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Delabaere A, Marceau G, Coste K, Blanchon L, Déchelotte PJ, Blanc P, Sapin V, Gallot D. Effects of tracheal occlusion with retinoic acid administration on normal lung development. Prenat Diagn 2017; 37:427-434. [DOI: 10.1002/pd.5012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 01/09/2017] [Accepted: 01/29/2017] [Indexed: 12/24/2022]
Affiliation(s)
- Amélie Delabaere
- EA7281 - Retinoids, Reproduction Developmental Diseases; Auvergne University; Clermont-Ferrand France
- Fetal Maternal Medicine Unit, Obstetrics and Gynecology Department; Clermont-Ferrand University Hospital; Clermont-Ferrand France
| | - Geoffroy Marceau
- EA7281 - Retinoids, Reproduction Developmental Diseases; Auvergne University; Clermont-Ferrand France
- Biochemistry and Molecular Biology Department; Clermont-Ferrand University Hospital; Clermont-Ferrand France
| | - Karen Coste
- EA7281 - Retinoids, Reproduction Developmental Diseases; Auvergne University; Clermont-Ferrand France
- Department of Paediatrics; Clermont-Ferrand University Hospital; Clermont-Ferrand France
| | - Loïc Blanchon
- EA7281 - Retinoids, Reproduction Developmental Diseases; Auvergne University; Clermont-Ferrand France
| | | | - Pierre Blanc
- EA7281 - Retinoids, Reproduction Developmental Diseases; Auvergne University; Clermont-Ferrand France
| | - Vincent Sapin
- EA7281 - Retinoids, Reproduction Developmental Diseases; Auvergne University; Clermont-Ferrand France
- Biochemistry and Molecular Biology Department; Clermont-Ferrand University Hospital; Clermont-Ferrand France
| | - Denis Gallot
- EA7281 - Retinoids, Reproduction Developmental Diseases; Auvergne University; Clermont-Ferrand France
- Fetal Maternal Medicine Unit, Obstetrics and Gynecology Department; Clermont-Ferrand University Hospital; Clermont-Ferrand France
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102
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Moaddab A, Nassr AA, Belfort MA, Shamshirsaz AA. Ethical issues in fetal therapy. Best Pract Res Clin Obstet Gynaecol 2017; 43:58-67. [PMID: 28268059 DOI: 10.1016/j.bpobgyn.2017.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 02/05/2017] [Accepted: 02/06/2017] [Indexed: 02/03/2023]
Abstract
The introduction of routine fetal ultrasound and the technical improvements in ultrasound equipment have greatly increased our ability to diagnose fetal anomalies. As a consequence, congenital anomalies are diagnosed today earlier and in a greater number of patients than ever before. The development of fetal intervention and fetal surgery techniques, improved anesthesia methodology, and sophisticated perinatal care at the limits of viability, have now made prenatal management of some birth defects or fetal malformations a reality. The increasing number of indications for fetal therapy and the apparent desire of parents to seek out these procedures have raised concern regarding the ethical issues related to the therapy. While fetal therapy may have a huge impact on the prenatal management of some congenital birth defects and/or fetal malformations, because of the invasive nature of these procedures, the lack of sufficient data regarding long-term outcomes, and the medical/ethical uncertainties associated with some of these interventions there is cause for concern. This chapter aims to highlight some of the most important ethical considerations pertaining to fetal therapy, and to provide a conceptual ethical framework for a decision-making process to help in the choice of management options.
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Affiliation(s)
- Amirhossein Moaddab
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, United States
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, United States; Department of Obstetrics and Gynecology, Women's Health Hospital, Assiut University, Assiut, Egypt
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, United States
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, United States.
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103
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Marwan AI, Shabeka U, Dobrinskikh E. Suggested Mechanisms of Tracheal Occlusion Mediated Accelerated Fetal Lung Growth: A Case for Heterogeneous Topological Zones. Front Pediatr 2017; 5:295. [PMID: 29376042 PMCID: PMC5770375 DOI: 10.3389/fped.2017.00295] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 12/21/2017] [Indexed: 12/17/2022] Open
Abstract
In this article, we report an up-to-date summary on tracheal occlusion (TO) as an approach to drive accelerated lung growth and strive to review the different maternal- and fetal-derived local and systemic signals and mechanisms that may play a significant biological role in lung growth and formation of heterogeneous topological zones following TO. Pulmonary hypoplasia is a condition whereby branching morphogenesis and embryonic pulmonary vascular development are globally affected and is classically seen in congenital diaphragmatic hernia. TO is an innovative approach aimed at driving accelerated lung growth in the most severe forms of diaphragmatic hernia and has been shown to result in improved neonatal outcomes. Currently, most research on mechanisms of TO-induced lung growth is focused on mechanical forces and is viewed from the perspective of homogeneous changes within the lung. We suggest that the key principle in understanding changes in fetal lungs after TO is taking into account formation of unique variable topological zones. Following TO, fetal lungs might temporarily look like a dynamically changing topologic mosaic with varying proliferation rates, dissimilar scale of vasculogenesis, diverse patterns of lung tissue damage, variable metabolic landscape, and different structures. The reasons for this dynamic topological mosaic pattern may include distinct degree of increased hydrostatic pressure in different parts of the lung, dissimilar degree of tissue stress/damage and responses to this damage, and incomparable patterns of altered lung zones with variable response to systemic maternal and fetal factors, among others. The local interaction between these factors and their accompanying processes in addition to the potential role of other systemic factors might lead to formation of a common vector of biological response unique to each zone. The study of the interaction between various networks formed after TO (action of mechanical forces, activation of mucosal mast cells, production and secretion of damage-associated molecular pattern substances, low-grade local pulmonary inflammation, and cardiac contraction-induced periodic agitation of lung tissue, among others) will bring us closer to an appreciation of the biological phenomenon of topological heterogeneity within the fetal lungs.
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Affiliation(s)
- Ahmed I Marwan
- Division of Pediatric Surgery, Department of Surgery, University of Colorado Denver School of Medicine, Denver, CO, United States
| | - Uladzimir Shabeka
- Division of Pediatric Surgery, Department of Surgery, University of Colorado Denver School of Medicine, Denver, CO, United States
| | - Evgenia Dobrinskikh
- Department of Medicine, University of Colorado Denver School of Medicine, Denver, CO, United States
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104
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Feasibility and Outcomes of Fetoscopic Tracheal Occlusion for Severe Left Diaphragmatic Hernia. Obstet Gynecol 2017; 129:20-29. [DOI: 10.1097/aog.0000000000001749] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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105
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Fetal Tracheal Occlusion for Severe Pulmonary Hypoplasia in Isolated Congenital Diaphragmatic Hernia. Ann Surg 2016; 264:929-933. [DOI: 10.1097/sla.0000000000001675] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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106
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Braga ADFDA, da Silva Braga FS, Nascimento SP, Verri B, Peralta FC, Bennini Junior J, Jorge K. [Fetoscopic tracheal occlusion for severe congenital diaphragmatic hernia: retrospective study]. Rev Bras Anestesiol 2016; 67:331-336. [PMID: 27157206 DOI: 10.1016/j.bjan.2015.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 12/29/2015] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The temporary fetal tracheal occlusion performed by fetoscopy accelerates lung development and reduces neonatal mortality. The aim of this paper is to present an anesthetic experience in pregnant women, whose fetuses have diaphragmatic hernia, undergoing fetoscopic tracheal occlusion (FETO). METHOD Retrospective, descriptive study, approved by the Institutional Ethics Committee. Data were obtained from medical and anesthetic records. RESULTS FETO was performed in 28 pregnant women. Demographic characteristics: age 29.8±6.5; weight 68.64±12.26; ASA I and II. Obstetric: IG 26.1±1.10 weeks (in FETO); 32.86±1.58 (reversal of occlusion); 34.96±2.78 (delivery). Delivery: cesarean section, vaginal delivery. Fetal data: Weight (g) in the occlusion and delivery times, respectively (1045.82±222.2 and 2294±553); RPC in FETO and reversal of occlusion: 0.7±0.15 and 1.32±0.34, respectively. Preoperative maternal anesthesia included ranitidine and metoclopramide, nifedipine (VO) and indomethacin (rectal). Preanesthetic medication with midazolam IV. Anesthetic techniques: combination of 0.5% hyperbaric bupivacaine (5-10mg) and sufentanil; continuous epidural predominantly with 0.5% bupivacaine associated with sufentanil, fentanyl, or morphine; general. In 8 cases, there was need to complement via catheter, with 5 submitted to PC and 3 to BC. Thirteen patients required intraoperative sedation; ephedrine was used in 15 patients. Fetal Anesthesia: fentanyl 10 to 20mg·kg-1 and pancuronium 0,1-0,2mg·kg-1 (IM). Neonatal survival rate was 60.7%. CONCLUSION FETO is a minimally invasive technique for severe congenital diaphragmatic hernia repair. Combined blockade associated with sedation and fetal anesthesia proved safe and effective for tracheal occlusion.
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Affiliation(s)
| | - Franklin Sarmento da Silva Braga
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Anestesiologia, Campinas, SP, Brasil
| | | | - Bruno Verri
- Hospital Vivalle, São José dos Campos, SP, Brasil
| | - Fabio C Peralta
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Tocoginecologia, Campinas, SP, Brasil
| | - João Bennini Junior
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Tocoginecologia, Campinas, SP, Brasil
| | - Karina Jorge
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Tocoginecologia, Campinas, SP, Brasil
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107
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Enhanced Pulmonary Vascular and Alveolar Development via Prenatal Administration of a Slow-Release Synthetic Prostacyclin Agonist in Rat Fetal Lung Hypoplasia. PLoS One 2016; 11:e0161334. [PMID: 27529478 PMCID: PMC4987057 DOI: 10.1371/journal.pone.0161334] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 08/03/2016] [Indexed: 12/05/2022] Open
Abstract
Lung hypoplasia and pulmonary hypertension are the major causes of mortality in neonates with congenital diaphragmatic hernia (CDH). Although the prostaglandin pathway plays a pivotal role in lung development, the reported efficacy of postnatal prostaglandin agonist treatment is suboptimal. We hypothesized that prenatal treatment with ONO-1301SR, a slow-release form of a novel synthetic prostacyclin agonist with thromboxane inhibitory activity, might enhance the development of lungs exhibiting hypoplasia in the fetal period. On embryonic day (E) 9.5, nitrofen was given to pregnant Sprague-Dawley rats to establish a CDH-related lung hypoplasia model, whereas normal rats received the vehicle only. The same day, either ONO-1301SR or a placebo was also randomly administered. On E21.5, the fetuses of the normal group and those exhibiting CDH were analyzed. Prenatal ONO-1301SR administration had no influence on the incidence of nitrofen-induced CDH. The lung-to-body weight ratio in the CDH+ONO group was greater than that in the CDH group. Histologically, the medial wall in the CDH+ONO group was two-thirds thinner than that in the CDH group. In addition, the number of Ttf-1-positive cells and the capillary density were ≥1.5 times greater in the CDH+ONO group than in the CDH group, and this increase was associated with higher expression of vascular endothelial growth factor and stromal cell-derived factor in the CDH+ONO group, suggesting enhanced development of the alveolar and capillary networks. Thus, prenatal ONO-1301SR was protective against the progression of lung hypoplasia associated with CDH in a nitrofen-induced rat model, indicating the potential of this treatment for pathologies exhibiting lung hypoplasia.
