A multidisciplinary team made up of 34 specialists from Royal Manchester Children’s Hospital (RMCH) and Saint Mary’s Hospital (SMH), part of the Manchester University NHS Foundation Trust, safely performed an Ex Utero Intrapartum Treatment (EXIT) for the third time in the hospitals’ history, with the added challenge of carrying out the surgery during the Coronavirus pandemic.
This rare and complicated procedure is performed when there is a known obstruction of the baby’s airway, meaning that the baby would be unable to breathe when they are born.
For mother, Deborah Kavanagh and father William Deaville from Stoke, this became apparent at Deborah’s 20 week scan at Royal Stoke University Hospital, which showed that there was a large lump in the baby’s neck. Deborah was then referred to the Fetal Medicine Unit at SMH who were able to provide specialist care from highly experienced consultants and midwives for the remainder of her pregnancy.
The large teratoma, a rare type of tumour in Kayleigh’s neck was pressing on the gullet (food pipe) causing increased fluid in the womb. During delivery the lump in the neck would block the airway, so an EXIT procedure was vital to ensure survival.
In order to prepare for a safe delivery, scenario training was carried out by the specialist team to map out the complex, life-saving surgery. The training session took place on 17th April, with a view to perform a planned caesarean section on Monday, April 20th. However, just the following day (Saturday, April 18th), Deborah’s waters broke and the team of professionals from across both hospitals were mobilised to deliver baby Kayleigh and carry out the surgery.
The multidisciplinary team from across both hospitals was made up of Ear Nose and Throat (ENT) surgeons, neonatologists, obstetricians, midwives, obstetric and paediatric anaesthetists and theatre teams.
Additional time was required for the anaesthetic for Deborah, and the baby had to be turned from breech (bottom down) to be head first. Kayleigh was delivered by caesarean section, but only partly up to the top of her shoulders, which allowed the theatre team to then begin the complex procedure on the baby’s neck. Skilled ENT surgeons were able to secure the airway, whilst the placenta (afterbirth) from Deborah continued to provide Kayleigh with oxygen whilst she was still partly in the womb.
Jaya Nichani Consultant Paediatric ENT Surgeon at RMCH said: “The time critical operation whilst Kayleigh’s airway was secured tested everyone’s resilience and the safe delivery is a real credit to the team effort. The whole procedure was more challenging by the need to wear full Personal Protective Equipment (PPE) throughout the operation. The entire team did an outstanding job and the safety of the mother and baby was a priority throughout.”
Once Kayleigh was delivered and her airway safely secured, she was then fitted with a tracheostomy, which is an opening created in the front of the neck so a tube could be inserted into the windpipe (trachea) to help her breathe. Following this, she was transferred to the Neonatal Intensive Care Unit (NICU) at SMH for further round-the-clock care.
Ajit Mahaveer, Consultant Neonatologist at Saint Mary’s Hospital said: “Even though Kayleigh made an early appearance, we were all prepared and were at the delivery to ensure she had the best start possible. She spent nine weeks on NICU, where at times it was a real challenge to keep her stable, especially before she had her operation. It was apparent from the start was that Kayleigh was a little fighter and coped well with all the procedures she had to go through. We were really pleased to have contributed to her successful outcome.”
Ten days after the delivery, further surgery took place to remove more of the teratoma which was blocking Kayleigh’s airway.
Neil Bateman Consultant Paediatric ENT Surgeon at RMCH, who was part of the team involved with the follow up surgery said: “Kayleigh weighed 1.3kg (with the teratoma) and the resection surgery to remove more of the lump which was blocking her airway was undoubtedly one of the most challenging operations I have been involved with in my career. The success of this surgery was a real team effort and a skilled anaesthetic team kept Kayleigh alive with the support of the entire team.”
Catherine Doherty, Consultant Paediatric Anaesthetist said: “The resection of the teratoma was extremely challenging as Kayleigh required a massive blood transfusion and suffered a cardiac arrest during surgery. Thankfully Kayleigh responded well to resuscitation and blood replacement which really highlights how resilient baby Kayleigh was.”
Following this surgery, Kayleigh’s airway improved considerably and she was transferred to their local hospital in Stoke.
Parents Deborah and William said; “Kayleigh is doing really well and we finally got to take her home to meet her excited big sister on June 25th who greeted her with lots of kisses!
“All the staff at SMH and RMCH were fantastic, right from the very beginning, to the very end. The team involved with the EXIT were brilliant, all doing their bit to get Kayleigh out safely. The ENT surgeons were excellent with their positive attitude that kept us going during pregnancy, to the successful EXIT and the operation to remove most of the teratoma.
“All the nurses and midwives that looked after us during pregnancy, in NICU and High Dependency Unit were exceptional and the care was fantastic all the way through. Doctors were caring, sensitive and very good to answer our questions. We were treated brilliantly, even with the added challenge of Coronavirus.
“To all amazing staff who got us through our time in Manchester, we wish we could personally shake every single person’s hand and thank them all.”
During Kayleigh’s nine-week stay at MFT, round-the-clock care was provided by specialist teams on the Newborn Intensive Care Unit at SMH with the ENT team at RMCH checking on Kayleigh every day.
Dr Samangaya, Consultant in Obstetrics and Fetal and Maternal Medicine at Saint Mary’s Hospital who led the team said; “Despite being in the midst of the Coronavirus pandemic in very busy Hospitals at MFT, we were able to meticulously plan this procedure to ensure the safe delivery of baby Kayleigh.
“It has been a real team effort and many staff members rushed in from home on their day off. I am so proud of everyone involved.
“This is the third time an EXIT procedure has been performed in Manchester, and every member of staff was committed to ensuring that mother and baby were safe throughout.”
Kayleigh is due to return to the Hospital for further surgery later this year to remove the rest of the teratoma and excess skin from the first operation. From then Kayleigh will have regular check-ups to monitor her health and progress.
Banner photo: (L-R) Maryam Bibi Staff Nurse SMH, Ajit Mahaveer Consultant Neonatologist SMH, Rebekah Samangaya Consultant in Obstetrics and Fetal and Maternal Medicine SMH, Lucy Hartley Consultant Paediatric Anaesthetist RMCH, Neil Bateman Consultant Paediatric ENT Surgeon RMCH and Yvonne Francis Theatre Sister RMCH.