Reproductive outcomes in subsequent pregnancies after a pregnancy complicated by open maternal-fetal surgery (1996-2007)

OBJECTIVE

The reproductive and gynecologic outcomes for women after the pregnancy complicated by open maternal-fetal surgery (OMFS) were evaluated.

STUDY DESIGN

The retrospective review identified 93 women with OMFS from a single institution (1996-2007). Consent and questionnaires were sent to women. Institutional review board approval was obtained from the Committee for Protection of Human Subjects.

RESULTS

The total return rate was 57.3%. Total pregnancies reported were 47, with 36 delivering after 20 weeks' gestation. The uterine dehiscence and rupture rates were 14% and 14%, respectively. Fetal anomalies occurred in 4 subsequent pregnancies. Normal conception occurred in 98% of subsequent pregnancies. Gynecologic issues were reported by 8 women, with infertility, abdominal pain, and ovarian and uterine factors.

CONCLUSION

The reproductive outcomes of uterine dehiscence (14%) and rupture (14%) in a subsequent pregnancy continue to be a major counseling issue for OMFS. Fertility and gynecologic factors do not appear to be increased for women undergoing OMFS.

Neurodevelopmental outcome of infants with congenital diaphragmatic hernia prospectively enrolled in an interdisciplinary follow-up program

PURPOSE

The purpose of the study was to evaluate the neurodevelopmental outcome in infants with congenital diaphragmatic hernia (CDH).

METHODS

Between June 2004 and September 2007, 41 CDH survivors were prospectively enrolled in an interdisciplinary follow-up program. Neurodevelopmental status was evaluated using the Bayley Scales of Infant Development II (prior 2006, n = 9), the Bayley Scales of Infant Development III (after 2006, n = 27), or the Wechsler Preschool and Primary Scale of Intelligence III (children older than 4 years, n = 5). Scores were grouped as average, mildly delayed, and severely delayed by standard deviation intervals (115-85, 71-84, <70), and mixed if average and mildly delayed in either cognitive or language.

RESULTS

Median age at last assessment was 24 months (range, 6-62). Average, mixed, mildly delayed, and severely delayed scores for neurocognitive and language skills were found in 49%, 19%, 17%, and 15%, respectively. Psychomotor scores were normal, mildly delayed, and severely delayed in 46%, 23%, and 31%, respectively. Autism was present in 7%. Abnormal muscle tonicity was found in 51% (49% hypotonic, 2% hypertonic). Multivariate risk factors for borderline or delayed neurodevelopmental, neurocognitive, and/or psychomotor outcome were intrathoracic liver position (P = .02), presence of a right-sided CDH (P = .02), extracorporeal membrane oxygenation need (P < .001), Gore-Tex patch repair (P = .02), O(2) requirement at 30 days of life (P < .01), and hypotonicity (P < .01).

CONCLUSIONS

The prospective evaluation in an interdisciplinary follow-up program uncovered striking morbidities in neurodevelopmental status in approximately half of the CDH infants. The most common neurologic sequelae are neuromuscular hypotonicity and psychomotor dysfunction. Patient-specific factors are important determinants of adverse neurologic outcome.

Predicting the severity of congenital high airway obstruction syndrome

BACKGROUND

Congenital high airway obstruction syndrome (CHAOS) is caused by complete or near-complete obstruction of the fetal airway. Obstruction sets in motion a sequence of events that can ultimately lead to fetal demise. However, on rare occasions in utero airway decompression occurs, reversing syndromic findings and improving the prognosis. In our relatively large series of CHAOS patients, we have observed a spectrum of clinical severity. The aim of this study was to identify the prenatal characteristics of CHAOS predictive of a milder postnatal course.

METHODS

The medical charts of all fetuses observed at our institution with the diagnosis of CHAOS were reviewed for radiologic findings, delivery information, perinatal course, autopsy or discharge report, and long-term follow-up.

RESULTS

Between 1996 and 2008, 12 fetuses with CHAOS were identified. Four fetuses had no evidence of hydrops on initial imaging. Of the 8 fetuses displaying hydrops, 3 were terminated, 2 died in utero, and 1 with multiple anomalies died at birth. Six fetuses were delivered via the ex utero intrapartum therapy procedure for attempted salvage, and 5 of the 6 survived the neonatal period including all 4 fetuses without hydrops. Serial prenatal imaging demonstrated less severe signs of CHAOS in 3 fetuses, and in 2 of them, direct laryngoscopy revealed a tiny opening in the airway. All 3 fetuses that showed improvement on serial imaging survived the neonatal period and were discharged home by 2-10 weeks of age.

CONCLUSIONS

Although the natural history of CHAOS is variable, trends in prenatal ultrasound findings are highly predictive of postnatal outcome and are a valuable guide to prenatal counseling.

Prospective, interdisciplinary follow-up of children with prenatally diagnosed giant omphalocele: short-term neurodevelopmental outcome

PURPOSE

The objective of this study is to determine the short-term neurodevelopmental outcome in infants with giant omphalocele (GO).

MATERIALS AND METHODS

Between January 2002 and December 2007, 31 consecutive infants with GO received prenatal and postnatal care at our institution. Overall survival was 81% (25/31). Twenty (80%) of the survivors were enrolled in a prospective interdisciplinary follow-up program. Fifteen were at least 6 months of age and received detailed neurodevelopmental evaluation using the Bayley Scales of Infant Development II (BSID-II [before 2006, n = 3]) or BSID-III (after 2006, n = 12). Scores were grouped as average, mildly delayed, and severely delayed by SD intervals (115-85, 71-84, <70). Scores were considered mixed if cognitive or language skills were in different ranges.

RESULTS

Median age at evaluation was 12 months (range, 6-26 months). Average, mildly delayed, and severely delayed scores for cognitive and language skills were found in 6 (40%), 2 (13%), and 6 (40%), respectively. One child had mixed scores (severely delayed for cognitive and mildly delayed for language skills). Motor scores were normal, mildly delayed, and severely delayed in 6 (40%), 2 (13%), and 7 (47%), respectively. The neuromuscular examination was abnormal in 8 patients (62%). Five (33%) scored within the average range, whereas 6 (40%) demonstrated severe delays for cognitive, language, and motor outcome. Of the 6 children with severe delays, 2 (13% of total) have autism, 4 required tracheostomy, and 1 was diagnosed with Williams syndrome.

CONCLUSIONS

The presence of GO is associated with deficits in developmental achievements in most of the affected infants ranging from mild to profound delays. These findings underscore the importance of early and standardized neurodevelopmental evaluation throughout childhood for all survivors with GO. Larger studies are warranted for risk factor stratification.

Management of prenatally diagnosed congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a congenital anomaly that presents with a broad spectrum of severity dependent upon components of pulmonary hypoplasia and pulmonary hypertension. While advances in neonatal care have improved the overall survival of CDH in experienced centers, mortality and morbidity remain high in a subset of CDH infants with severe CDH. The most important prenatal predictor of outcome in left-sided CDH is liver position. More precise and reproducible prenatal predictive parameters need to be developed to allow standardization of results between centers and appropriate design of clinical trials in CDH. Thus far, all randomized trials comparing prenatal intervention to standard postnatal therapy have shown no benefit to prenatal intervention. Although recent non-randomized reports of success with balloon tracheal occlusion (and release) are promising, prenatal therapy should not be widely adopted until a well-designed prospective randomized trial demonstrating efficacy is performed. The increased survival and subsequent morbidity of CDH survivors has resulted in the need to provide resources for the long-term follow-up and support of the CDH population.

Effect of preextracorporeal membrane oxygenation ventilation days and age on extracorporeal membrane oxygenation survival in critically ill children

PURPOSE

The aim of the study is to test the effect of age and preextracorporeal membrane oxygenation (pre-ECMO) days of ventilation on ECMO survival in the pediatric population.

METHODS

Retrospective analysis of noncardiac, pediatric (age >30 days) ECMO patients for the period January 1984 to June 2006. Pre-ECMO demographic, ventilatory, and lung injury severity variables were modeled with stepwise logistic regression to estimate survival probabilities associated with pre-ECMO ventilation duration and patient age. Patients were excluded from review for the following: pre-ECMO cardiac arrest, pre-ECMO ventilation of more than 30 days (chronic), or multiple runs on ECMO.