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108
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Blumenthal-Barby JS, Krieger H, Wei A, Kim D, Olutoye OO, Cass DL. Communication about maternal-fetal surgery for myelomeningocele and congenital diaphragmatic hernia: preliminary findings with implications for informed consent and shared decision-making. J Perinat Med 2016; 44:645-53. [PMID: 25870957 DOI: 10.1515/jpm-2015-0039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 03/15/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To examine the style and content of consultations for maternal-fetal surgery and draw conclusions about best practices for informed consent and shared decision-making. STUDY DESIGN Qualitative study of 15 h-long consultations with women diagnosed with fetal myelomeningocele (MMC, n=11) or congenital diaphragmatic hernia (CDH, n=4) who were potential candidates for maternal-fetal surgery at a large children's hospital in the Southwestern US. RESULTS Major findings were that physicians tended to discuss the risks of fetal prognosis qualitatively more often than quantitatively (70% compared to 30%) and when mortality was a risk the "positive" (percentage survival) frame was always given rather than the morality frame. On average, families only talked 15% of the time and 45% of all their questions were about diagnostic or surgical procedure clarification. CONCLUSION Efforts should be made to minimize qualitative presentation of risk, which can be vague and confusing to patients. Both survival and mortality frames should be used to avoid biased decision-making. Communication and decision support tools that facilitate more shared decision-making between families and physicians are needed.
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109
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Gien J, Kinsella JP. Management of pulmonary hypertension in infants with congenital diaphragmatic hernia. J Perinatol 2016; 36 Suppl 2:S28-31. [PMID: 27225962 DOI: 10.1038/jp.2016.46] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 02/10/2016] [Accepted: 02/16/2016] [Indexed: 11/09/2022]
Abstract
In infants with congenital diaphragmatic hernia (CDH), a posterolateral diaphragmatic defect results in herniation of abdominal contents into the chest and compression of the intrathoracic structures. In the most severe cases, hypoplasia of the ipsilateral and contralateral lungs, severe pulmonary hypertension (PH) and left ventricular (LV) hypoplasia/dysfunction all contribute to increased mortality. The management of PH in CDH is complicated by structural and functional changes in the heart, pulmonary vasculature, airways and lung parenchyma; consequently, determining optimal management strategies is challenging. Treatment of PH in patients with CDH changes as the underlying pathophysiology evolves in the days and weeks after birth. During the early transition, the use of pulmonary vasodilators is limited by LV structural and functional abnormalities, and pulmonary vasodilators such as inhaled nitric oxide (iNO) may have a limited role (for example, stabilization for extracorporeal membrane oxygenation (ECMO), treatment of marked preductal desaturation and treatment of PH as LV performance improves). In contrast, subacute treatment of PH in CDH with iNO has an important role in recurrent or persistent PH and potentially improves survival. Chronic PH and vascular abnormalities may persist into childhood in patients with CDH, contributing to late mortality. It is unclear how pulmonary vasodilator therapies, such as iNO, sildenafil and bosentan, will modulate late outcomes in CDH with late/chronic PH.
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Affiliation(s)
- J Gien
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - J P Kinsella
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
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110
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Ruano R, Britto ISW, Sananes N, Lee W, Sangi-Haghpeykar H, Deter RL. Growth Patterns of Fetal Lung Volumes in Healthy Fetuses and Fetuses With Isolated Left-Sided Congenital Diaphragmatic Hernia. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:1159-1166. [PMID: 27091916 DOI: 10.7863/ultra.15.08005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 08/31/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To evaluate fetal lung growth using 3-dimensional sonography in healthy fetuses and those with congenital diaphragmatic hernia (CDH). METHODS Right and total lung volumes were serially evaluated by 3-dimensional sonography in 66 healthy fetuses and 52 fetuses with left-sided CDH between 20 and 37 weeks' menstrual age. Functions fitted to these parameters were compared for 2 groups: (1) healthy versus those with CDH; and (2) fetuses with CHD who survived versus those who died. RESULTS Fetal right and total lung volumes as well as fetal observed-to-expected right and total lung volume ratios were significantly lower in fetuses with CDH than healthy fetuses (P< .001) and in those fetuses with CDH who died (P< .001). The observed-to-expected right and total lung volume ratios did not vary with menstrual age in healthy fetuses or in those with CDH (independent of outcome). CONCLUSIONS Lung volume rates were lower in fetuses with left-sided CDH compared to healthy fetuses, as well as in fetuses with CDH who died compared to those who survived. The observed-to-expected right and total lung volume ratios were relatively constant throughout menstrual age in fetuses with left-sided CDH, suggesting that the origin of their lung growth abnormalities occurred before 20 weeks and did not progress. The observed-to-expected ratios may be useful in predicting the outcome in fetuses with CDH independent of menstrual age.
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Affiliation(s)
- Rodrigo Ruano
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas USA
| | - Ingrid Schwach Werneck Britto
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas USADepartment of Obstetrics and Gynecology, Medical Science College of Santa Casa of São Paulo, São Paulo, Brazil
| | - Nicolas Sananes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas USA
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas USA
| | - Haleh Sangi-Haghpeykar
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas USA
| | - Russell L Deter
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas USA
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111
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The extracellular calcium-sensing receptor regulates human fetal lung development via CFTR. Sci Rep 2016; 6:21975. [PMID: 26911344 PMCID: PMC4766410 DOI: 10.1038/srep21975] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 02/02/2016] [Indexed: 11/24/2022] Open
Abstract
Optimal fetal lung growth requires anion-driven fluid secretion into the lumen of the developing organ. The fetus is hypercalcemic compared to the mother and here we show that in the developing human lung this hypercalcaemia acts on the extracellular calcium-sensing receptor, CaSR, to promote fluid-driven lung expansion through activation of the cystic fibrosis transmembrane conductance regulator, CFTR. Several chloride channels including TMEM16, bestrophin, CFTR, CLCN2 and CLCA1, are also expressed in the developing human fetal lung at gestational stages when CaSR expression is maximal. Measurements of Cl−-driven fluid secretion in organ explant cultures show that pharmacological CaSR activation by calcimimetics stimulates lung fluid secretion through CFTR, an effect which in humans, but not mice, was also mimicked by fetal hypercalcemic conditions, demonstrating that the physiological relevance of such a mechanism appears to be species-specific. Calcimimetics promote CFTR opening by activating adenylate cyclase and we show that Ca2+-stimulated type I adenylate cyclase is expressed in the developing human lung. Together, these observations suggest that physiological fetal hypercalcemia, acting on the CaSR, promotes human fetal lung development via cAMP-dependent opening of CFTR. Disturbances in this process would be expected to permanently impact lung structure and might predispose to certain postnatal respiratory diseases.
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112
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Zambaiti E, Bussani R, Calcaterra V, Zandonà L, Silvestri F, Peiró JL, Marotta M, Andreatta E, Pelizzo G. Myocardial effects of fetal endoscopic tracheal occlusion in lambs with CDH. Prenat Diagn 2016; 36:362-7. [PMID: 26850832 DOI: 10.1002/pd.4789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 02/01/2016] [Accepted: 02/01/2016] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Fetal endoscopic tracheal occlusion in congenital diaphragmatic hernia (CDH) may reduce pulmonary hypertension and ameliorate postnatal cardiac output. The effects of sustained early (ETO) and late (LTO) tracheal occlusion on left ventricular (LV) cells in the lamb model have not been described. MATERIALS AND METHODS CDH was created in lambs at 70 days' gestation (term = 145 days). ETO (85 days) or LTO (105 days) was sustained till term. After cesarean section (140 days) fetuses were euthanized and hearts harvested. LV myocardial cells were studied by histological and immunofluorescence (TGF-beta 1, endothelin-1) assays in CDH, ETO, LTO, and the control group (two subjects per group). Small intramyocardial arteries were evaluated by traditional histology. RESULTS LV myocardial histology in CDH and LTO was similar. ETO-induced LV myocardial cell enlargement and increased endothelin-1 and TGF-beta 1 staining; a weaker immunofluorescence signal was observed in LTO compared with ETO. Myocardial vascular wall thickness was greater in CDH than in controls. ETO was associated with a vascular wall thickness within the range of controls. CONCLUSION With only two fetuses in each group, only an explorative evaluation was possible. The time point at which TO is performed seems to have an effect on cardiac morphology. Functional studies as well as confirmation in clinical samples are mandatory.
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Affiliation(s)
- Elisa Zambaiti
- Pediatric Surgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Rossana Bussani
- Institute of Pathologic Anatomy, University of Trieste, Trieste, Italy
| | - Valeria Calcaterra
- Pediatric Unit, Department of Internal Medicine, University of Pavia, Pavia, Italy.,Department of Maternal and Children's Health, Pediatric Unit, Fondazione IRCCS Policlinico San Matteo Pavia, Pavia, Italy
| | - Lorenzo Zandonà
- Institute of Pathologic Anatomy, University of Trieste, Trieste, Italy
| | - Furio Silvestri
- Institute of Pathologic Anatomy, University of Trieste, Trieste, Italy
| | - José Luis Peiró
- Cinicinnati Fetal Center, The Center for Fetal, Cellular, and Molecular Therapy, Pediatric Surgery Division, CCHMC, Cincinnati, OH, USA.,Fetal Surgery Program, Congenital Malformations Research Group, Research Institute of Hospital Universitari Vall d'Hebron, Edifici Infantil, Barcelona, Spain
| | - Mario Marotta
- Cinicinnati Fetal Center, The Center for Fetal, Cellular, and Molecular Therapy, Pediatric Surgery Division, CCHMC, Cincinnati, OH, USA.,Fetal Surgery Program, Congenital Malformations Research Group, Research Institute of Hospital Universitari Vall d'Hebron, Edifici Infantil, Barcelona, Spain
| | - Erika Andreatta
- Pediatric Surgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Gloria Pelizzo
- Pediatric Surgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
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113
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Abstract
Background: Congenital diaphragmatic hernia (CDH) is a simple diaphragmatic defect that is seen frequently in antenatal scans. Though the surgical repair is relatively easy in the neonate, the mortality is high due to pulmonary hypoplasia and pulmonary vascular changes. Materials and Methods: The goals of prenatal imaging are to establish the diagnosis. Assessment in a tertiary scanning center would identify prognostic factors which assist in counselling and planning antenatal management. However, the pulmonary hypoplasia associated with the CDH in moderate and severe cases makes the prognosis poor. Conclusions: Fetal intervention such as, fetal tracheal occlusion, is being trialled and may change the outcomes in the future.
