Maternal-Fetal Specialists Use Novel Surgery to Resolve Congenital High Airway Obstruction Syndrome
The Orlando Health Women’s Fetal Care Center recently completed one of the region’s first multidisciplinary, open fetal surgical procedures to treat congenital high airway obstruction syndrome (CHAOS). Skilled experts performed delicate specialized tracheal surgery in conjunction with a novel ex utero intrapartum treatment (EXIT) delivery to successfully address this rare condition.
“CHAOS occurs early in fetal life when a membrane blocks the developing trachea,” says Emanuel (Mike) Vlastos, MD, director of Orlando Health Women’s Fetal Care Center and chief of Orlando Health Winnie Palmer Maternal-Fetal Medicine. Dr. Vlastos is a board-certified, maternal-fetal medicine physician internationally recognized for his skill diagnosing and treating fetal anomalies and performing fetal surgical procedures.
The fate of CHAOS fetuses is generally very poor, with approximately 40% dying in utero. “Although a fetus does not breathe in the womb, the trachea needs to be open to allow the normal lung secretions produced in utero to leave the lungs,” says Dr. Vlastos. “With CHAOS, these secretions accumulate in the lungs, resulting in fetal hydrops.”
In Summer 2025, a patient was referred to the Orlando Health team at 22 weeks of pregnancy with CHAOS and developing fetal hydrops. A small endoscope placed into the amniotic fluid and through the fetal mouth displayed a 5 mm obstruction just below the vocal cords. A laser fiber advanced and energized could not penetrate the obstruction.
The fetal care center convened a multidisciplinary group to discuss an innovative potential therapy exposing only the fetal head and shoulders with the surgical placement of a transcutaneous catheter into the trachea below the occlusion, allowing fluid to escape the lungs prior to delivery.
Physicians at the Orlando Health Women’s Fetal Care Center have performed more than 60 cases of open fetal surgery. Additionally, the center is among only a few with the expertise to perform an EXIT delivery. “An EXIT delivery allows up to an hour for the trachea to be opened, stabilized and the fetus assisted to breathe,” says Dr. Vlastos.
Following approval by the Orlando Health Ethics Committee, the innovative procedure was performed successfully at 25 weeks of pregnancy. “Over the next four weeks the hydrops resolved, the fetal lungs became smaller,” says Dr. Vlastos. “At 31 weeks, the mother went into premature labor. We performed an EXIT delivery, found that the baby’s airway was assured and then the baby was taken to the NICU with a tracheostomy tube in place.”
The baby later underwent two further staged operations to remove obstructive tissue and open the tracheal obstruction while minimizing risks to the vocal cords and surrounding tissues. The baby was expected to be discharged in mid-December.