RESULTS

For the period of review, 2550 patients met inclusion/exclusion criteria. The population had a mean age of 3.6 +/- 5.1 years (median age, 1 year). The mean pre-ECMO days of ventilation were 5.2 +/- 4.9 (median, 4 days). The overall survival probability was 58.6%. The mean oxygen index and Pao(2)/Fio(2) ratio were 62.2 +/- 48.2 and 95.5 +/- 48.2, respectively. The population overall demonstrated a statistically significant, exponential decline in survival as pre-ECMO days of ventilation increased (P < .05). For each additional year of age, survival decreased by an average of 2.5%. For each additional day of pre-ECMO ventilation, survival decreased by an average of 2.9%. Younger ages were generally associated with higher survival probabilities at each ventilation day.

CONCLUSIONS

In the pediatric population, survival decreases significantly as pre-ECMO ventilator days increase. Survival is also inversely related to patient age. Thus, patient age and duration of ventilation should be considered when evaluating suitability for ECMO.

Postnatal management and long-term outcome for survivors with congenital diaphragmatic hernia

Significant advances in the postnatal management of patients with congenital diaphragmatic hernia (CDH) have resulted in a remarkable improvement in survival rates over the past two decades. The success of current postnatal management of CDH patients has rendered fetal intervention to be limited to the most severe cases, and the role for prenatal treatment of CDH patients remains unclear. The adoption of lung-preserving strategies including high-frequency oscillatory ventilation (HFOV) and extracorporeal membrane oxygenation (ECMO) have improved CDH outcomes especially in those patients with significant ventilatory or circulatory compromise. Survival rates of up to 90% are being reported in some high-volume centers. However, the increased survival in CDH patients has been accompanied by an increase in neurological, nutritional and musculoskeletal morbidity among the long-term survivors. This has resulted in the need to provide resources for the long-term follow-up and support of this patient population. In this article, the postnatal management strategies and primary and secondary outcomes of high-volume international pediatric surgical centers will be reviewed. Finally, the role of a multidisciplinary management team for the follow-up of long-term CDH survivors will be discussed.

Congenital high airway obstruction syndrome: MR/US findings, effect on management, and outcome

BACKGROUND

Congenital high airway obstruction syndrome (CHAOS) is a rare disorder defined as any fetal abnormality that obstructs the larynx or trachea. Prompt airway intervention at delivery after accurate prenatal diagnosis may allow survival of this otherwise fatal condition.

OBJECTIVE

To identify prenatal MRI findings in CHAOS, to compare these findings with those of fetal US, to determine if imaging alters diagnosis and management decisions, and to correlate prenatal with postnatal imaging findings.

MATERIALS AND METHODS

Records and MRI scans of ten fetuses with CHAOS were reviewed, and the findings correlated with outside and same-day fetal US and postnatal imaging findings. Fetal lung volumes were measured on MRI scans.

RESULTS

Large lung volumes were found in 90% of the fetuses. Increased lung signal intensity, inverted diaphragm, and a dilated, fluid-filled lower airway were identified in all. The obstruction level was identified in 90%. MRI changed screening US diagnosis in 70%, but was concordant with the tertiary care US imaging in 90%. Seven fetuses were terminated or died in utero, and three fetuses survived after ex utero intrapartum tracheostomy placement. Autopsy or bronchoscopy performed in 60% confirmed CHAOS. Postnatal chest radiographs and CT showed hyperinflation, while US and fluoroscopy showed diminished diaphragmatic motion.

CONCLUSION

MRI demonstrates large lung volumes, increased lung signal intensity, inverted diaphragm, and dilated fluid-filled lower airway, and usually identifies the obstruction level. The degree of correlation between MRI and tertiary prenatal US is high, but CHAOS is frequently misdiagnosed on screening US. Correct diagnosis may enable planned airway management. Voluminous lungs and diaphragmatic abnormalities persist on postnatal imaging.

Fetal tracheal occlusion for severe congenital diaphragmatic hernia in humans: a morphometric study of lung parenchyma and muscularization of pulmonary arterioles

OBJECTIVE

The aim of this study is to examine structure of lung parenchyma (Pp) and muscularization of pulmonary arterioles (PAs) in human fetuses that underwent tracheal occlusion (TO) therapy for severe congenital diaphragmatic hernia (CDH).

MATERIAL

Fifteen fetuses underwent TO, with 5 survivors (Am J Obstet Gynecol. 2000:183;1059-1066). Paraffin-embedded lung specimens from 7 of 10 nonsurvivors (CDH-TO) and 6 age-matched fetuses (CDH) were available for morphometric analysis, which included measurements of point fraction of lung Pp and surface density. The PAs were categorized according to external diameter (<70 microm and 70 <or= 140 microm). Percent medial wall thickness (%MWT) was calculated by dividing raw measurements of MWT by external diameter.

RESULTS

Gestational age at TO was 27.6 +/- 0.9 weeks with a mean duration of TO of 32.6 +/- 6.8 days. Gestational age at delivery (CDH-TO 31.9 +/- 0.9 vs CDH 35.4 +/- 1.8 weeks; P = .18) and postnatal survival time (CDH-TO 20.5 +/- 6.0 vs CDH 18.6 +/- 7.8 days; P = .85) were not significantly different between groups. Tracheal occlusion significantly increased the lung-to-body weight ratio (CDH-TO 13.0 +/- 2.2 vs CDH 6.6 +/- 0.9; P = .02). Tracheal occlusion tended to decrease right-lung Pp (CDH-TO 54.6% +/- 2.6% vs CDH 65.7% +/- 5.9%; P = .05), whereas left-lung Pp was not different between groups (CDH-TO 63.0% +/- 3.5% vs CDH 66.7% +/- 4.1%; P = .51). Surface density of airspaces was not different between groups in either left (CDH-TO 171.3 +/- 16.1 cm(-1) vs CDH 151.1 +/- 8.1 cm(-1); P = .34) or right (CDH-TO 172.0 +/- 10.6 cm(-1) vs CDH 160.8 +/- 3.6 cm(-1); P = .33) lungs. The %MWT in small and large PA was similar between groups.

CONCLUSIONS

Open prenatal TO in human fetuses increased lung growth, as evidenced by an increase in lung weight, but did not improve parenchymal structure or muscularization of PAs.

Abnormalities of intestinal rotation in patients with congenital heart disease and the heterotaxy syndrome

OBJECTIVE

Abnormalities of intestinal rotation (AIR) are seen in association with congenital heart disease and heterotaxy syndrome. The prevalence of these abnormalities and recommendations for management are unclear. Our objective was to determine the prevalence of screening for AIR by elective imaging among our group and prophylactic vs. emergent surgical intervention for AIR in patients with congenital heart disease and heterotaxy syndrome.

METHODS

From October 1988 through October 2000, we identified 74 patients with congenital heart disease and heterotaxy syndrome, 44 (59%) asplenia, 30 (41%) polysplenia. Abdominal imaging was performed in 34 patients (45%). Twenty-four (32%) were found to have AIR. Of 34 patients imaged, 22 (65%) were found to have AIR. Two patients not imaged were found to have AIR: one at autopsy, and the other, incidentally during other abdominal surgery. Because imaging was performed based on individual cardiologist's practice style that did not change over the period of the study and rarely secondary to symptoms, it is likely that the prevalence of AIR in the patients that were not electively imaged would be similar.

RESULTS

There was no statistical difference in the presence of AIR between asplenic (34%[15/44]) and polysplenic (30%[9/30]) patients. Of the 22 patients imaged with AIR, 18 underwent Ladd procedure. Five of 12 imaged patients without AIR were found to have other significant gastrointestinal pathologies requiring intervention including gastrostomy tube placement for reflux (3), duodenal web (1), and biliary atresia (1). Of the 40 patients who were not pre-emptively imaged, none suffered acute obstruction solely secondary to AIR. However, in 2 patients intestinal obstruction was suspected and subsequently discovered by imaging and/or laparotomy due to other intestinal anomalies.

CONCLUSIONS

AIR is common among patients with heterotaxy syndrome and congenital heart disease. We recommend that patients with congenital heart disease and heterotaxy syndrome have routine elective abdominal imaging of their gastrointestinal tract at birth as part of their evaluation.

Prenatal ultrasonographic gastrointestinal abnormalities in fetuses with gastroschisis do not correlate with postnatal outcomes

PURPOSE

In the setting of gastroschisis, the clinical significance of prenatal ultrasound findings of secondary changes in bowel appearance remains unknown. The purpose of this study was to correlate prenatal identification of additional gastrointestinal sonographic abnormalities with postnatal clinical outcome.

METHODS

A retrospective review was conducted on 64 fetuses with a prenatal diagnosis of gastroschisis treated at the Children's Hospital of Philadelphia from 2000 to 2007. Postnatal outcomes were compared between newborns with additional sonographic gastrointestinal abnormalities and those without secondary changes to the bowel appearance.