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Affiliation(s)
- Jay Marlow
- Mater Centre for Maternal Fetal Medicine Mater Mothers Hospital Raymond Terrace South Brisbane Queensland Australia
| | - Joseph Thomas
- Mater Centre for MaternalFetal Medicine Mater MothersHospital Raymond Terrace South BrisbaneQueenslandAustralia; Department of ObstetricsGynecology School of Medicine UniversityQueensland St Lucia BrisbaneQueenslandAustralia
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114
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Vuckovic A, Herber-Jonat S, Flemmer AW, Ruehl IM, Votino C, Segers V, Benachi A, Martinovic J, Nowakowska D, Dzieniecka M, Jani JC. Increased TGF-β: a drawback of tracheal occlusion in human and experimental congenital diaphragmatic hernia? Am J Physiol Lung Cell Mol Physiol 2015; 310:L311-27. [PMID: 26637634 DOI: 10.1152/ajplung.00122.2015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 12/03/2015] [Indexed: 12/15/2022] Open
Abstract
Survivors of severe congenital diaphragmatic hernia (CDH) present significant respiratory morbidity despite lung growth induced by fetal tracheal occlusion (TO). We hypothesized that the underlying mechanisms would involve changes in lung extracellular matrix and dysregulated transforming growth factor (TGF)-β pathway, a key player in lung development and repair. Pulmonary expression of TGF-β signaling components, downstream effectors, and extracellular matrix targets were evaluated in CDH neonates who died between birth and the first few weeks of life after prenatal conservative management or TO, and in rabbit pups that were prenatally randomized for surgical CDH and TO vs. sham operation. Before tissue harvesting, lung tissue mechanics in rabbits was measured using the constant-phase model during the first 30 min of life. Human CDH and control fetal lungs were also collected from midterm onwards. Human and experimental CDH did not affect TGF-β/Smad2/3 expression and activity. In human and rabbit CDH lungs, TO upregulated TGF-β transcripts. Analysis of downstream pathways indicated increased Rho-associated kinases to the detriment of Smad2/3 activation. After TO, subtle accumulation of collagen and α-smooth muscle actin within alveolar walls was detected in rabbit pups and human CDH lungs with short-term mechanical ventilation. Despite TO-induced lung growth, mediocre lung tissue mechanics in the rabbit model was associated with increased transcription of extracellular matrix components. These results suggest that prenatal TO increases TGF-β/Rho kinase pathway, myofibroblast differentiation, and matrix deposition in neonatal rabbit and human CDH lungs. Whether this might influence postnatal development of sustainably ventilated lungs remains to be determined.
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Affiliation(s)
- Aline Vuckovic
- Laboratory of Physiology and Pathophysiology, Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium;
| | - Susanne Herber-Jonat
- Division of Neonatology, University Children's Hospital, Perinatal Center, Ludwig-Maximilian-University Munich, Munich, Germany
| | - Andreas W Flemmer
- Division of Neonatology, University Children's Hospital, Perinatal Center, Ludwig-Maximilian-University Munich, Munich, Germany
| | - Ina M Ruehl
- Division of Neonatology, University Children's Hospital, Perinatal Center, Ludwig-Maximilian-University Munich, Munich, Germany
| | - Carmela Votino
- Department of Obstetrics and Gynecology, Fetal Medicine Unit, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Valérie Segers
- Unit of Pediatric Pathology, Pathology Department, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandra Benachi
- Department of Obstetrics and Gynecology and Centre de Maladie Rare: Hernie de Coupole Diaphragmatique, Hôpital Antoine Béclère, Assistance Publique Hôpitaux de Paris (APHP), Université Paris Sud, Paris, France
| | - Jelena Martinovic
- Unit of Fetal Pathology, Hôpital Antoine Béclère, Assistance Publique Hôpitaux de Paris (APHP), Université Paris Sud, Paris, France
| | - Dorota Nowakowska
- Department of Fetal-Maternal Medicine and Gynecology, Medical University and the Research Institute Polish Mother's Memorial Hospital, Lodz, Poland; and
| | - Monika Dzieniecka
- Department of Clinical Pathology, Medical University and the Research Institute Polish Mother's Memorial Hospital, Lodz, Poland
| | - Jacques C Jani
- Department of Obstetrics and Gynecology, Fetal Medicine Unit, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
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Sananes N, Rodo C, Peiro JL, Britto ISW, Sangi-Haghpeykar H, Favre R, Joal A, Gaudineau A, Silva MMD, Tannuri U, Zugaib M, Carreras E, Ruano R. Prematurity and fetal lung response after tracheal occlusion in fetuses with severe congenital diaphragmatic hernia. J Matern Fetal Neonatal Med 2015; 29:3030-4. [PMID: 26633729 DOI: 10.3109/14767058.2015.1114080] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the independent association of fetal pulmonary response and prematurity to postnatal outcomes after fetal tracheal occlusion for congenital diaphragmatic hernia. METHODS Fetal pulmonary response, prematurity (<37 weeks at delivery) and extreme prematurity (<32 weeks at delivery) were evaluated and compared between survivors and non-survivors at 6 months of life. Multivariable analysis was conducted with generalized linear mixed models for variables significantly associated with survival in univariate analysis. RESULTS Eighty-four infants were included, of whom 40 survived (47.6%) and 44 died (52.4%). Univariate analysis demonstrated that survival was associated with greater lung response (p=0.006), and the absence of extreme preterm delivery (p=0.044). In multivariable analysis, greater pulmonary response after FETO was an independent predictor of survival (aOR 1.87, 95% CI 1.08-3.33, p=0.023), whereas the presence of extreme prematurity was not statistically associated with mortality after controlling for fetal pulmonary response (aOR 0.52, 95% CI 0.12-2.30, p=0.367). CONCLUSION Fetal pulmonary response after FETO is the most important factor associated with survival, independently from the gestational age at delivery.
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Affiliation(s)
- Nicolas Sananes
- a Department of Obstetrics and Gynecology , Texas Children's Fetal Center, Baylor College of Medicine , Houston , TX , USA .,b Service De Gynécologie Obstétrique, CMCO - HUS, Hôpitaux Universitaires De Strasbourg , Strasbourg , France
| | - Carlota Rodo
- c Fetal Surgery Program, Hospital Universitari Vall D'hebron , Barcelona , Spain
| | - Jose Luis Peiro
- c Fetal Surgery Program, Hospital Universitari Vall D'hebron , Barcelona , Spain
| | - Ingrid Schwach Werneck Britto
- a Department of Obstetrics and Gynecology , Texas Children's Fetal Center, Baylor College of Medicine , Houston , TX , USA
| | - Haleh Sangi-Haghpeykar
- a Department of Obstetrics and Gynecology , Texas Children's Fetal Center, Baylor College of Medicine , Houston , TX , USA
| | - Romain Favre
- b Service De Gynécologie Obstétrique, CMCO - HUS, Hôpitaux Universitaires De Strasbourg , Strasbourg , France
| | - Arnaud Joal
- b Service De Gynécologie Obstétrique, CMCO - HUS, Hôpitaux Universitaires De Strasbourg , Strasbourg , France
| | - Adrien Gaudineau
- b Service De Gynécologie Obstétrique, CMCO - HUS, Hôpitaux Universitaires De Strasbourg , Strasbourg , France
| | | | | | - Marcelo Zugaib
- e Department of Obstetrics and Gynecology , Faculdade De Medicina, Universidade De Sao Paulo , Sao Paulo , Brazil
| | - Elena Carreras
- b Service De Gynécologie Obstétrique, CMCO - HUS, Hôpitaux Universitaires De Strasbourg , Strasbourg , France
| | - Rodrigo Ruano
- a Department of Obstetrics and Gynecology , Texas Children's Fetal Center, Baylor College of Medicine , Houston , TX , USA .,e Department of Obstetrics and Gynecology , Faculdade De Medicina, Universidade De Sao Paulo , Sao Paulo , Brazil
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Dobrescu O, Cannie MM, Cordier AG, Rodó C, Fabietti I, Benachi A, Carreras E, Persico N, Hurtado I, Gucciardo L, Jani JC. Prophylactic use of the Arabin cervical pessary in fetuses with severe congenital diaphragmatic hernia treated by fetoscopic endoluminal tracheal occlusion (FETO): preliminary experience. Prenat Diagn 2015; 36:81-7. [DOI: 10.1002/pd.4716] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 10/26/2015] [Accepted: 10/27/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Oana Dobrescu
- Department of Obstetrics and Gynaecology; University Hospital Brugmann, Université Libre de Bruxelles; Brussels Belgium
| | - Mieke M. Cannie
- Department of Radiology; University Hospital Brugmann, Université Libre de Bruxelles; Brussels Belgium
- Department of Radiology; UZ Brussel, Vrije Universiteit Brussel; Brussel Belgium
| | - Anne-Gael Cordier
- Department of Obstetrics, Gynecology and Reproductive Medicine and Centre Maladies Rares: Hernie de Coupole Diaphragmatique; Hôpital Antoine Béclère, APHP, Université Paris Sud; Paris France
| | - Carlota Rodó
- Department of Obstetrics, Gynecology and Reproductive Medicine; Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Barcelona Spain
| | - Isabella Fabietti
- Department of Obstetrics and Gynecology ‘L. Mangiagalli’; Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico; Milan Italy
| | - Alexandra Benachi
- Department of Obstetrics, Gynecology and Reproductive Medicine and Centre Maladies Rares: Hernie de Coupole Diaphragmatique; Hôpital Antoine Béclère, APHP, Université Paris Sud; Paris France
| | - Elena Carreras
- Department of Obstetrics, Gynecology and Reproductive Medicine; Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona; Barcelona Spain
| | - Nicola Persico
- Department of Obstetrics and Gynecology ‘L. Mangiagalli’; Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico; Milan Italy
