Surgical procedure saves baby’s life at birth

MADISON, Wis. – It began when Andy and Ashley Manderle of Waupun were referred to the Center for Perinatal Care at UnityPoint Health – Meriter by their OB-GYN at UW Health due to abnormalities on Ashley’s 16-week ultrasound.

The abnormality turned out to be a mass that would block the baby’s airway as soon as she was born, so on Feb. 1, 2023, the UW Health Fetal Diagnosis and Treatment Center team performed a surgery to save the life of the Manderles' baby.

The surgery is called ex-utero intrapartum treatment, or EXIT, which enables the team to partially deliver the baby via cesarean and establish a safe airway before completing the cesarean delivery.

They delivered the head, neck, one arm and the 17-centimeter tumor blocking the baby’s airway while Ashley was under anesthesia. They had 30 minutes to establish an airway around the tumor while keeping the rest of the baby supported by her mom via the placenta, which provides oxygen and blood flow. After 30 minutes placental support would run out and the baby would need to be fully delivered. The expert team completed the procedure in just 12 minutes.

“I was scared, but everything I did in my pregnancy was to take care of Layla, so I just trusted the amazing doctors,” Ashley said.

Between the 16-week ultrasound and the surgery, the UW Health Fetal Diagnosis and Treatment Center provided extensive tracking and imaging that enabled the doctors and the Manderles to see and understand what was going on inside Ashley’s womb. A three-dimensional model was created from Layla’s fetal MRI to help doctors plan for the surgery and counsel the Manderles, according to Dr. Inna Lobeck, pediatric and fetal surgeon, and director of the UW Health Fetal Diagnosis and Treatment Center. The fetal MRI and surgery took place at American Family Children’s Hospital.

“Our fetal diagnosis and treatment team met Ashley at 20 weeks, and we developed a game plan with experts from maternal-fetal medicine, ear, nose and throat, plastic surgery and neonatal intensive care,” Lobeck said. “The tumor was growing quickly and was by far the largest one we’ve seen at our center.”

The hope was to get Ashley to 37 weeks before the EXIT, but the safest timing for Ashley and Layla was ultimately 33 weeks due to Ashley’s previous history of delivering prematurely, Lobeck said.

An EXIT procedure is performed when a baby has a high risk for cardiorespiratory complications or death at delivery because of airway obstruction, according to Lobeck.

“Had she been born without an EXIT, she would have gone 12 minutes without breathing, which would have resulted in death or severe brain injury,” said Lobeck, who is also an assistant professor of surgery at the University of Wisconsin School of Medicine and Public Health.

Four days after Layla Manderle was born, the team at the center removed the tumor completely and Layla began her road to recovery in the neonatal intensive care unit.

Layla’s tumor was called a teratoma, which is a solid mass, and a very rare anomaly that can develop in pregnancy. It is usually benign, which means it is not cancerous, Lobeck said.

As expected, tests confirmed the tumor was not cancerous. Layla stayed at the NICU for 2½ months due to her prematurity and tumor removal but is doing very well now, according to Lobeck.

Layla was Ashley’s seventh baby and by far the most challenging pregnancy, Ashley said.

“With my other children I had gone into labor early, but they were all natural deliveries and did not have the complications we did with Layla, so I was nervous,” Ashley said. “But I knew the doctors were going to save my baby.”

The surgical team knew the Manderles planned to name the baby Layla, so they played the song “Layla” by Derek and the Dominos as Ashley was wheeled into the operating room to put her at ease, she said.

More than 40 doctors and nurses were in the operating room at American Family Children’s Hospital including Dr. Michael Beninati, maternal-fetal medicine and critical care physician, UW Health Kids, and Dr. Michael Puricelli, pediatric ear, nose and throat specialist, UW Health Kids, who worked with Lobeck to establish the airway.

“These families put so much trust in us and it is an honor to help them go home with healthy babies,” Lobeck said.

“We live an hour away so we can’t imagine if we had to go out of state for care,” Ashley said. “We are so grateful the doctors helped us have a healthy baby girl.”

The UW Health Fetal Diagnosis and Treatment Center is a collaboration between UW Health and UnityPoint Health – Meriter to treat pregnant patients and their unborn babies who have birth defects before, during and after birth.

The center started seeing patients in March 2022 and includes a team of pediatric and fetal specialists, high-risk obstetricians and genetic counselors who evaluate, diagnose and perform fetal intervention when warranted, plus delivery and care after birth. The center also includes social workers and coordinators who support families’ needs throughout their care journey and beyond.

This was the third EXIT procedure done at the center. The first EXIT procedure was done in the late 1990s, so it is a relatively new treatment but offers families hope, according to Lobeck.

“Our center is on the cutting edge of the latest treatments and technology that we can use to save babies and it is a privilege to take care of these families,” she said. “Layla is a healthy baby girl and without this procedure, the outcome could have had a very different.”