RESULTS

Thirty (47%) patients had at least one gastrointestinal abnormality (eg, bowel dilatation, echogenic bowel, thickened bowel, matted bowel, herniation of the stomach through the abdominal wall defect, or segmental loss of bowel peristalsis) on prenatal ultrasound. There were no significant differences between groups with respect to the time to initial and full enteral nutrition, total hospital stay, requirement for ventilator support, central line infection rates, reoperation rates, or mortality.

CONCLUSIONS

In the setting of gastroschisis, isolated findings of gastrointestinal abnormalities on prenatal ultrasound do not correlate with adverse postnatal outcome.

Outcomes after postnatal resection of prenatally diagnosed asymptomatic cystic lung lesions

BACKGROUND

Symptomatic congenital lung lesions require surgical resection, but the management of asymptomatic lung lesions is controversial. Some surgeons advocate observation because of concerns about potential operative morbidity and mortality, as well as a lack of long-term follow-up information. On the other hand, malignant degeneration, pneumonia, and pneumothorax are known consequences of cystic lung lesions. This study aims to assess the safety of resection for asymptomatic lung lesions that were diagnosed before birth.

METHODS

A retrospective review of all patients with prenatally diagnosed lung lesions at Children's Hospital of Philadelphia (Philadelphia, Penn) was performed from 1996 to 2005. The perioperative course of patients who were asymptomatic was analyzed.

RESULTS

One hundred five complete records of children with asymptomatic lesions were reviewed. Overall mortality was 0% and morbidity was 6.7% including 2.9% significant postoperative air leak and 3.8% transfusion requirement. Nine patients had a pathologic diagnosis that differed from preoperative radiological findings, and 9 patients had additional pathologic findings.

CONCLUSION

This series demonstrates that surgery can be performed safely on patients who were asymptomatic with congenital cystic adenomatoid malformation of the lung and other types of lung lesions with no mortality and minimal morbidity. The frequency of disparate pathologic diagnoses and the potential for development of malignancy and other complications support the argument for early resection.

Pregnancy outcomes following bipolar umbilical cord cauterization for selective termination in complicated monochorionic multiple gestations

OBJECTIVE

To review pregnancy and childhood outcomes following selective termination by ultrasound guided bipolar umbilical cord cauterization (UCC) in complicated monochorionic multifetal pregnancies.

STUDY DESIGN

Consenting patients (27 of 49, 55%) had review of pregnancy history and pediatric development in the surviving twin following selective UCC.

RESULTS

UCC was performed at 21.2 +/- 2.8 weeks gestational age, followed by a liveborn delivery (n = 28) at 34.4 +/- 4.7 weeks. Mean birth weight was 2,218 +/- 926 g. Complications included preterm labor (25.0%), premature rupture of membranes (17.8%), placental abruption (10.7%) and chorioamnionitis (7.1%). Perinatal mortality was 10.3% in continuing fetuses. However, 96.2% of pregnancies achieved livebirths with 96% of neonates showing apparently normal development between ages 1.5 and 5 years.

CONCLUSION

Bipolar UCC is a reasonably safe and effective treatment for selective termination in complicated monochorionic pregnancies.

Liver position and lung-to-head ratio for prediction of extracorporeal membrane oxygenation and survival in isolated left congenital diaphragmatic hernia

OBJECTIVE

The purpose of this study was to determine the ability of liver position and lung-to-head ratio to predict outcome in isolated left congenital diaphragmatic hernia.

STUDY DESIGN

We reviewed prenatal studies and postnatal outcomes of congenital diaphragmatic hernia between January 1996 and January 2006.

RESULTS

Eighty-nine patients received prenatal and postnatal care at 1 institution. In fetuses with liver up, extracorporeal membrane oxygenation was required in 39 of 49 fetuses (80%), compared with 10 of 40 fetuses (25%) for those with liver down (P < .0001). Overall survival rate was 45%, compared with 93% for those with liver down (P < .00005). Low lung-to-head ratio (<1.0) predicted increased incidence of extracorporeal membrane oxygenation (75%; P = .036) and lower survival (35%; P = .0003). However, when measured at <24 weeks of gestation, lung-to-head ratio was not predictive of outcome (extracorporeal membrane oxygenation, P = .108; survival, P = .150); liver position remained highly predictive (extracorporeal membrane oxygenation, P = .006; survival, P = .001).

CONCLUSION

Liver position is the best prenatal predictor of outcome in isolated left congenital diaphragmatic hernia. Lung-to-head ratio alone should not be used to counsel families regarding mid gestational management choices.

Pulmonary arteriole muscularization in lambs with diaphragmatic hernia after combined tracheal occlusion/glucocorticoid therapy

OBJECTIVE

A morphometric study was performed to examine the effects of prenatal glucocorticoids, which were administered 48 hours before birth, on muscularization of small pulmonary arterioles (<60 microm diameter) in lambs with diaphragmatic hernia (DH) after fetal tracheal occlusion (TO).

STUDY DESIGN

DH was created in 23 fetal sheep at 65 days gestation. TO was performed in 16 of 24 fetuses between 110 and 140 days of gestation; 9 of the fetuses were exposed prenatally to betamethasone (0.5 mg/kg body weight) 48 hours before delivery. Six sham-operated animals served as controls. Sections of paraffin that were embedded in lung tissues were stained with Elastin-Van Gieson, and the percentage of medial wall thickness (MWT) was determined.

RESULTS

The percentage of MWT in DH lambs (29.6% +/- 1.9%) was increased compared with sham animals (18.1% +/- 1.3%) and was not different from that of DH/TO animals (30.3% +/- 1.7%). In DH/TO + glucocorticoid lambs, the percentage of MWT (24.6% +/- 1.2%) was significantly lower than in the DH/TO group but was higher than the sham group.

CONCLUSION

In fetuses who underwent prolonged TO therapy for severe DH, prenatal glucocorticoid treatment decreased medial hypertrophy of pulmonary arterioles by approximately 19%. We speculate that such structural changes may have contributed to improve gas exchange that was observed in this model.

Prenatally diagnosed fetal lung lesions with associated conotruncal heart defects: Is there a genetic association?

Congenital lung malformation can easily be diagnosed by prenatal ultrasound. Associated extrapulmonary malformations such as heart defects and chromosomal aberrations are rare.

OBJECTIVE

The objective of this study was to describe the natural history, outcome and other associated malformations in fetuses with lung lesions and an associated heart defect.

METHODS

Retrospective analysis of 4 cases of prenatally diagnosed fetal CCAMs and hybrid lesions with an associated heart defect and review of 8 cases in the literature.

RESULTS

At a single referral center 1.9% of the fetuses with Congenital cystic adenomatoid malformation (CCAM) were diagnosed with an associated heart defect. Seven of the total 12 cases (58%) reviewed had a conotruncal heart abnormality. Chromosomal abnormalities were found in 5 (42%) of the cases.

CONCLUSION

This retrospective review shows that karyotyping in fetal lung lesions with an associated heart defect or isolated large lung lesions is indicated. It also suggests that there is a subpopulation of fetuses with CCAMs who have conotruncal heart defects. This finding may suggest a common genetic background.

Postnatal Chest Wall Deformities after Fetal Thoracoamniotic Shunting for Congenital Cystic Adenomatoid Malformation

OBJECTIVES

Large macrocystic congenital cystic adenomatoid malformations (CCAMs) can be treated with thoracoamniotic (TA) shunting to reduce CCAM volume. Two CCAM fetuses treated with TA shunt had postnatal radiographic rib deformities.

STUDY DESIGN

Retrospective review of prenatal TA shunting for large macrocystic CCAMs evaluated for the presence of rib deformities. Comparison groups not eligible for TA shunting included nonshunted CCAMs resected postnatally (group A) and size-matched nonshunted CCAMs resected postnatally (group B).

RESULTS

Chest wall abnormalities were identified in 77% of newborns ranging from severe concavity and fractures (in two fetuses shunted at 18 and 20 weeks of gestation) to rib thinning compared to comparison groups A and B. The severity of chest wall deformity correlated with earlier gestational age at shunting.

CONCLUSIONS

TA shunting at less than 21 weeks of gestational age may result in postnatal chest wall deformity. This observation should be discussed during counseling for this procedure.

Effect of Maternal Betamethasone Administration on Prenatal Congenital Cystic Adenomatoid Malformation Growth and Fetal Survival

OBJECTIVE

To evaluate the effect of prenatal steroid treatment on the growth of congenital cystic adenomatoid malformations (CCAM) and survival in affected fetuses not amenable to other percutaneous ultrasound-guided prenatal interventions.