| | - Ivan Hurtado
- Department of Obstetrics and Gynaecology; University Hospital Brugmann, Université Libre de Bruxelles; Brussels Belgium
| | - Léonardo Gucciardo
- Department of Obstetrics and Gynaecology; University Hospital Brugmann, Université Libre de Bruxelles; Brussels Belgium
- Department of Obstetrics; UZ Brussel, Vrije Universiteit Brussel; Brussel Belgium
| | - Jacques C. Jani
- Department of Obstetrics and Gynaecology; University Hospital Brugmann, Université Libre de Bruxelles; Brussels Belgium
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Grivell RM, Andersen C, Dodd JM. Prenatal interventions for congenital diaphragmatic hernia for improving outcomes. Cochrane Database Syst Rev 2015; 2015:CD008925. [PMID: 26611822 PMCID: PMC8947621 DOI: 10.1002/14651858.cd008925.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH), is an uncommon but severe condition in which there is a developmental defect in the fetal diaphragm, resulting in liver and bowel migrating to the chest cavity and impairing lung development and function for the neonate. This condition can be diagnosed during pregnancy and as such, is potentially amenable to in-utero prenatal intervention. Neonatal surgical repair is possible, but even with early surgical repair and improving neonatal management, neonatal morbidity and mortality is high. Prenatal interventions described to date have included maternal antenatal corticosteroid administration and fetal tracheal occlusion, with both methods aiming to improve lung growth and maturity. However surgical procedures have potential maternal complications, as the uterus and amniotic sac are breached in order to gain access to the fetus. OBJECTIVES To compare the effects of prenatal versus postnatal interventions for CDH on perinatal mortality and morbidity, longer-term infant outcomes and maternal morbidity, and to compare the effects of different prenatal interventions with each other. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2015) and reference lists of retrieved studies. SELECTION CRITERIA All published (including those published in abstract form), unpublished, and ongoing randomised controlled trials comparing prenatal and postnatal interventions for fetuses with CDH. Quasi-RCTs were eligible for inclusion but none were identified. Trials using a cross-over design are not eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors evaluated trials for inclusion and methodological quality without consideration of their results according to the stated eligibility criteria and extracted data independently. Data were checked for accuracy. MAIN RESULTS We identified 11 studies for potential inclusion. Of those, we included three studies involving 97 women. Two additional studies are ongoing.Two trials examined in-utero fetal tracheal occlusion with standard (postnatal) care in fetuses with severe diaphragmatic hernia. Whilst the trials utilised fetal interventions that were similar, there were important differences in how access was gained to the fetus and in the timing and mode of delivery. Therefore, we did not combine these trials in meta-analysis and the results are examined in separate comparisons. One trial examined the effect of antenatal corticosteroids versus placebo. Overall, the methodological quality of the trials was variable and no data were available for a number of this review's secondary outcomes. In-utero fetal occlusion by maternal laparotomy versus standard postnatal management (one trial, 24 women)For the primary infant outcome (perinatal mortality), there were no data suitable for inclusion in the analysis. There was no difference between groups in terms of long-term infant survival (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.66 to 1.69). In-utero fetal occlusion by minimally invasive fetoscopy versus standard postnatal management (one trial, 41 women)The primary infant outcome (perinatal mortality) was not reported. Minimally invasive fetoscopy was associated with a small reduction in the mean gestational age at birth (mean difference (MD) -1.80 weeks, 95% CI -3.13 to -0.47), but there was no clear difference in the risk of preterm birth before 37 weeks (RR 1.75, 95% CI 0.78 to 3.92). Long-term infant survival (three to six months) (RR 10.50, 95% CI 1.48 to 74.71) was increased with the intervention when compared with standard management, and there was a corresponding reduction in pulmonary hypertension (RR 0.58, 95% CI 0.36 to 0.93) associated with the intervention. There was no difference between groups in terms of preterm ruptured membranes (< 37 weeks) (RR 1.47, 95% CI 0.56 to 3.88) or maternal infectious morbidity (RR 3.14, 95% CI 0.14 to 72.92), and there were no maternal blood transfusions. Antenatal corticosteroids versus placebo (one trial, 32 women)We also included one trial (involving 32 women) examining the effect of antenatal corticosteroids versus placebo. There was no clear difference in the incidence of perinatal mortality (our primary infant outcome) between the group of women who received antenatal corticosteroids and the placebo control (RR 1.24, 95% CI 0.50 to 3.08). Data (mean only) were reported for two of our secondary outcomes (mechanical ventilation and days of hospital admission) but standard deviations (SDs) were not provided. For the purposes of this review and to permit further analysis we have estimated the SDs based on the reported P values reported in the trial report, although our estimation does assume that the SD is the same in both the intervention and control groups. There were no differences between the antenatal corticosteroid group and the placebo control in terms of days of mechanical ventilation (MD 18.00 days, 95% CI -14.77 to 50.77) or days of hospital admission (MD 17.00 days, 95% CI -13.93 to 47.93) . AUTHORS' CONCLUSIONS There is currently insufficient evidence to recommend in-utero intervention for fetuses with CDH as a part of routine clinical practice. We identified three small studies, with only one study adequately reporting on the primary outcome of this review - perinatal mortality, and there were few data pertaining to many of this review's secondary outcomes.WIth regard to the administration of antenatal corticosteroids, there remains a gap in current research, and a large multicentre trial with adequate statistical power should be undertaken to answer this unresolved question. More studies are needed to further examine the effect of in-utero fetal tracheal occlusion on important neonatal outcomes and long-term infant survival and health. Long-term follow-up is of particular importance, and should include morbidity and mortality measures. Further studies should examine the benefits of an in-utero intervention on subgroups with moderate and severe congenital diaphragmatic hernia. Indeed, there are three ongoing studies, being conducted by European, North and South American fetal medicine centres, which will contribute to this gap. Ongoing research and any implementation into clinical practice should include standardisation of the procedure, inclusion criteria and long-term childhood follow-up.
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Affiliation(s)
- Rosalie M Grivell
- The University of Adelaide, Women's and Children's HospitalDiscipline of Obstetrics and Gynaecology, Robinson Research Institute72 King William RoadAdelaideSouth AustraliaAustraliaSA 5006
| | - Chad Andersen
- Women's and Children's HospitalDepartment of Neonatal Medicine72 King William RoadNorth AdelaideSouth AustraliaAustralia5006
| | - Jodie M Dodd
- The University of Adelaide, Women's and Children's HospitalSchool of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology72 King William RoadAdelaideSouth AustraliaAustralia5006
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Britto ISW, Sananes N, Olutoye OO, Cass DL, Sangi-Haghpeykar H, Lee TC, Cassady CI, Mehollin-Ray A, Welty S, Fernandes C, Belfort MA, Lee W, Ruano R. Standardization of Sonographic Lung-to-Head Ratio Measurements in Isolated Congenital Diaphragmatic Hernia: Impact on the Reproducibility and Efficacy to Predict Outcomes. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:1721-1727. [PMID: 26307118 DOI: 10.7863/ultra.15.14.11064] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 12/16/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate the impact of standardization of the lung-to-head ratio measurements in isolated congenital diaphragmatic hernia on prediction of neonatal outcomes and reproducibility. METHODS We conducted a retrospective cohort study of 77 cases of isolated congenital diaphragmatic hernia managed in a single center between 2004 and 2012. We compared lung-to-head ratio measurements that were performed prospectively in our institution without standardization to standardized measurements performed according to a defined protocol. RESULTS The standardized lung-to-head ratio measurements were statistically more accurate than the nonstandardized measurements for predicting neonatal mortality (area under the receiver operating characteristic curve, 0.85 versus 0.732; P = .003). After standardization, there were no statistical differences in accuracy between measurements regardless of whether we considered observed-to-expected values (P > .05). Standardization of the lung-to-head ratio did not improve prediction of the need for extracorporeal membrane oxygenation (P> .05). Both intraoperator and interoperator reproducibility were good for the standardized lung-to-head ratio (intraclass correlation coefficient, 0.98 [95% confidence interval, 0.97-0.99]; bias, 0.02 [limits of agreement, -0.11 to +0.15], respectively). CONCLUSIONS Standardization of lung-to-head ratio measurements improves prediction of neonatal outcomes. Further studies are needed to confirm these results and to assess the utility of standardization of other prognostic parameters.
