid is most immature dark. It's got to be more solid than cystic. And it has kind of the color of brain. But it has all germs, all layers are represented. Here there's some carvings on top and you know, buccus equating cells and maybe transvaginal squamous epithelium, the stroma settler. A little bit immature. Some immature stroma and strated muscle like cells. And on top you see some settler blue areas which are neuro epithelium. And these often have mitosis like underwrite. And you certain extent you can judge a maturity of a tarotoma by the way all the germ cell layers look. It's all just a fun. It's most easy to look at the neuro epithelium. And in this patient, the amount of neuro epithelium indicated that it was sort of a grade two. May perhaps be a grade two. There was an evidence of yolk sac which is usually the one people worry about in this setting. Thyroid tissue is not identified. Usually in the thyroid or ones, you see thyroid tissue and many sections of the edge. Of course as I mentioned the, it's an exquisite reception, the margins in some areas are close. This is a bit of a thorny issue throughout the decades. How you know, how to grade immature tarotomas. And as I mentioned, the amount of immature neuro epithelium seems to be what's used now. Yeah. So, yeah. Dr. Baskin and Dr. Abar wrote a paper, well, 40 year review of cervical tarotomas. And there were no, no malignant ones. I guess recently there's been one one. And the placenta, there was some evidence of fetal distress. There's some trauma, some trauma into cervical, sorry, the fetal placental veins and some fibrolysis for a broadest sclerosis, and some normal blasts in the fetal blood. Thank you. Thank you so much. And also about the postpartum visit, something that was diagnosed in the placental pathology was some based on my major fibres, suggestive of some low rate of placenta acrita. And because this patient had some risk factors, IVF, dilation extraction and the index pregnancy. And also now, a full thickness, my metrial incision on the posterior side with this based on my mychal fiber and the current pregnancy. It's a very high risk for having the placenta acrita in the future pregnancy. Knowing the fact that the incision was posterior, the future, I think it's going to be very, very complicated, more than a usual anterior acrita. And the patient was consoled about having a very firm contraception and the uDivas placed. That's the end of our case and we're now going to the second case. I think there's only five minutes left. I don't go to the second case, but in reality, again, you know, just want to let, you know, one of the biggest volume that we see is it, you know, complex, one of the coordinate dominated twins. And these three set up the twins that you see is the production of our program, you know, healthy kids in the delivery, mostly at the close to the term. But with that said, I want to get a little bit about the landscape of the fetal centers, you know, if you can see in it, and this is a landscape on 2020 Boston Children's, we just only perform a fetal cardio compared to competitors in a national such as CHOP, you know, Texas Children's Hospital, you know, Cincinnati Children's Hospital that, you know, most of them are very comprehensive fetal centers. With that said, again, I just want to say that from all of these that are, you know, no checkbox, everything's checkbox, the CDH, the degenerative acrimhernia, we do have it approved from FDA to perform the intervention of Boston Children's and our IRBs in the cooking process, therefore, you know, probably in the very near future, we'll start doing the CDH at the Boston Children. But also, you know, I also think about, you know, we need to move to the next level. Unfortunately, Darren is not here to present the end of the gallon, but this is one of the innovation of the fetal center Boston Children. This is the only place that doing under the FDA approval and interestingly, we do have a third case Friday in the Boston Children's OR and this will the first case that we will do it in Boston Children. Also, there's two other studies ongoing. The one is called as a Fluidment Study. This is it regarding the VASOR Previa. This is the only FDA approved study that we got approval from the, you know, FDA. The ORB is pending. We're close to, you know, get approval from IRB and hopefully we can perform through that, you know, IRB, we do have a permission to do 20 cases of these VASOR Previa and this laser applation of those vessels and hopefully not that we can put the conclusion that do we need to do this, you know, surgery as a fetal surgery or not. And the other one is also, you know, some medication, the museum, I do believe in a fetal surgery, not only you need to do intervention, but also you can give some medication. And passing through the mom and one of those medication is serolimos. We do have a study call as a metropans. There's, you know, in process in Boston Children. We've got approval from the North American fetal tripe net working that we call as an AFNET. We discovered the IND and the ORB is pending. We did that said, you know, as you can see, there's lots of lots of people working together. You know, we came along in the past year. There's lots of work. There's tons of support for all the in chiefs from the leadership, from the CEO, you know, Dr. Peter Lawson is almost in Dr. C. Fisherman is almost, you know, incredible support of the program or all of the in chiefs that I'm seeing many of those people here for sure. But it's a growing service. Definitely, you know, on the tree pillar, we do need, in the first pillar of staff, we need more and more staff. Regarding the space, this is the new system. You know, service in Boston Children's, I know the space is, is lucktress here, but definitely we do also need a space for our clinical team. And the third is coming down to the marketing. This is the new service. Definitely we need to have a different type of the marketing strategy to push down to these new customers and get more and more patients, not only from the region, but also from the national and international. With that said, thank you very much everybody. It was incredible. In a case, you wanted to do it. Does enough to, you know, multiple, the same range meetings. And as you can see, it was wonderful outcome at the end. Thank you. So I'm happy to ask any questions. Well, thanks to this entire team and this is the epitome of teamwork. I think we can all see that. I wish we had time to have seen the 22-inch interviews in case there's some incredible videos and I've had the privilege of watching some of these cases. More to come. This is just the first teaser into our field intervention. We only have a couple minutes left. That clock is a little fast. And if they happen to open to questions, there's about 215 people on the Zoom. I'm sorry that my Zoom just cut off. So we're going to limit the questions in one or two minutes to people in the room if there are any. Orbs, wow. I want to just thank all of you. And this is, as Shami said, a small percentage of the people involved in not only this particular case that was used as a demonstra case, but in all these cases, and we've gone from sort of nearly nothing to full speed ahead. And as Shami showed, we are approved and just waiting for the first patient for a mild and singular mild and initial appear field tracheoclusion for diaphragm and a churnia. The vein of gale is already happening. The cardiac procedures are long established. There's lots more coming. I would like to use the last minute to remind people that we will do this twice a year. We'll get a chance for Darren to show his vein of gale in case. And send me an email. If you have cases, we have some great cases lined up probably for October, a skull-based case, an orthopedic oncology case. And we really believe and we know from prior cases, there's already been introductions and interactions that have made from people who have ideas for each other. So please let me know if you have cases you think others can benefit from learning and seeing what you do. Thanks, Tallah.