METHODS

A retrospective review of patients with a CCAM or hybrid lesion treated with two maternal prenatal betamethasone injections was performed. Patients receiving cyst aspiration or thoracoamniotic shunting at the time of or after steroid administration were excluded. Growth rates and survival data were compared to historical non-steroid treated controls.

RESULTS

Eleven patients were treated with prenatal steroids (10 microcystic and 1 macrocystic). Survival was 100% in fetuses with hydrops (5/5) or a CCAM volume ratio (CVR) >1.6 (7/7) at the time of steroid administration. This compares to a mortality of 100 and 56.2% respectively in historical non-treated controls. Resolution of hydrops was seen in 80% (4/5) of steroid-treated patients. CCAM growth rates were variable after steroid administration. However, when compared to historical data where CVR and CCAM volume have been documented to increase until 28 weeks' gestation, the CVR and CCAM volume growth rates decreased in 72.73% and 50% of patients respectively from the time of steroid administration to 28 weeks' gestation.

CONCLUSIONS

In the fetus with a CCAM, the presence of hydrops fetalis or a CVR >1.6 is indicative of poor fetal outcome without prenatal intervention. The observed effect of antenatal steroid treatment on CCAM growth is variable, but its potential to improve survival in these high-risk groups is encouraging and warrants further controlled evaluations.

Does a Myelomeningocele Sac Compared to No Sac Result in Decreased Postnatal Leg Function following Maternal Fetal Surgery for Spina Bifida Aperta?

OBJECTIVE

A fetus with large sac S1 myelomeningocele (MMC) but bilateral talipes prompted the question, 'Does the presence or size of an MMC sac affect postnatal leg function?'

STUDY DESIGN

An MMC database with prenatal, birth, and a minimum of 1-year follow-up evaluation was reviewed. All fetuses had in-utero MMC repair at 20 + 0 to 25 + 6 weeks at a single institution. Fifty-four fetuses had prenatal evaluation, with 48 children completing a birth and a 1-year evaluation of leg function.

RESULTS

An MMC sac was present in 38/54 (70%) of fetuses evaluated in-utero and had been present in 35/48 (73%) of children evaluated at 1 year of age. Although leg function evaluated at 1 year was better than expected in the 'no sac' group (p = 0.059), this did not reach statistical significance.

CONCLUSION

The presence of an MMC sac may increase postnatal lower limb morbidity.

Gastroschisis: Growth Patterns and a Proposed Prenatal Surveillance Protocol

OBJECTIVE

To assess intrauterine growth for fetuses with gastroschisis using retrospective serial ultrasound assessment from fetuses diagnosed prenatally with gastroschisis. The growth assessment could be available as a prospective tool to direct an antepartum fetal surveillance protocol.

METHODS

This is a retrospective review of all cases of gastroschisis evaluated prenatally at a single institution between February 1996 and March 2002. Charts were reviewed for serial ultrasound assessment, gestational age at delivery, mode of delivery, and birth weight. Growth assessment was determined for abdominal circumference, biparietal diameter, head circumference, femur length, and estimated fetal weight (IRB No. 2002-1-2648).

RESULTS

Forty patients had delivered by March 2002. One hundred and two ultrasound reports were reviewed. Gastroschisis growth curves showed that the 50th percentile was shifted to the right when compared to normal growth curves for abdominal circumference, biparietal diameter, head circumference, and femur length. The average birth weight was 2,359 g. Compared with a standard population, 44% (16/36) were below the 5th percentile, 61% (22/36) were below the 10th percentile, and 95% (34/36) were below the 50th percentile for gestational age. The average gestational age at delivery was 36.3 weeks. Mothers were nulliparous in 78%, with a mean age of 21.3 years.

CONCLUSIONS

(1) Fetuses with gastroschisis show a symmetric intrauterine growth restriction pattern consistent with early development of growth delay; (2) the 50th percentile biometry measurements for the gastroschisis population are shifted to the right on normal fetal growth curves; (3) the birth weight is at or below the 10th percentile in 61% of the newborns with gastroschisis, and (4) an antepartum surveillance protocol is proposed based on growth patterns of fetuses with gastroschisis.

Prenatal glucocorticoids improve lung morphology and partially restores surfactant mRNA expression in lambs with diaphragmatic hernia undergoing fetal tracheal occlusion

In fetal sheep with surgically created diaphragmatic hernia (DH), tracheal occlusion (TO) can restore lung growth but does not ameliorate the increase in inter-alveolar wall thickness (T(W)). We determined whether prenatal exposure to glucocorticoids (GC) could reduce T(w) in fetuses with DH undergoing TO. At 65 days of gestation, DH was created in 12 fetal sheep, and TO subsequently performed at 110 days (DH/TO). Six of these fetuses were exposed to betamethasone (DH/TO + GC; 0.5 mg/kg; maternal, IM) 48 hr before delivery; Sham operated fetuses (n = 7) served as controls. At 139 days, we measured alveolar surface density (S(V)), parenchymal tissue fraction, T(W), alveolar type 2 (AE2) cell density and lung surfactant protein (SP) mRNA expression. Prenatal GC decreased T(W) and S(V) by 33% and 27% respectively, and increased fixed lung volume (by 55%), AE2 cell density and partially restored SPmRNA expression. Our data indicate that prenatal exposure to GC can reverse some of the negative effects of prolonged fetal TO. We hypothesize that a GC-induced reduction in lung liquid volume during TO contributes, in part, to the observed increase in AE2 cell density and SPmRNA expression.

Diagnosis and characterization of fetal sacrococcygeal teratoma with prenatal MRI

OBJECTIVE

The purpose of this study was to determine whether prenatal MRI provides additional information about fetal sacrococcygeal teratoma compared with prenatal sonography.

MATERIALS AND METHODS

Twenty-two pregnant women with fetal sacrococcygeal teratoma underwent prenatal MRI (mean gestational age, 23 weeks). The size, location, mass characteristics, and compressive effects of the tumors were determined and correlated with sonography and postnatal findings.

RESULTS

Based on the MRI findings, the following American Academy of Pediatrics, Surgical Section classifications were assigned: type I in six patients, type II in 12, and type III in four. No type IV tumors were found. The sacrococcygeal teratoma appeared entirely cystic in five fetuses, microcystic in one, mixed cystic and solid in 12, and solid in four. The diagnosis of sacrococcygeal teratoma was accurate in all cases assessed at our center using both MRI and sonography. Two additional patients initially referred with the diagnosis of sacrococcygeal teratoma had a different diagnosis at reevaluation at our institution (healthy, n = 1; myelomeningocele, n = 1). MRI was superior to sonography for detecting displacement of the colon (n = 11), urinary tract dilatation (n = 9), hip dislocation (n = 4), intraspinal extension (n = 2), and vaginal dilation (n = 1). In fetuses with sacrococcygeal teratoma types II and III, MRI better showed the cephalic extent of the tumor compared with sonography. MRI findings were confirmed at surgery or autopsy in all patients. Three fetuses with high output cardiac physiology underwent open fetal resection of the tumor at 21-, 24-, and 26-weeks' gestational age with two surviving.

CONCLUSION

Our results show that ultrafast fetal MRI is a useful adjunct to the prenatal evaluation of fetal sacrococcygeal teratoma. Compared with sonography, MRI more accurately characterized the intrapelvic and abdominal extent of the tumors and provided more information on compression of adjacent organs. The additional anatomic resolution provided by MRI resulted in more accurate prenatal counseling and improved preoperative planning for surgical resection.

Prenatal glucocorticoids and exogenous surfactant therapy improve respiratory function in lambs with severe diaphragmatic hernia following fetal tracheal occlusion

Fetal tracheal occlusion (TO) accelerates lung growth and can reverse severe lung hypoplasia associated with diaphragmatic hernia (DH), however, lung compliance (Cl) and respiratory gas exchange remain abnormal. We determined the individual and combined effects of prenatal glucocorticoids (GC) and exogenous surfactant therapy (S) on postnatal pulmonary function in lambs with DH that underwent prolonged TO. DH was created in 22 fetal sheep at 65 d of gestation and TO performed at 110 d. Eleven DH/TO animals received prenatal GC (betamethasone, 0.5 mg/kg) 48 h before delivery; six GC-treated and five non-GC lambs were administered surfactant (Infasurf, 3 mg/kg) at birth. Six sham-operated lambs served as controls. Lambs were delivered at 139 d gestation and ventilated for 2 h. GC or surfactant therapy alone significantly improved respiratory gas exchange, Cl, and ventilatory efficiency index. Total lung capacity was normalized only in DH/TO lambs that received both GC and S.