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Affiliation(s)
- Ingrid Schwach Werneck Britto
- Texas Children's Fetal Center, Houston, Texas USA (I.S.W.B., N.S., O.O.O., D.L.C., T.C.L., C.I.C., A.M.-R., S.W., C.F., M.A.B., W.L., R.R.); and Department of Obstetrics and Gynecology (I.S.W.B., N.S., H.S.-H., M.A.B., W.L., R.R.), Michael E. DeBakey Department of Surgery (O.O.O., D.L.C., T.C.L.), Department of Radiology (C.I.C., A.M.-R.), and Department of Pediatrics, Section of Neonatology (S.W., C.F.), Baylor College of Medicine, Houston, Texas USA
| | - Nicolas Sananes
- Texas Children's Fetal Center, Houston, Texas USA (I.S.W.B., N.S., O.O.O., D.L.C., T.C.L., C.I.C., A.M.-R., S.W., C.F., M.A.B., W.L., R.R.); and Department of Obstetrics and Gynecology (I.S.W.B., N.S., H.S.-H., M.A.B., W.L., R.R.), Michael E. DeBakey Department of Surgery (O.O.O., D.L.C., T.C.L.), Department of Radiology (C.I.C., A.M.-R.), and Department of Pediatrics, Section of Neonatology (S.W., C.F.), Baylor College of Medicine, Houston, Texas USA
| | - Oluyinka O Olutoye
- Texas Children's Fetal Center, Houston, Texas USA (I.S.W.B., N.S., O.O.O., D.L.C., T.C.L., C.I.C., A.M.-R., S.W., C.F., M.A.B., W.L., R.R.); and Department of Obstetrics and Gynecology (I.S.W.B., N.S., H.S.-H., M.A.B., W.L., R.R.), Michael E. DeBakey Department of Surgery (O.O.O., D.L.C., T.C.L.), Department of Radiology (C.I.C., A.M.-R.), and Department of Pediatrics, Section of Neonatology (S.W., C.F.), Baylor College of Medicine, Houston, Texas USA
| | - Darrell L Cass
- Texas Children's Fetal Center, Houston, Texas USA (I.S.W.B., N.S., O.O.O., D.L.C., T.C.L., C.I.C., A.M.-R., S.W., C.F., M.A.B., W.L., R.R.); and Department of Obstetrics and Gynecology (I.S.W.B., N.S., H.S.-H., M.A.B., W.L., R.R.), Michael E. DeBakey Department of Surgery (O.O.O., D.L.C., T.C.L.), Department of Radiology (C.I.C., A.M.-R.), and Department of Pediatrics, Section of Neonatology (S.W., C.F.), Baylor College of Medicine, Houston, Texas USA
| | - Haleh Sangi-Haghpeykar
- Texas Children's Fetal Center, Houston, Texas USA (I.S.W.B., N.S., O.O.O., D.L.C., T.C.L., C.I.C., A.M.-R., S.W., C.F., M.A.B., W.L., R.R.); and Department of Obstetrics and Gynecology (I.S.W.B., N.S., H.S.-H., M.A.B., W.L., R.R.), Michael E. DeBakey Department of Surgery (O.O.O., D.L.C., T.C.L.), Department of Radiology (C.I.C., A.M.-R.), and Department of Pediatrics, Section of Neonatology (S.W., C.F.), Baylor College of Medicine, Houston, Texas USA
| | - Timothy C Lee
- Texas Children's Fetal Center, Houston, Texas USA (I.S.W.B., N.S., O.O.O., D.L.C., T.C.L., C.I.C., A.M.-R., S.W., C.F., M.A.B., W.L., R.R.); and Department of Obstetrics and Gynecology (I.S.W.B., N.S., H.S.-H., M.A.B., W.L., R.R.), Michael E. DeBakey Department of Surgery (O.O.O., D.L.C., T.C.L.), Department of Radiology (C.I.C., A.M.-R.), and Department of Pediatrics, Section of Neonatology (S.W., C.F.), Baylor College of Medicine, Houston, Texas USA
| | - Christopher I Cassady
- Texas Children's Fetal Center, Houston, Texas USA (I.S.W.B., N.S., O.O.O., D.L.C., T.C.L., C.I.C., A.M.-R., S.W., C.F., M.A.B., W.L., R.R.); and Department of Obstetrics and Gynecology (I.S.W.B., N.S., H.S.-H., M.A.B., W.L., R.R.), Michael E. DeBakey Department of Surgery (O.O.O., D.L.C., T.C.L.), Department of Radiology (C.I.C., A.M.-R.), and Department of Pediatrics, Section of Neonatology (S.W., C.F.), Baylor College of Medicine, Houston, Texas USA
| | - Amy Mehollin-Ray
- Texas Children's Fetal Center, Houston, Texas USA (I.S.W.B., N.S., O.O.O., D.L.C., T.C.L., C.I.C., A.M.-R., S.W., C.F., M.A.B., W.L., R.R.); and Department of Obstetrics and Gynecology (I.S.W.B., N.S., H.S.-H., M.A.B., W.L., R.R.), Michael E. DeBakey Department of Surgery (O.O.O., D.L.C., T.C.L.), Department of Radiology (C.I.C., A.M.-R.), and Department of Pediatrics, Section of Neonatology (S.W., C.F.), Baylor College of Medicine, Houston, Texas USA
| | - Stephen Welty
- Texas Children's Fetal Center, Houston, Texas USA (I.S.W.B., N.S., O.O.O., D.L.C., T.C.L., C.I.C., A.M.-R., S.W., C.F., M.A.B., W.L., R.R.); and Department of Obstetrics and Gynecology (I.S.W.B., N.S., H.S.-H., M.A.B., W.L., R.R.), Michael E. DeBakey Department of Surgery (O.O.O., D.L.C., T.C.L.), Department of Radiology (C.I.C., A.M.-R.), and Department of Pediatrics, Section of Neonatology (S.W., C.F.), Baylor College of Medicine, Houston, Texas USA
| | - Caraciolo Fernandes
- Texas Children's Fetal Center, Houston, Texas USA (I.S.W.B., N.S., O.O.O., D.L.C., T.C.L., C.I.C., A.M.-R., S.W., C.F., M.A.B., W.L., R.R.); and Department of Obstetrics and Gynecology (I.S.W.B., N.S., H.S.-H., M.A.B., W.L., R.R.), Michael E. DeBakey Department of Surgery (O.O.O., D.L.C., T.C.L.), Department of Radiology (C.I.C., A.M.-R.), and Department of Pediatrics, Section of Neonatology (S.W., C.F.), Baylor College of Medicine, Houston, Texas USA
| | - Michael A Belfort
- Texas Children's Fetal Center, Houston, Texas USA (I.S.W.B., N.S., O.O.O., D.L.C., T.C.L., C.I.C., A.M.-R., S.W., C.F., M.A.B., W.L., R.R.); and Department of Obstetrics and Gynecology (I.S.W.B., N.S., H.S.-H., M.A.B., W.L., R.R.), Michael E. DeBakey Department of Surgery (O.O.O., D.L.C., T.C.L.), Department of Radiology (C.I.C., A.M.-R.), and Department of Pediatrics, Section of Neonatology (S.W., C.F.), Baylor College of Medicine, Houston, Texas USA
| | - Wesley Lee
- Texas Children's Fetal Center, Houston, Texas USA (I.S.W.B., N.S., O.O.O., D.L.C., T.C.L., C.I.C., A.M.-R., S.W., C.F., M.A.B., W.L., R.R.); and Department of Obstetrics and Gynecology (I.S.W.B., N.S., H.S.-H., M.A.B., W.L., R.R.), Michael E. DeBakey Department of Surgery (O.O.O., D.L.C., T.C.L.), Department of Radiology (C.I.C., A.M.-R.), and Department of Pediatrics, Section of Neonatology (S.W., C.F.), Baylor College of Medicine, Houston, Texas USA
| | - Rodrigo Ruano
- Texas Children's Fetal Center, Houston, Texas USA (I.S.W.B., N.S., O.O.O., D.L.C., T.C.L., C.I.C., A.M.-R., S.W., C.F., M.A.B., W.L., R.R.); and Department of Obstetrics and Gynecology (I.S.W.B., N.S., H.S.-H., M.A.B., W.L., R.R.), Michael E. DeBakey Department of Surgery (O.O.O., D.L.C., T.C.L.), Department of Radiology (C.I.C., A.M.-R.), and Department of Pediatrics, Section of Neonatology (S.W., C.F.), Baylor College of Medicine, Houston, Texas USA.
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Nawapun K, Eastwood MP, Diaz-Cobos D, Jimenez J, Aertsen M, Gomez O, Claus F, Gratacós E, Deprest J. In vivo evidence by magnetic resonance volumetry of a gestational age dependent response to tracheal occlusion for congenital diaphragmatic hernia. Prenat Diagn 2015; 35:1048-56. [PMID: 26135752 DOI: 10.1002/pd.4642] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 06/23/2015] [Accepted: 06/25/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVE We aimed to assess in vivo changes in lung and liver volumes in fetuses with isolated congenital diaphragmatic hernia, either expectantly managed or treated in utero. METHOD This is a secondary analysis of prospectively collected data at two fetal therapy centers. We used archived magnetic resonance images of fetuses taken ≥7 days apart, creating paired observations in 20 expectantly managed cases, 41 with a second magnetic resonance prior to balloon reversal and 64 after balloon removal. We measured observed to expected total fetal lung volume (O/E TFLV) and liver-to-thoracic volume ratio. We calculated changes in volume as compared with the initial measurement and its rate as a function of gestational age (GA) at occlusion. RESULTS The liver-to-thoracic volume ratio did not change in either group. In expectantly managed fetuses, O/E TFLV did not increase with gestation. In fetuses undergoing tracheal occlusion, the measured increase in volume was 2.6 times larger with balloon in place as compared with that after its removal. GA at tracheal occlusion was an independent predictor of the O/E TFLV. The net rate seems to initially increase and plateau at a maximum of 1.5% per week by 35 to 45 days after occlusion. CONCLUSIONS Tracheal occlusion induces a net increase in volume, its magnitude essentially dependent on the GA at occlusion.
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Affiliation(s)
- Katika Nawapun
- Cluster Organ Systems, Department of Development and Regeneration, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium.,Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology Siriraj Hospital, Faculty of Medicine, Mahidol University, Bangkok, Thailand
| | - Mary Patrice Eastwood
- Cluster Organ Systems, Department of Development and Regeneration, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Daysi Diaz-Cobos
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (BCNatal), Hospital Clinic and Hospital Sant Joan de Deu, IDIBAPS, University of Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Julio Jimenez
- Cluster Organ Systems, Department of Development and Regeneration, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Michael Aertsen
- Division of Medical Imaging, Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Olga Gomez
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (BCNatal), Hospital Clinic and Hospital Sant Joan de Deu, IDIBAPS, University of Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Filip Claus
- Division of Medical Imaging, Department of Radiology, University Hospitals Leuven, Leuven, Belgium.,Department of Radiology, Onze Lieve Vrouw Hospital Aalst, Aalst, Belgium
| | - Eduard Gratacós
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (BCNatal), Hospital Clinic and Hospital Sant Joan de Deu, IDIBAPS, University of Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Jan Deprest
- Cluster Organ Systems, Department of Development and Regeneration, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium.,Fetal Medicine Unit, Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
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Antolin E, Rodriguez R, Encinas JL, Herrero B, Muner M, Perez R, Ortiz L, Bartha JL. Patterns of fetal lung growth in fetuses with isolated left-sided congenital diaphragmatic hernia. J Matern Fetal Neonatal Med 2015; 29:2443-50. [PMID: 26414203 DOI: 10.3109/14767058.2015.1087496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate right lung growth pattern in fetuses with isolated left-sided congenital diaphragmatic hernia (iL-CDH) and to analyze the pattern according to postnatal outcome. METHODS Lung-to-head ratio (LHR) and observed-to-expected LHR (O/E LHR) were obtained in 58 cases. Correlation and regression analysis for the total number of measurements, general linear models for those cases with a least three serial measurements and linear mixed effect models were used to analyze the influence of gestational age on the right lung size. Cases expectantly managed and those with fetal endoscopic tracheal occlusion were analyzed separately. RESULTS LHR, but not O/E LHR, increased significantly with gestational age (GA) (r = 0.43, p = 0.003 and r = -0.13, p = 0.30, respectively). According to neonatal mortality, in those fetuses that died, LHR remained unchanged and O/E LHR decreased significantly with GA (r = 0.07, p = 0.65 and r = -0.37, p = 0.02, respectively). In those cases with at least three serial measurements, the same two patterns were found. Similarly, in cases with expectant management, surviving fetuses showed a significantly higher weekly increase in LHR (p = 0.01) and a trend to a lower weekly decrease in O/E LHR (p = 0.17) than in those that died. CONCLUSIONS Patterns of right lung growth in iL-CDH differ according to postnatal survival. Serial measurements, but not a single one, might increase the prediction of neonatal death.