Cystic adenomatoid malformation of the lung: review of genetics, prenatal diagnosis, and in utero treatment

Prenatal identification of lung abnormalities has increased with prenatal surveillance. Treatment usually requires serial ultrasound observation but in rare situations in utero therapy may be required for fetal survival. We review the genetics, prenatal evaluation, and treatment of lung abnormalities with congenital cystic adenomatoid malformation (CCAM). Other lung lesions, bronchopulmonary sequestration (BPS), hybrid lesions involving both malformations, congenital lobar emphysema (CLE), are briefly included as differential diagnosis options. Outcome of fetuses identified to have CCAM lung abnormalities resulting in fetal hydrops and having in utero therapy (thoracoamniotic shunting, fetal thoracotomy, EXIT delivery) are discussed. In the appropriate situation, this maternal fetal surgery approach for CCAM is life-saving for the affected fetus with acceptable maternal morbidity risks in the present and future pregnancies.

Tracheal occlusion in fetal rats alters expression of mesenchymal nuclear transcription factors without affecting surfactant protein expression

BACKGROUND/PURPOSE

Mesenchymal nuclear transcription factors (MNTF) are involved in lung development and maturation and regulate surfactant protein (SP) expression. Prolonged (>2 weeks) fetal tracheal occlusion (TO) has been shown to accelerate lung growth and inhibit pulmonary surfactant synthesis. The effects of TO on SP expression and MNTF, however, have not been formally assessed. The objectives of this study were to evaluate the effects of short-term (3 days) TO on normal lung growth and protein expression of pulmonary MNTF involved in SP synthesis.

METHODS

At E19 (term, 22 days), 2 fetuses per time-dated Sprague-Dawley rats underwent either TO (n = 23) or a sham (n = 22) operation. Lungs were harvested 72 hours post surgery. Pulmonary SP-A; SP-B; SP-C messenger RNA (mRNA) expression; and SP-A and SP-B, Hoxb5, thyroid transcription factor 1, and retinoic X receptor-alpha protein expression were analyzed.

RESULTS

Lung weight was significantly increased by TO (TO 0.32 +/- 0.02g vs SHAM 0.14 +/- 0.01 g; P < .001), resulting in 123% increase of the lung-to-body-weight ratio. No difference of SP-A-mRNA (177 +/- 4.3 TO vs 169 +/- 4.4 SHAM; P = .25), SP-B-mRNA (87.7 +/- 0.2 TO vs 87.4 +/- 0.02 SHAM; P = .33), and SP-C-mRNA (186.5 +/- 3.2 TO vs 183.2 +/- 2.7 SHAM; P = .45) expression was found. Surfactant protein A (175.6 +/- 25.3 TO vs 192.5 +/- 19.8 SHAM; P = .59) and SP-B (163.4 +/- 5.2 TO vs 166.8 +/- 9.3 SHAM; P = .75) protein expression were similar in both groups; however, Hoxb5 (70.3 +/- 18.9 TO vs 130.6 +/- 5.1 SHAM; P = .02) and thyroid transcription factor 1 (102.6 +/- 19 TO vs 181.1 +/- 6.3 SHAM; P = .007) expression were significantly decreased. Retinoic X receptor-alpha expression tended to be increased by TO (171.9 +/- 6.0 TO vs 155.4 +/- 6.7 SHAM; P = .06).

CONCLUSIONS

Short-term TO late in gestation induces rapid lung growth. Surfactant protein-mRNA and protein expression are not significantly altered. Thyroid transcription factor 1 and Hoxb5 are down-regulated by TO, suggesting that duration and timing of occlusion are important in balancing the effects of TO on lung growth vs lung maturation.

Severe pulmonary hypoplasia associated with giant cervical teratomas

BACKGROUND

The use of the ex utero intrapartum treatment (EXIT) procedure has salvaged many fetuses with giant neck masses. Despite an adequate airway, a subset of these patients die from an inability to achieve adequate gas exchange.

METHODS

We reviewed our experience with the EXIT procedure from 1996 to 2004. The EXIT was used to deliver 23 fetuses with giant neck masses.

RESULTS

Three fetuses with giant cervical teratomas died of severe pulmonary hypoplasia. On postmortem, these patients had severe airway distortion by the mass. The carina was retracted superiorly to the first or second rib resulting in compression of the lungs in the apices of the chest and pulmonary hypoplasia. Hypoplasia was reflected in the lung weights of 24 vs 38 g and 17 vs 34 g for age-matched normal lung.

CONCLUSIONS

Unsuspected obstructive fetal neck masses can be fatal because of an inability to secure an airway. Prenatal ultrasonography can identify fetuses at risk, allowing the fetus to be salvaged using the EXIT procedure. Despite obtaining airway control, a subset of these patients will die because of pulmonary hypoplasia. When counseling patients with large cervical masses it is important to discuss potential pulmonary hypoplasia in these patients.

Long-term outcomes in children treated by prenatal vesicoamniotic shunting for lower urinary tract obstruction

OBJECTIVE

Limited information is available about long-term outcomes in children treated prenatally for lower urinary tract obstruction. Our aim was to evaluate outcomes in children treated in utero with vesicoamniotic shunts.

METHODS

Clinical outcomes in 20 pregnancies with a singleton male fetus, oligo/anhydramnios, and lower urinary tract obstruction were studied using chart review and phone and written clinical questionnaire for parents, pediatricians, and urologists.

RESULTS

Overall 1-year survival was 91%. Two neonatal deaths occurred from pulmonary hypoplasia. Mean gestational age at delivery was 34.6 weeks, mean days from shunting to delivery were 84.4, and mean birth weight was 2,574 g. Prenatal urinary prognosis was good in 13, borderline in 2, and poor in 3 of the survivors. Mean age at follow-up was 5.83 years. Posterior urethral valves were confirmed in 7 males, urethral atresia in 4, and prune belly syndrome in 7. Eight children had acceptable renal function, 4 had mild insufficiency, and 6 required dialysis and eventual renal transplant. Eleven children had normal bladder function with spontaneous voiding, 6 required catheterization, and 1 child still had a vesicostomy. Height and weight were below the 25th percentile in 9 children. Persistent respiratory problems were present in 8, musculoskeletal problems in 9, and frequent urinary tract infections were reported in 9. Health-related quality of life results in our group with lower urinary tract obstruction were similar to those in a healthy child population.

CONCLUSION

Male children who underwent prenatal bladder shunting were neurodevelopmentally normal. Although one third of the surviving babies required dialysis and transplantation, the majority have acceptable renal and bladder function and report satisfactory quality of life.

LEVEL OF EVIDENCE

III.

Impact of Continuous Intraoperative Monitoring on Outcomes in Open Fetal Surgery

OBJECTIVES

There are shifts in fetal hemodynamics during open fetal surgery that were not appreciated until the use of intraoperative fetal echocardiography. We have developed an intraoperative monitoring strategy to continuously assess fetal hemodynamics. We hypothesized that this approach would enhance intraoperative management and survival.

METHODS

Medical records of open fetal surgery patients were reviewed since the implementation of this approach. Intraoperative fetal monitoring was accomplished by continuous echocardiography, pulse oximetry, establishment of intravenous access, and arterial blood gas and hemoglobin measurement. Overall survival was compared to fetal surgeries performed prior implementation of this monitoring strategy.

RESULTS

Resections of a congenital cystic adenomatoid malformation or a sacrococcygeal teratoma in nine hydropic fetuses were performed while using this monitoring strategy. Intraoperative echocardiography resulted in a change of management in 7 of 9 fetuses. The main observations on fetal echocardiography resulting in intraoperative intervention were decreased ventricular filling, bradycardia, and decreased ventricular contractility. Therapy included administration of volume expanders and/or inotropic agents. Overall fetal survival was 78% compared to a survival of 42% prior to the implementation of this approach.

CONCLUSION

Continuous intraoperative fetal monitoring provides real time assessment of fetal hemodynamics which results in changes in intraoperative management. The overall outcomes in these critically ill fetuses have been improved.

The ex utero intrapartum therapy procedure for high-risk fetal lung lesions

BACKGROUND

Indications for the ex utero intrapartum therapy (EXIT) procedure have expanded to include any fetal anomaly in which resuscitation of the neonate may be compromised.

METHODS

We reviewed the medical records of 9 patients after resection of lung lesions during the EXIT procedure.

RESULTS

The mean gestational age at EXIT procedure was 35.4 weeks. All lung masses maintained large sizes late into gestation with mean mass volume/head circumference ratio of 2.5 at presentation and 2.2 at EXIT. Seven of 9 fetuses demonstrated hydropic changes (n = 6) and/or polyhydramnios (n = 5), and underwent prenatal intervention including thoracentesis, thoracoamniotic shunt placement, amnioreduction, and/or betamethasone administration. Overall survival after EXIT for lung mass resection was 89%. The average time on placental bypass was 65 minutes. Postnatal complications included reoperation for air leak (n = 1), reoperation for bleeding (n = 1), and death from sepsis and prematurity (n = 1). Venoarterial extracorporeal membrane oxygenation was used in 4 neonates for persistent pulmonary hypertension. Maternal prenatal complications included polyhydramnios (n = 5), preterm labor (n = 4), and chorioamnionitis (n = 1). One mother required perioperative blood transfusion.

CONCLUSION

The EXIT procedure allows for controlled resection of large fetal lung lesions at delivery, avoiding acute respiratory decompensation related to mediastinal shift, air trapping, and compression of normal lung.

Surfactant protein expression is increased in the ipsilateral but not contralateral lungs of fetal sheep with left-sided diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) impairs fetal lung growth and increases the density of alveolar epithelial type 2 (AE2) cells. There is controversy whether surfactant protein (SP) expression is altered in CDH. The primary aim of this study was to assess SP expression (mRNA and protein) in the left and right lungs of fetal sheep with and without a diaphragmatic hernia (DH). Left-sided DH was created in four fetal sheep at 65 days of gestational age (g.a.). Sham-operated animals were used as controls. At 138 days g.a., lungs were harvested and the following parameters were measured: SP-A, -B, and -C mRNA expression (Northern blot), SP-A and -B expression (Western blot), and AE2 cell density (immunohistochemistry). The lung weight-to-body weight ratio was reduced by 42% in DH animals. The left-to-right lung weight ratio was lower in DH animals (0.47 +/- 0.03 vs. 0.69 +/- 0.03), indicative of asymmetric lung growth. SP-A, -B, and -C mRNA expression were increased by 61.7%, 32.9%, and 75.5%, respectively, in the left lungs of DH animals. SP-A and SP-B were also increased in DH. In the right lung, SP expression (mRNA and protein) was not different between groups. AE2 cell density was higher (by 67%) in the left but not right lungs of DH animals. Although DH in fetal sheep results in significant lung hypoplasia, SP expression is not reduced. On the contrary, SP expression was increased in the ipsilateral lung of fetuses with left-sided DH. Furthermore, AE2 cell density is increased in DH, suggesting that the increase in SP mRNA and protein levels is due to increases AE2 cell number. Our data further support the premise that fetal lung hypoplasia favors an AE2 phenotype.

Management of fetal mediastinal teratoma

BACKGROUND/PURPOSE

Mediastinal teratomas are rare congenital germ cell tumors that prenatally can compress mediastinal structures and cause hydrops. Two possible presentations of massive fetal mediastinal teratoma include hydrops leading to fetal demise, or fetal esophageal and airway compression causing late-gestation polyhydramnios and preterm labor. The authors present 2 cases of fetal mediastinal teratoma that illustrate successful strategies for either of these presentations.

METHODS

A 37-year-old woman carrying a fetus with a mediastinal mass and secondary hydrops at 23 weeks of gestation underwent in utero resection of the mass. Delivery was by cesarean delivery at 25 weeks because of preterm labor. A 24-year-old mother carrying a fetus with a mediastinal mass and severe polyhydramnios at 36 weeks of gestation underwent an ex utero intrapartum therapy procedure for establishment of an airway and tumor resection on uteroplacental support.

RESULTS

These strategies resulted in physiologic improvement in the first case and controlled resection and resuscitation in the second. The first patient had significant sequelae of prematurity including bronchopulmonary dysplasia but is currently well at 9 months of age. The second patient is well at 1 year of age.

CONCLUSIONS

Massive fetal mediastinal teratoma can result in fetal or neonatal mortality by a variety of mechanisms. Optimal prenatal and perinatal management is required to salvage fetuses compromised by this lesion.

Prenatal Diagnosis and Management of Mainstem Bronchial Atresia

The prenatal diagnosis, natural history and management of mainstem bronchial atresia have not been described previously. We report two cases of prenatally diagnosed proximal bronchial atresia. The first patient presented at 18 weeks with sonographic and MRI findings consistent with bronchial atresia with fetal hydrops. The mother developed the mirror syndrome and labor was induced. A non-viable fetus was delivered at 25 weeks. The second patient presented at 16 weeks gestation with evidence of an intrathoracic mass that was subsequently prenatally diagnosed as a right mainstem bronchial atresia. The right lung increased rapidly in size and was associated with the onset of fetal hydrops. At 24 weeks, fetal pneumonectomy was performed but the fetus expired intraoperatively due to cardiovascular collapse. Post-mortem findings in both cases confirmed the presence of an atretic mainstem bronchus with massive enlargement of the lung. Bronchial atresia involving the mainstem bronchus is associated with a poor prognosis.

Fetal head biometry following in-utero repair of myelomeningocele

OBJECTIVE

To evaluate the impact of prenatal myelomeningocele repair on fetal head biometry.

METHODS

Fifty fetuses underwent open fetal myelomeningocele repair at our institution between January 1998 and July 2002. All had serial head circumference (HC) and lateral ventricular diameter (VD) measurements taken preoperatively and weekly for 8 weeks after repair. Cortical index (CI) was defined as HC/VD. Measurements were compared with gestational age-matched values from nomograms. One-sample t-test, ANOVA and repeated measures analysis were used to assess HC, VD and CI after fetal repair.

RESULTS

Preoperatively, the HC in fetuses with myelomeningocele was smaller than control values (186.4 vs. 198.8 mm, P = 0.0004). Eight weeks' postoperatively this difference had resolved (293 vs. 301.6 mm, P = 0.76). The mean increase in CI after repair was 20% (P = 0.02) compared with the predicted 51% in normal cases. The average increase in VD was 3.9 mm (38.8%, P < 0.001).

CONCLUSIONS

Mid-gestational repair of myelomeningocele alters fetal head growth. Increased CI suggests HC changes are not due to ventriculomegaly alone.

Prenatally diagnosed giant omphaloceles: short- and long-term outcomes

OBJECTIVES

To review prenatal findings, short- and long-term outcomes of giant omphaloceles (GO) managed at a single institution (1996-2001).

METHODS

Prenatal findings and early postnatal outcomes were retrospectively reviewed. Clinical short- and long-term outcomes were analyzed in eight and five children respectively. Parents and physicians of the children were surveyed by written questionnaires about the children's subsequent health issues. (IRB 2002-2-2683).

RESULTS

Seventeen pregnancies with GO were identified: Eight fetuses were live born, four ended in (terminations), two died in utero and three were lost to follow-up. Live-born fetuses had prenatal ascites, extreme levocardia and were delivered by cesarean section at a mean of 37 weeks' gestation with a mean birth weight of 2903 g. All neonates required intubation. Two infants (2/8) died within one year. Four of the six survivors had respiratory insufficiency with a mean ventilation time of 76 days. Respiratory and feeding problems complicated the early neonatal course. Long-term follow-up was available for five patients (mean age of 33.2 months). Asthma, recurrent pulmonary infections, feeding problems, gastroesophageal reflux and failure to thrive were the major problems.

CONCLUSIONS

Respiratory and feeding problems were the most common neonatal and long-term medical management issues. Parents need to be counseled prenatally about the probability of multiple surgeries and long hospitalization following birth.

Reproductive outcomes after pregnancy complicated by maternal-fetal surgery

OBJECTIVE

The reproductive outcomes for women after the pregnancy complicated by maternal-fetal surgery were evaluated to obtain evidence-based information for prenatal risk counseling.

STUDY DESIGN

The retrospective review identified 83 women with maternal-fetal surgery from a single institution (1996-2002). These women were sent a consent form and a questionnaire to document postoperative problems, fertility, obstetric outcomes, and psychosocial concerns in pregnancy after the index fetal therapy. Institutional Review Board approval was obtained from Committee for Protection of Human Subjects.

RESULTS

The total return rate was 55 (66%). The pregnancy rate was 62% (18% spontaneous abortion, 24% preterm delivery, and 58% term delivery). Complications were reported in 12 of 34 pregnancies (35%), including uterine dehiscence/rupture (12%/6%), cesarean hysterectomy (3%), and antepartum hemorrhage requiring transfusion (9%).