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Affiliation(s)
- Eugenia Antolin
- a Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology , Hospital Universitario La Paz , Madrid , Spain
| | - Roberto Rodriguez
- a Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology , Hospital Universitario La Paz , Madrid , Spain
| | - Jose Luis Encinas
- b Department of Pediatric Surgery , Hospital Universitario La Paz , Madrid , Spain , and
| | - Beatriz Herrero
- a Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology , Hospital Universitario La Paz , Madrid , Spain
| | - Marta Muner
- a Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology , Hospital Universitario La Paz , Madrid , Spain
| | - Ricardo Perez
- c Fetal Medicine Unit, Department of Obstetrics and Gynecology , Hospital Universitario Gregorio Marañon , Madrid , Spain
| | - Luis Ortiz
- c Fetal Medicine Unit, Department of Obstetrics and Gynecology , Hospital Universitario Gregorio Marañon , Madrid , Spain
| | - Jose Luis Bartha
- a Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology , Hospital Universitario La Paz , Madrid , Spain
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Werneck Britto IS, Olutoye OO, Cass DL, Zamora IJ, Lee TC, Cassady CI, Mehollin-Ray A, Welty S, Fernandes C, Belfort MA, Lee W, Ruano R. Quantification of liver herniation in fetuses with isolated congenital diaphragmatic hernia using two-dimensional ultrasonography. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:150-154. [PMID: 25366655 DOI: 10.1002/uog.14718] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 10/04/2014] [Accepted: 10/22/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To describe a method of quantifying the amount of liver herniation in fetuses with isolated congenital diaphragmatic hernia (CDH) using two-dimensional ultrasonography and to correlate this finding with neonatal outcome. METHODS Ultrasound images obtained from 77 consecutive fetuses that presented with isolated CDH between January 2004 and July 2012 were reviewed. Liver herniation and thoracic area were measured in a cross-sectional plane of the fetal chest at the level of the four-chamber view of the heart (the same section as is used to measure the lung area-to-head circumference ratio) and the ultrasound-derived liver-to-thoracic area ratio (US-LiTR) was calculated by dividing the liver herniation area by the thoracic area. Receiver-operating characteristics (ROC) curve analysis was used to evaluate the performance of US-LiTR in predicting neonatal outcome (survival to 6 months after delivery and need for extracorporeal membrane oxygenation (ECMO)). In addition, the US-LiTR was compared with the magnetic resonance imaging (MRI)-derived volume ratio (MRI-LiTR) and percentage of liver herniation (MRI-%LH). RESULTS The overall neonatal mortality in the 77 cases with isolated CDH was 20.8% (16/77). ECMO was needed in 35.5% (27/76) of the newborns, with a survival rate of 52%. The US-LiTR was associated statistically with mortality (P < 0.01) and with the need for ECMO (P < 0.01). Good correlations were observed between US-LiTR and MRI-LiTR (r = 0.87; P < 0.001) and between US-LiTR and MRI-%LH (r = 0.90; P < 0.001). Based on ROC curve analysis, all three parameters had similar accuracy in predicting mortality (US-LiTR: area under the ROC curve (AUC), 0.78 (95% CI, 0.65-0.92), P < 0.01; MRI-LiTR: AUC, 0.77 (95% CI, 0.63-0.90), P < 0.01; MRI-%LH: AUC, 0.79 (95% CI, 0.65-0.92), P < 0.01, respectively) as well as the need for ECMO (US-LiTR: AUC, 0.72 (95% CI, 0.60-0.84), P < 0.01; MRI-LiTR: AUC, 0.73 (95% CI, 0.60-0.88), P < 0.01; MRI-%LH: AUC, 0.77 (95% CI, 0.64-0.89), P < 0.01, respectively). CONCLUSIONS Two-dimensional ultrasound measurement of the amount of liver herniation in fetuses with isolated CDH is feasible and demonstrates a predictive accuracy for neonatal outcome similar to that of MRI.
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MESH Headings
- Adult
- Cohort Studies
- Extracorporeal Membrane Oxygenation/methods
- Female
- Fetal Diseases/diagnostic imaging
- Fetal Diseases/pathology
- Fetal Diseases/therapy
- Hernias, Diaphragmatic, Congenital/diagnostic imaging
- Hernias, Diaphragmatic, Congenital/pathology
- Hernias, Diaphragmatic, Congenital/surgery
- Hernias, Diaphragmatic, Congenital/therapy
- Humans
- Infant, Newborn
- Liver Diseases/diagnostic imaging
- Liver Diseases/embryology
- Liver Diseases/pathology
- Liver Diseases/therapy
- Magnetic Resonance Imaging/methods
- Predictive Value of Tests
- Pregnancy
- Retrospective Studies
- Ultrasonography, Prenatal/methods
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Affiliation(s)
- I S Werneck Britto
- Texas Children's Fetal Center, Houston, TX, USA
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - O O Olutoye
- Texas Children's Fetal Center, Houston, TX, USA
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - D L Cass
- Texas Children's Fetal Center, Houston, TX, USA
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - I J Zamora
- Texas Children's Fetal Center, Houston, TX, USA
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - T C Lee
- Texas Children's Fetal Center, Houston, TX, USA
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - C I Cassady
- Texas Children's Fetal Center, Houston, TX, USA
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - A Mehollin-Ray
- Texas Children's Fetal Center, Houston, TX, USA
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - S Welty
- Texas Children's Fetal Center, Houston, TX, USA
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - C Fernandes
- Texas Children's Fetal Center, Houston, TX, USA
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - M A Belfort
- Texas Children's Fetal Center, Houston, TX, USA
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - W Lee
- Texas Children's Fetal Center, Houston, TX, USA
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - R Ruano
- Texas Children's Fetal Center, Houston, TX, USA
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
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Cordier AG, Jani JC, Cannie MM, Rodó C, Fabietti I, Persico N, Saada J, Carreras E, Senat MV, Benachi A. Stomach position in prediction of survival in left-sided congenital diaphragmatic hernia with or without fetoscopic endoluminal tracheal occlusion. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:155-161. [PMID: 25487417 DOI: 10.1002/uog.14759] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 12/02/2014] [Accepted: 12/04/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To investigate the value of fetal stomach position in predicting postnatal outcome in left-sided congenital diaphragmatic hernia (CDH) with and without fetoscopic endoluminal tracheal occlusion (FETO). METHODS This was a retrospective review of CDH cases that were expectantly managed or treated with FETO, assessed from May 2008 to October 2013, in which we graded, on a scale of 1-4, stomach position on the four-chamber view of the heart with respect to thoracic structures. Logistic regression analysis was used to investigate the effect of management center (Paris, Brussels, Barcelona, Milan), stomach grading, observed-to-expected lung area-to-head circumference ratio (O/E-LHR), gestational age at delivery, birth weight in expectantly managed CDH, gestational ages at FETO and at removal and period of tracheal occlusion, on postnatal survival in CDH cases treated with FETO. RESULTS We identified 67 expectantly managed CDH cases and 47 CDH cases that were treated with FETO. In expectantly managed CDH, stomach position and O/E-LHR predicted postnatal survival independently. In CDH treated with FETO, stomach position and gestational age at delivery predicted postnatal survival independently. CONCLUSION In left-sided CDH with or without FETO, stomach position is predictive of postnatal survival.
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Affiliation(s)
- A-G Cordier
- Department of Obstetrics, Gynaecology and Reproductive Medicine and Centre Maladies Rares: Hernie de Coupole Diaphragmatique, Hospital Antoine Beclere, APHP, Paris Sud University, Clamart, Paris, France
| | - J C Jani
- Department of Obstetrics and Gynaecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - M M Cannie
- Department of Radiology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
- Department of Radiology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - C Rodó
- Department of Obstetrics, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - I Fabietti
- Department of Obstetrics and Gynecology 'L. Mangiagalli', Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - N Persico
- Department of Obstetrics and Gynecology 'L. Mangiagalli', Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - J Saada
- Department of Obstetrics, Gynaecology and Reproductive Medicine and Centre Maladies Rares: Hernie de Coupole Diaphragmatique, Hospital Antoine Beclere, APHP, Paris Sud University, Clamart, Paris, France
| | - E Carreras
- Department of Obstetrics, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - M-V Senat
- Department of Obstetrics and Gynaecology, Hospital Bicêtre, APHP, Paris Sud University, Kremlin Bicêtre, Paris, France
| | - A Benachi
- Department of Obstetrics, Gynaecology and Reproductive Medicine and Centre Maladies Rares: Hernie de Coupole Diaphragmatique, Hospital Antoine Beclere, APHP, Paris Sud University, Clamart, Paris, France
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Mychaliska G, Bryner B, Dechert R, Kreutzman J, Becker M, Hirschl R. Safety and efficacy of perflubron-induced lung growth in neonates with congenital diaphragmatic hernia: Results of a prospective randomized trial. J Pediatr Surg 2015; 50:1083-7. [PMID: 25799085 DOI: 10.1016/j.jpedsurg.2015.03.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 03/06/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Mechanical transduction has been shown to promote fetal lung growth. We examined the safety and efficacy of perflubron-induced lung growth (PILG) in neonates with congenital diaphragmatic hernia (CDH) requiring extracorporeal membrane oxygenation (ECMO). METHODS Infants with left-sided CDH requiring ECMO were eligible. Exclusion criteria included active air leak, intracranial hemorrhage, major congenital anomalies, and oxygenation index >25 for 24hours. Perflubron was instilled endotracheally and continuous positive airway pressure was applied without ventilation. Survival to discharge was the primary outcome. Daily chest radiographs were used to quantify lung size (the secondary outcome). Midway through the study our institutional practice shifted toward earlier repair of CDH. RESULTS Eight infants were randomized to each arm. In the conventional-ventilation arm, six survived to discharge (75%). In the perflubron arm, four survived (50%); the others succumbed to suprasystemic pulmonary hypertension. No adverse events related to perflubron occurred. Within the perflubron group, 4/8 patients had "late repair" (15-19days of life [DOL]) and 4 had "early repair" (2-3 DOL). "Early repair" patients had similar total lung growth, but accelerated growth and shorter ECMO runs. CONCLUSION PILG is safe in CDH and doubles the total lung size on average (accelerated with early repair). Despite amelioration of pulmonary hypoplasia with PILG, pulmonary hypertension persists.