CONCLUSION

The reproductive outcome of uterine dehiscence, rupture, and hysterectomy was 12%, 6%, and 3%, respectively, after a pregnancy complicated by maternal-fetal surgery. The uterine rupture rate is similar to the rupture rate after "classical" cesarean section (4%-9%).

Acute Cardiovascular Effects of Fetal Surgery in the Human

Background— Prenatal surgery for congenital anomalies can prevent fetal demise or alter the course of organ development, resulting in a more favorable condition at birth. The indications for fetal surgery continue to expand, yet little is known about the acute sequelae of fetal surgery on the human cardiovascular system.

Methods and Results— Echocardiography was used to evaluate the heart before, during, and early after fetal surgery for congenital anomalies, including repair of myelomeningocele (MMC, n=51), resection of intrathoracic masses (ITM, n=15), tracheal occlusion for congenital diaphragmatic hernia (CDH, n=13), and resection of sacrococcygeal teratoma (SCT, n=4). Fetuses with MMC all had normal cardiovascular systems entering into fetal surgery, whereas those with ITM, CDH, and SCT all exhibited secondary cardiovascular sequelae of the anomaly present. At fetal surgery, heart rate increased acutely, and combined cardiac output diminished at the time of fetal incision for all groups including those with MMC, which suggests diminished stroke volume. Ventricular dysfunction and valvular dysfunction were identified in all groups, as was acute constriction of the ductus arteriosus. Fetuses with ITM and SCT had the most significant changes at surgery.

Conclusions— Acute cardiovascular changes take place during fetal surgery that are likely a consequence of the physiology of the anomaly and the general effects of surgical stress, tocolytic agents, and anesthesia. Echocardiographic monitoring during fetal surgery is an important adjunct in the management of these patients.

Thoracoamniotic Shunts: Fetal Treatment of Pleural Effusions and Congenital Cystic Adenomatoid Malformations

OBJECTIVE

To determine whether fetuses that underwent thoracoamniotic shunt placement for treatment of pleural effusion (PE) or macrocystic congenital cystic adenomatoid malformation (CCAM) have an improved outcome as compared with an untreated population.

METHODS

A retrospective review from a single tertiary center was performed using thoracoamniotic shunt placement to treat PE or macrocystic CCAM between 1998 and 2001. Thoracoamniotic shunts were used on 26 occasions in 19 pregnancies.

RESULTS

The average gestational age at the diagnosis of PE and CCAM was 22 + 4 and 20 + 0 weeks, respectively. Shunts were offered in pregnancies complicated by hydrops or at significant risk for pulmonary hypoplasia. Shunts were placed at 26 + 2 weeks (average) and 23 + 1 weeks (average) in the PE and CCAM groups, respectively. In CCAM patients, the mean pre- and postshunting mass volumes were 50.5 and 25.7 cm(3), representing a 51% reduction in mass volume following shunt placement. In the PE group, the average delivery age was 33 + 5 weeks, with an average shunt placement to delivery time of 7 + 3 weeks. In the CCAM group, the average delivery was 33 + 3 weeks, with an average shunt placement to delivery time of 10 + 2 weeks. The postnatal survival rates were 67% (6/9) and 70% (7/10) in the PE and CCAM groups, respectively.

CONCLUSIONS

(1) Thoracoamniotic shunts should be considered as a treatment option for selected PE or macrocystic CCAM fetuses with hydrops or a significant risk for pulmonary hypoplasia; (2) the neonatal survival with shunting was similar for PE and CCAM groups and was improved as compared with literature reports, and (3) fetuses with CCAM presented earlier with hydrops than those with PE. Successful shunting resulted in a prolongation of pregnancy into the 3rd trimester in both groups.

Right congenital diaphragmatic hernia: Prenatal assessment and outcome

PURPOSE

To understand the natural history of right congenital diaphragmatic hernia (CDH), the authors retrospectively reviewed 27 cases of right CDH that presented for prenatal evaluation or postnatal treatment.

METHODS

Between 1995 and September 2002, a total of 194 cases of fetal CDH were evaluated and included 22 right-sided defects. The authors reviewed prenatal diagnostic studies (ultrasound scan, magnetic resonance imaging [MRI] echocardiography) and pre- and postnatal outcomes in these 22 cases of right CDH. Five additional cases of right CDH without a prenatal diagnosis were reviewed.

RESULTS

The mean gestational age at evaluation was 26.1 weeks. The lung area to head circumference ratio (LHR) ranged from 0.32 to 2.5. In all cases, the fetal liver was herniated into the right chest. Associated anomalies were common. There were no karyotype abnormalities (17 of 22 tested). There were 4 terminations. Nine of the 18 (50%) continuing pregnancies had polyhydramnios, premature rupture of membranes, or preterm labor. The mean gestational age at birth was 36.8 weeks. One patient underwent tracheal occlusion at 27 weeks, and 2 patients died before postnatal repair. Overall survival rate (22 prenatal plus 5 postnatal diagnoses) was 19 of 27 (70%). Postnatal survival rate was 19 of 23 (83%). A Gore-tex (W. L. Gore and Associates, Flagstaff, AZ) patch was utilized in 14 of 21 neonates undergoing surgery. Twelve of 23 (52%) required extracorporeal membrane oxygenation (ECMO) with a 75% survival rate. Significant morbidity occurred in 10 of 19 survivors and included neurologic sequelae in 6 of 19 (32%).

CONCLUSIONS

MRI was helpful in the determination of liver position and confirmation of diagnosis. The high incidence of preterm complications, frequent need for ECMO, and high prevalence of comorbidities are indicative of the severity of this CDH population and warrant close prenatal surveillance and delivery at a tertiary care center with ECMO capability.

Sacrococcygeal teratoma: prenatal assessment, fetal intervention, and outcome

PURPOSE

To understand the natural history and define indications for fetal intervention in sacrococcygeal teratoma (SCT), the authors reviewed all cases of fetal SCT presenting for evaluation.

METHODS

Prenatal diagnostic studies including ultrasound scan, magnetic resonance imaging (MRI), echocardiography and pre- and postnatal outcomes were reviewed in 30 cases of SCT that presented between September 1995 and January 2003.

RESULTS

The mean gestational age (GA) at presentation was 23.9 weeks (range, 19 to 38.5) with 3 sets of twins (10%). Overall outcomes included 4 terminations, 5 fetal demises, 7 neonatal deaths, and 14 survivors. Significant obstetric complications occurred in 81% of the 26 continuing pregnancies: polyhydramnios (n = 7), oligohydramnios (n = 4), preterm labor (n = 13), preeclampsia (n = 4), gestational diabetes (n = 1), HELLP syndrome (n = 1), and hyperemesis (n = 1). Fetal intervention included cyst aspiration (n = 6), amnioreduction (n = 3), amnioinfusion (n = 1), and open fetal surgical resection (n = 4). Indications for cyst aspiration and amnioreduction were maternal discomfort, preterm labor, and prevention of tumor rupture at delivery. Although 15 SCTs were solid causing risk for cardiac failure, only 4 fetuses met criteria for fetal debulking based on ultrasonographic and echocardiographic evidence of impending high output failure and favorable anatomy at 21, 23.6, 25, and 26 weeks' gestation. Intraoperative events included maternal blood transfusion (n = 1), fetal blood transfusion (n = 2), chorioamniotic membrane separation (n = 2), and fetal arrest requiring successful cardiopulmonary resuscitation (CPR) (n = 1). In the fetal resection group, 3 of 4 survived with mean GA at delivery of 29 weeks (range, 27.6 to 31.7 weeks), mean birth weight of 1.3 kg, hospital stay ranging from 16 to 34 weeks, and follow-up ranging from 20 months to 6 years. Postnatal complications in the fetal surgery group included neonatal death (n = 1, secondary to premature closure of ductus arteriosus with cardiac failure), embolic event (n = 1, resulting in unilateral renal agenesis, jejunal atresia), chronic lung disease (n = 1), and tumor recurrence (n = 1).

CONCLUSIONS

For fetal SCT, the rapidity at which cardiac compromise can develop and the high incidence of obstetric complications warrant close prenatal surveillance. Amnioreduction, cyst aspiration, and surgical debulking are potentially life-saving interventions.

Fetal myelomeningocele repair: short-term clinical outcomes

OBJECTIVE

The study was undertaken to evaluate short-term clinical outcomes with antenatal myelomeningocele (MMC) repair.

STUDY DESIGN

Retrospective review of 50 fetuses that underwent open fetal MMC closure was performed. Inclusion criteria included less than 26 weeks' gestation, thoracic to S1 level defect, absent clubfoot deformity, Arnold-Chiari malformation, ventriculomegaly less than 17 mm, normal karyotype, and no other anomalies.

RESULTS

Perinatal survival was 94% (47/50 fetuses). Mean age at delivery was 34 weeks 3 days. All fetuses demonstrated reversal of hindbrain herniation. Forty-three percent of the 50 fetuses have required ventriculoperitoneal shunting compared with 100% thoracic, 88% lumbar, and 68% sacral (85% overall) in 297 historic controls. Better-than-predicted leg function was seen in 57% of thoracic and lumbar level lesion patients.

CONCLUSION

Early experience with fetal MMC repair suggests a decreased need for ventriculoperitoneal shunting, arrest or slowing of progressive ventriculomegaly, and consistent resolution of hindbrain herniation. However, further long-term follow-up is needed to evaluate neurodevelopment and bladder and bowel function.

Chorioamniotic membrane separation following open fetal surgery: pregnancy outcome

OBJECTIVE

To review the incidence of posthysterotomy chorioamniotic membrane separation and delivery outcome following open fetal surgery [myelomeningocele (MMC); cystic adenomatoid malformation (CCAM); congenital diaphragmatic hernia (CDH); sacrococcygeal teratoma (SCT)].

STUDY DESIGN

Retrospective review of a maternal population undergoing open fetal surgery at a single tertiary level program (1998-2001) following the initiation of close postoperative ultrasound follow-up for membrane separation. Onset of membrane separation was coded as not present (NP), immediate (<2 weeks) or delayed (>2 weeks) from day of surgery.

RESULTS

Fifty-three charts were reviewed: MMC 43, CCAM 7, CDH 1, and SCT 2. In the MMC group there were 26 NP, 8 immediate, and 9 delayed. Preterm labor occurred in 4 patients with only 2 having had membrane separation. Risk of membrane separation is increased for surgery done at less than 23 weeks gestation (p < 0.005). Delay from MMC surgery to delivery was 11.0, 9.8, 12.0 weeks for NP, immediate, and delay, respectively. In the MMC group, there were 3 neonatal deaths (NND) at 9, 9, and 21 days post surgery (PROM/PTL; chorioamnionitis, PROM/PTL, respectively). No membrane separation was present in the CCAM, CDH, and SCT cases.

CONCLUSIONS

(1) Membrane separation was significantly more likely to occur if surgery was performed prior to 23 weeks. (2) Membrane separation post hysterotomy (17/50 = 34%) may be associated with an increased risk of PROM but not delivery before 30 weeks gestation. (3) Delivery prior to 33 weeks gestation for MMC groups was 12/43 (28%) with 3 NND (7%). (4) Elective delivery at 36-37 weeks gestation was possible for 43% of the fetal surgery population.

Ex utero intrapartum therapy

The hallmark of ex utero intrapartum therapy (EXIT) procedure is the maintenance of uteroplacental blood flow and gas exchange. This goal is achieved with the use of inhalational agents to relax uterine tone, a continuous amnioinfusion to stabilize uterine volume, and partial exposure of the fetus. From March 1996 to December 2002, 43 EXIT procedures were performed at the Children's Hospital of Philadelphia (CHOP). Indications included airway obstruction from fetal neck masses (n = 19), reversal of tracheal occlusion for congenital diaphragmatic hernia (CDH; n = 13), resection of massive congenital cystic adenomatoid malformation of the lung (n = 5), congenital high airway obstruction syndrome (n = 3), EXIT-to-extracorporeal membrane oxygenation for a fetus with CDH and a cardiac defect (n = 1), unilateral pulmonary agenesis (n = 1), and thoracoomphalopagus conjoined twins (n = 1). Eight fetuses required initial tracheotomy at the time of EXIT to secure the airway. One death occurred during the EXIT procedure secondary to inability to secure the airway with parental refusal for tracheotomy. In all cases, the EXIT procedure provided time on uteroplacental gas exchange to perform procedures such as direct laryngoscopy, bronchoscopy, tracheotomy, arterial and venous access, resection of neck or lung masses, and ECMO cannulation, thereby converting an emergent crisis into a controlled situation.

Congenital high airway obstruction syndrome: natural history and management

BACKGROUND

Congenital high airway obstruction syndrome (CHAOS) is a life-threatening condition with a poorly understood natural history.

METHODS

A retrospective review of five patients with CHAOS between 1997 and 2002 was performed.

RESULTS

All fetuses had large echogenic lungs, dilated airways, inverted diaphragms, and massive ascites. One fetus with a laryngeal cyst was terminated at 22 weeks. A twin fetus with findings suggestive of a tracheal web had progressive hydrops, which led to fetal demise. The remaining 3 patients delivered via the ex utero intrapartum treatment (EXIT) procedure survived. The first patient tolerated progressive hydrops for 12 weeks in utero. He had tracheal atresia but underwent laryngotracheoplasty successfully. He is the first long-term CHAOS survivor and is speaking at 5 years of age. The 2 patients with relatively stable lung volumes prenatally have laryngeal atresia with a pinpoint posterior laryngeal fistula. Their postnatal clinical courses were much more benign than the first survivor.

CONCLUSIONS

The prenatal natural history and postnatal course of CHAOS depends on whether the airway obstruction is complete. The EXIT procedure offers the potential for salvage of this otherwise lethal condition. Hydrops may be well tolerated prenatally for weeks with potential resolution if airway fistulization is present.

Temporary tracheal occlusion in fetal sheep with lung hypoplasia does not improve postnatal lung function

Prolonged fetal tracheal occlusion (TO) accelerates lung growth but leads to loss of alveolar epithelial type II (AE2) cells. In contrast, temporary TO leads to recovery of AE2 cells and their ability to produce surfactant. The aim of this study was to determine the effects of temporary TO in fetal sheep with lung hypoplasia on postnatal lung function, structure, and surfactant protein mRNA expression. Diaphragmatic hernia (DH) was created in 22 fetal sheep at 65 days of gestation. TO was performed between 110 days of gestation and full term (DH/TO, n = 7) and between 110 and 130 days of gestation (DH/TO+R, n = 6). Sham-operated fetuses (n = 11) served as controls. Lambs were delivered at approximately 139 days of gestation, and blood gas tensions were monitored over a 2-h resuscitation period. Temporary TO increased growth of the hypoplastic lung and restored surfactant protein mRNA expression and AE2 cell density but did not improve respiratory function above that of animals that underwent prolonged TO; DH/TO and DH/TO+R lambs were hypoxic and hypercapnic compared with Sham animals. Lung compliance remained low in DH/TO+R lambs, most likely as a consequence of the persistent increase in alveolar wall thickness in these animals.

History of fetal diagnosis and therapy: Children's Hospital of Philadelphia experience

Since its inception in 1995, the mission of the Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia (CHOP) has been to provide comprehensive, multidisciplinary expertise in all facets of prenatal diagnosis, reproductive genetics, and prenatal, perinatal, and postnatal treatment for abnormal fetuses. Most of the authors were trained and/or served on faculty at centers in San Francisco (N.S.A., A.W.F., T.M.C., L.J.H.) or Detroit (A.W.F, M.P.J.). Accurate prenatal detection by serial sonographic study and the development of ultrafast magnetic resonance imaging (MRI) scanners has permitted delineation of the natural history of anatomic malformations. Definition of the pathophysiological features that affect clinical outcome and formulation of management based on prognosis has allowed families to make informed decisions. Outcomes have been improved through carefully planned and coordinated perinatal management. In some cases of life-threatening or severely debilitating defects, prenatal surgery has been offered.

Computer-assisted stereology: point fraction of lung parenchyma and alveolar surface density in fetal and newborn sheep

The aim of this study was to determine the accuracy of a new computer-assisted stereological technique in obtaining structural information of the lung. We compared the point fraction of lung parenchyma (Pp) and alveolar surface density (Sv) obtained by established manual point/intercept counting methods and compared them with those obtained using a computer-assisted method. Lung tissues obtained from normally grown fetal sheep (n = 6) and from newborn lambs with severe lung hypoplasia (n = 5) were inflation fixed via the trachea and processed for light microscopy. In verification-of-technique experiments, Pp and Sv correlated well with known values. There was a significant linear correlation between manual and computer-assisted stereological measurements for values of Pp (r2 = 0.92) and Sv (r2 = 0.98). Our data lead us to believe that the computer-assisted stereological technique described in this study provides accurate estimates of Pp and Sv and hence may be a valuable tool for evaluating the effects of factors upon structural development of the lung.