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Affiliation(s)
- George Mychaliska
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Medical School and C.S. Mott Children's Hospital, Ann Arbor, MI.
| | - Benjamin Bryner
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Medical School and C.S. Mott Children's Hospital, Ann Arbor, MI
| | - Ronald Dechert
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Medical School and C.S. Mott Children's Hospital, Ann Arbor, MI
| | - Jeannie Kreutzman
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Medical School and C.S. Mott Children's Hospital, Ann Arbor, MI
| | - Mike Becker
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Medical School and C.S. Mott Children's Hospital, Ann Arbor, MI
| | - Ronald Hirschl
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Medical School and C.S. Mott Children's Hospital, Ann Arbor, MI
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DeKoninck P, Toelen J, Roubliova X, Carter S, Pozzobon M, Russo FM, Richter J, Vandersloten PJ, Verbeken E, De Coppi P, Deprest J. The use of human amniotic fluid stem cells as an adjunct to promote pulmonary development in a rabbit model for congenital diaphragmatic hernia. Prenat Diagn 2015; 35:833-40. [PMID: 25976324 DOI: 10.1002/pd.4621] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE This study aimed to evaluate the potential benefit of intra-tracheal injection of human amniotic fluid stem cells (hAFSC) on pulmonary development combined with TO in a rabbit model for CDH. METHODS In time-mated pregnant does a left diaphragmatic defect was created at d23 (term = 31). At d28, previously operated fetuses were assigned to either TO and injection with 70 μL of phosphate buffered saline (PBS) or 1.0 × 10(6) c-Kit positive hAFSC expressing LacZ or were left untouched (CDH). Harvesting was done at d31 to obtain their lung-to-body weight ratio (LBWR), airway and vascular lung morphometry, X-gal staining and immunohistochemistry for Ki67 and surfactant protein-B (SP-B). RESULTS CDH-induced pulmonary hypoplasia is countered by TO + PBS, this reverses LBWR, mean terminal bronchiole density (MTBD) and medial thickness to normal. The additional injection of hAFSC decreases MTBD and results in a non-significant decrease in muscularization of intra-acinary vessels. There were no inflammatory changes and LacZ positive hAFSC were dispersed throughout the lung parenchyma 4 days after injection. CONCLUSION HAFSC exert an additional effect on TO leading to a decrease in MTBD, a measure of alveolar number surrounding the terminal bronchioles, without signs of toxicity. © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Philip DeKoninck
- Organ systems cluster, Department of Development and Regeneration, and Center for Surgical Technologies, Group Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Jaan Toelen
- Organ systems cluster, Department of Development and Regeneration, and Center for Surgical Technologies, Group Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Xenia Roubliova
- Organ systems cluster, Department of Development and Regeneration, and Center for Surgical Technologies, Group Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Shea Carter
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, Group Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Michela Pozzobon
- Stem Cells and Regenerative Medicine Lab, Fondazione Istituto di Ricerca Pediatrica Città della Speranza, Department of Woman and Child Health, University of Padova, Padova, Italy
| | - Francesca Maria Russo
- Organ systems cluster, Department of Development and Regeneration, and Center for Surgical Technologies, Group Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Jute Richter
- Organ systems cluster, Department of Development and Regeneration, and Center for Surgical Technologies, Group Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Pieter-Jan Vandersloten
- Organ systems cluster, Department of Development and Regeneration, and Center for Surgical Technologies, Group Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Erik Verbeken
- Department of Pathology, Group Biomedical Sciences, University Hospitals Leuven, Belgium
| | - Paolo De Coppi
- Department of Pediatric Surgery, UCL Institute of Child Health and Great Ormond St Hospital, London, United Kingdom
| | - Jan Deprest
- Organ systems cluster, Department of Development and Regeneration, and Center for Surgical Technologies, Group Biomedical Sciences, KU Leuven, Leuven, Belgium
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Abstract
In utero fetal surgery interventions are currently considered in selected cases of congenital diaphragmatic hernia, cystic pulmonary abnormalities, amniotic band sequence, selected congenital heart abnormalities, myelomeningocele, sacrococcygeal teratoma, obstructive uropathy, and complications of twin pregnancy. Randomized controlled trials have demonstrated an advantage for open fetal surgery of myelomeningocele and for fetoscopic selective laser coagulation of placental vessels in twin-to-twin transfusion syndrome. The evidence for other fetal surgery interventions, such as tracheal occlusion in congenital diaphragmatic hernia, excision of lung lesions, fetal balloon cardiac valvuloplasty, and vesicoamniotic shunting for obstructive uropathy, is more limited. Conditions amenable to intrauterine surgical treatment are rare; the mother may consider termination of pregnancy as an option for many of them; treatment can be lifesaving but in itself carries risks to both the infant (preterm premature rupture of the membranes, preterm delivery) and the mother. This makes conducting prospective or randomized trials difficult and explains the relative lack of good-quality evidence in this field. Moreover, there is scanty information on long-term outcomes. It is recommended that fetal surgery procedures be performed in centers with extensive facilities and expertise. The aims of this review were to describe the main fetal surgery procedures and their evidence-based results and to provide generalist obstetricians with an overview of current indications for fetal surgery.
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Ruano R, Britto ISW, Sangi-Haghpeykar H, Bussamra LCS, Da Silva MM, Belfort MA, Deter RL, Lee W, Tannuri U, Zugaib M. Longitudinal assessment of lung area measurements by two-dimensional ultrasound in fetuses with isolated left-sided congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:566-571. [PMID: 24862641 DOI: 10.1002/uog.13420] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 05/10/2014] [Accepted: 05/16/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate lung growth in healthy fetuses and those with congenital diaphragmatic hernia (CDH) using two-dimensional (2D) ultrasound. METHODS Fetal right lung measurements obtained by 2D ultrasound between 19 and 37 weeks' gestation were evaluated longitudinally in 66 healthy fetuses and 52 fetuses with isolated left-sided CDH. Right lung areas were determined by the 'tracing' and 'longest-diameters' methods and, subsequently, lung area-to-head circumference ratios (LHRs) were calculated. Functions fitted to these size parameters with respect to gestational age were evaluated for three sets of group-wise comparisons: (1) healthy vs CDH fetuses; (2) different degrees of severity of CDH; and (3) CDH fetuses that survived vs those that died by 6 months postpartum. RESULTS There was a significantly slower increase in right lung areas and LHRs with advancing gestational age in CDH fetuses than in healthy individuals (P < 0.05). Compared to those with milder forms of CDH, lung areas and LHRs of fetuses with more severe forms displayed a smaller increase (P < 0.05) and LHRs of fetuses with severe CDH did not increase during pregnancy (P > 0.05). Individuals who died postpartum did not show any increase in LHR (P > 0.05) throughout gestation. CONCLUSIONS The right lung area and LHR, calculated using either the longest-diameters or tracing method, display reduced growth rates during gestation in cases of isolated left-sided CDH as compared with healthy fetuses. The growth curve characteristics of fetal lung areas and LHRs may be useful for predicting neonatal mortality.
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Affiliation(s)
- R Ruano
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, TX, USA; Department of Obstetrics and Gynecology, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
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Abstract
Since the first human fetal surgery was reported in 1965, several different fetal surgical procedures have been developed and perfected, resulting in significantly improved outcomes for many fetuses. The currently accepted list of fetal conditions for which antenatal surgery is considered include lower urinary tract obstruction, twin-twin transfusion syndrome, myelomeningocele, congenital diaphragmatic hernia, neck masses occluding the trachea, and tumors such as congenital cystic adenomatoid malformation or sacrococcygeal teratoma when associated with developing fetal hydrops. Until recently, it has been difficult to determine the true benefits of several fetal surgeries because outcomes were reported as uncontrolled case series. However, several prospective randomized trials have been attempted and others are ongoing, supporting a more evidence-based approach to antenatal intervention. Problems that have yet to be completely overcome include the inability to identify ideal fetal candidates for antenatal intervention, to determine the optimal timing of intervention, and to prevent preterm birth after fetal surgery. Confronting a fetal abnormality raises unique and complex issues for the family. For this reason, in addition to a maternal-fetal medicine specialist experienced in prenatal diagnosis, a pediatric surgeon, an experienced operating room team including a knowledgeable anesthesiologist, and a neonatologist, the family considering fetal surgery should have access to psychosocial support and a bioethicist.
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Abstract
There is a paucity of level 1 and level 2 evidence for best practice in surgical management of CDH. Antenatal imaging and prognostication is developing. Observed to expected lung-to-head ratio on ultrasound allows better predictive value over simple lung-to-head ratio. Based on 2 randomised studies, the verdict is still out in terms the best group and indication for antenatal intervention and their outcome. Tracheal occlusion is best suited for prospective randomised studies of benefit and outcome. Only one pilot randomised controlled study of thoracoscopic repair exists, suggesting increased acidosis; blood gases and CO2 levels should be closely monitored. Only poorly controlled retrospective studies suggest higher recurrence rates. Randomised studies on the outcome of thoracoscopic repair are needed. Careful selection, anaesthetic vigilance, monitoring and follow-up of these cases are required. There is no evidence to suggest the best patch material to decrease recurrences. Evidence suggests no benefit from routine fundoplication based on the one randomised study. Multi-disciplinary follow-up is required. This can be visits to different specialities, but may be best served by a multi-disciplinary one-stop clinic.
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Deprest J, Brady P, Nicolaides K, Benachi A, Berg C, Vermeesch J, Gardener G, Gratacos E. Prenatal management of the fetus with isolated congenital diaphragmatic hernia in the era of the TOTAL trial. Semin Fetal Neonatal Med 2014; 19:338-48. [PMID: 25447987 DOI: 10.1016/j.siny.2014.09.006] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Congenital diaphragmatic hernia (CDH) may be isolated or associated with other structural anomalies, the latter with poor prognosis. The defect allows viscera to herniate through the defect into the chest, competing for space with the developing lungs. At birth, pulmonary hypoplasia leads to respiratory insufficiency and persistent pulmonary hypertension that is lethal in up to 30% of patients. When isolated, survival chances can be predicted by antenatal measurement of lung size and liver herniation. Chromosomal microarrays and exome sequencing contribute to understanding genetic factors underlying isolated CDH. Prenatal intervention aims at stimulating lung development, clinically achieved by percutaneous fetal endoscopic tracheal occlusion (FETO) under local anesthesia. The Tracheal Occlusion To Accelerate Lung growth trial (www.totaltrial.eu) is an international randomized trial investigating the role of fetal therapy for severe and moderate pulmonary hypoplasia. Despite an apparent increase in survival following FETO, the search for lesser invasive and more potent prenatal interventions must continue.
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Affiliation(s)
- Jan Deprest
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, and Academic Department of Development and Regeneration, Organ System Cluster, Leuven, Belgium; TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial).
| | - Paul Brady
- Department of Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - Kypros Nicolaides
- TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial); Harris Birthright Centre, King's College Hospital, London, UK
| | - Alexandra Benachi
- TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial); Department of Obstetrics, Gynaecology and Reproductive Medicine, Hôpital Antoine Beclere, University Paris Sud, Clamart, France
| | - Christoph Berg
- TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial); Division of Fetal Surgery, Department of Obstetrics and Prenatal Medicine, University of Bonn, and Department of Obstetrics and Gynecology, University of Cologne, Germany
| | - Joris Vermeesch
- Department of Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - Glenn Gardener
- Mater Health Services, Mater Research UQ, Brisbane, Australia
| | - Eduard Gratacos
- TOTAL Consortium (Tracheal Occlusion To Accelerate Lung Growth Trial); BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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Done E, Debeer A, Gucciardo L, Van Mieghem T, Lewi P, Devlieger R, De Catte L, Lewi L, Allegaert K, Deprest J. Prediction of Neonatal Respiratory Function and Pulmonary Hypertension in Fetuses with Isolated Congenital Diaphragmatic Hernia in the Fetal Endoscopic Tracleal Occlusion Era: A Single-Center Study. Fetal Diagn Ther 2014; 37:24-32. [DOI: 10.1159/000364805] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 05/22/2014] [Indexed: 11/19/2022]
Abstract
Objective: To correlate prenatal indicators of pulmonary hypoplasia with neonatal lung function and pulmonary hypertension (PHT) in isolated congenital diaphragmatic hernia (iCDH). Materials and Methods: Prospective single-center study on 40 fetuses with iCDH either expectantly managed (n = 13) or undergoing tracheal occlusion (n = 27). Prenatal predictors included observed/expected lung-head ratio (O/E LHR), observed/expected total fetal lung volume, fetal pulmonary reactivity to maternal O2 administration (Δpulsatility index, ΔPI) and liver-to-thorax ratio (LiTR) as measured in the second and third trimesters. Postnatal outcome measures included survival until discharge, best oxygenation index (OI) and alveolar-arterial oxygen gradient [D(A-a)O2] in the first 24 h of life and the occurrence of PHT in the first 28 days of life. Results: Median gestational age (GA) at evaluations was 27.2 and 34.3 weeks. GA at delivery was 36.0 weeks, and overall survival was 55%. In the second trimester, measurement of lung size, LiTR and pulmonary reactivity were significantly related to survival and the best OI and D(A-a)O2.The occurrence of PHT was better predicted by ΔPI and LiTR. Conclusions: O/E LHR, LiTR and vascular reactivity correlate with ventilatory parameters in the first 24 h of life. Occurrence of PHT at ≥28 days was best predicted by LiTR and ΔPI, but not by lung size.
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Pelizzo G, Ballico M, Mimmi MC, Peirò JL, Marotta M, Federico C, Andreatta E, Nakib G, Sampaolesi M, Zambaiti E, Calcaterra V. Metabolomic profile of amniotic fluid to evaluate lung maturity: the diaphragmatic hernia lamb model. Multidiscip Respir Med 2014; 9:54. [PMID: 25419460 PMCID: PMC4239313 DOI: 10.1186/2049-6958-9-54] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 09/23/2014] [Indexed: 12/20/2022] Open
Abstract
Background Tracheal occlusion (TO) stimulates lung growth in fetuses affected with congenital diaphragmatic hernia (CDH) although the processes involved in lung maturation still remain unknown. The objective of this study was to evaluate the metabolomic profile of amniotic fluid (AF) following TO in fetal lamb model in order to obtain an indirect view of mechanisms involved in pulmonary reversal hypoplasia and biochemical maturity in response to fetal TO. Methods Liquid Chromatography Mass Spectrometry was performed on lamb AF samples at: age I (70 days’ gestation); age II (102 days’ gestation); age III (136 days’ gestation). CDH was induced at age I and TO at age II. Results Betaine, choline, creatinine were found significantly increased during gestation in the control group. The CDH group showed choline (p =0.007) and creatinine (p =0.004) decreases during pregnancy. In the TO group choline and creatinine profiles were restored. Conclusions Alveolar tissue and fetal global growth ameliorated after TO. Metabolomics provided useful information on biochemical details during lung maturation. Metabolomic profiling would help to identify the best time to perform TO, in order to increase survival of CDH affected patients.
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Affiliation(s)
- Gloria Pelizzo
- Department of the Mother and Child Health, Pediatric Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia and University of Pavia, Piazzale Golgi 2, 27100 Pavia, Italy
| | - Maurizio Ballico
- Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - Maria Chiara Mimmi
- Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - José Louis Peirò
- Cincinnati Fetal Center. Pediatric Surgery Division, CCHMC, Cincinnati, OH USA
| | - Mario Marotta
- Fetal Surgery Program, Congenital Malformations Research Group, Research Institute of Hospital Universitari Vall d'Hebron, Edifici Infantil, Barcelona, Spain
| | - Costanzo Federico
- Department of the Mother and Child Health, Pediatric Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia and University of Pavia, Piazzale Golgi 2, 27100 Pavia, Italy
| | - Erika Andreatta
- Department of the Mother and Child Health, Pediatric Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia and University of Pavia, Piazzale Golgi 2, 27100 Pavia, Italy
| | - Ghassan Nakib
- Department of the Mother and Child Health, Pediatric Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia and University of Pavia, Piazzale Golgi 2, 27100 Pavia, Italy
| | - Maurilio Sampaolesi
- Laboratory of Translational Cardiomyology, Stem Cell Interdepartmental Institute, KU Leuven and Human Anatomy, University of Pavia, Pavia, Italy
| | - Elisa Zambaiti
- Department of the Mother and Child Health, Pediatric Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia and University of Pavia, Piazzale Golgi 2, 27100 Pavia, Italy
| | - Valeria Calcaterra
- Department of the Mother and Child Health, Pediatric Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia and University of Pavia, Piazzale Golgi 2, 27100 Pavia, Italy ; Department of Internal Medicine, University of Pavia, Pavia, Italy
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Britto ISW, Araujo Júnior E, Sangi-Haghpeykar H, Bussamra LCS, Deter RL, Belfort MA, Lee W, Ruano R. Reference ranges for 2-dimensional sonographic lung measurements in healthy fetuses: a longitudinal study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:1917-1923. [PMID: 25336478 DOI: 10.7863/ultra.33.11.1917] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES The purpose of this study was to establish reference ranges for 2-dimensional sonographic measurements of fetal lungs from longitudinal data. METHODS A total of 214 fetal lung measurements were longitudinally evaluated in 62 healthy fetuses between 20 and 36 weeks' menstrual age. Both right and left lung areas were measured in the heart 4-chamber view using lung area tracing and axis diameter methods. Multilevel modeling was used to evaluate the expected values and variability with respect to menstrual age and to generate reference ranges for the lung area, lung-to-head ratio, quantitative lung index, and observed-to-expected lung-to-head ratio for both lungs. RESULTS The expected values varied with menstrual age for all parameters. Variance was menstrual age dependent for all parameters except the longest diameter area measurements and their lung-to-head ratios. CONCLUSIONS Models are presented for expected 2-dimensional sonographic lung size parameters and their variance as a function of menstrual age. These data have been used to generate age-specific reference ranges for both measurements and indices.
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Affiliation(s)
- Ingrid Schwach Werneck Britto
- Department of Obstetrics and Gynecology, Medical Science College of Santa Casa of São Paulo, São Paulo, Brazil (I.S.W.B., L.C.S.B.); Department of Obstetrics, Federal University of São Paulo, São Paulo, Brazil (E.A.J.); and Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas USA (H.S.-H., R.L.D., M.A.B., W.L., R.R.)
| | - Edward Araujo Júnior
- Department of Obstetrics and Gynecology, Medical Science College of Santa Casa of São Paulo, São Paulo, Brazil (I.S.W.B., L.C.S.B.); Department of Obstetrics, Federal University of São Paulo, São Paulo, Brazil (E.A.J.); and Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas USA (H.S.-H., R.L.D., M.A.B., W.L., R.R.)
| | - Haleh Sangi-Haghpeykar
- Department of Obstetrics and Gynecology, Medical Science College of Santa Casa of São Paulo, São Paulo, Brazil (I.S.W.B., L.C.S.B.); Department of Obstetrics, Federal University of São Paulo, São Paulo, Brazil (E.A.J.); and Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas USA (H.S.-H., R.L.D., M.A.B., W.L., R.R.)
| | - Luiz Cláudio Silva Bussamra
- Department of Obstetrics and Gynecology, Medical Science College of Santa Casa of São Paulo, São Paulo, Brazil (I.S.W.B., L.C.S.B.); Department of Obstetrics, Federal University of São Paulo, São Paulo, Brazil (E.A.J.); and Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas USA (H.S.-H., R.L.D., M.A.B., W.L., R.R.)
| | - Russell L Deter
- Department of Obstetrics and Gynecology, Medical Science College of Santa Casa of São Paulo, São Paulo, Brazil (I.S.W.B., L.C.S.B.); Department of Obstetrics, Federal University of São Paulo, São Paulo, Brazil (E.A.J.); and Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas USA (H.S.-H., R.L.D., M.A.B., W.L., R.R.)
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Medical Science College of Santa Casa of São Paulo, São Paulo, Brazil (I.S.W.B., L.C.S.B.); Department of Obstetrics, Federal University of São Paulo, São Paulo, Brazil (E.A.J.); and Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas USA (H.S.-H., R.L.D., M.A.B., W.L., R.R.)
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Medical Science College of Santa Casa of São Paulo, São Paulo, Brazil (I.S.W.B., L.C.S.B.); Department of Obstetrics, Federal University of São Paulo, São Paulo, Brazil (E.A.J.); and Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas USA (H.S.-H., R.L.D., M.A.B., W.L., R.R.)
| | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Medical Science College of Santa Casa of São Paulo, São Paulo, Brazil (I.S.W.B., L.C.S.B.); Department of Obstetrics, Federal University of São Paulo, São Paulo, Brazil (E.A.J.); and Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas USA (H.S.-H., R.L.D., M.A.B., W.L., R.R.).
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Intrapulmonary instillation of perflurooctylbromide improves lung growth, alveolarization, and lung mechanics in a fetal rabbit model of diaphragmatic hernia. Pediatr Crit Care Med 2014; 15:e379-88. [PMID: 25370070 DOI: 10.1097/pcc.0000000000000271] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Fetal tracheal occlusion of hypoplastic rabbit lungs results in lung growth and alveolarization although the surfactant protein messenger RNA expression is decreased and the transforming growth factor-β pathway induced. The prenatal filling of healthy rabbit lungs with perfluorooctylbromide augments lung growth without suppression of surfactant protein synthesis. We hypothesizes that Intratracheal perfluorooctylbromide instillation improves lung growth, mechanics, and extracellular matrix synthesis in a fetal rabbit model of lung hypoplasia induced by diaphragmatic hernia. SETTING AND INTERVENTIONS On day 23 of gestation, DH was induced by fetal surgery in healthy rabbit fetuses. Five days later, 0.8ml of perfluorooctylbromide (diaphragmatic hernia-perfluorooctylbromide) or saline (diaphragmatic hernia-saline) was randomly administered into the lungs of previously operated fetuses. After term delivery (day 31), lung mechanics, lung to body weight ratio, messenger RNA levels of target genes, assessment of lung histology, and morphological distribution of elastin and collagen were determined. Nonoperated fetuses served as controls. MEASUREMENTS AND MAIN RESULTS Fetal instillation of perfluorooctylbromide in hypoplastic lungs resulted in an improvement of lung-to-body weight ratio (0.016 vs 0.013 g/g; p = 0.05), total lung capacity (23.4 vs 15.4 μL/g; p = 0.03), and compliance (2.4 vs 1.2 mL/cm H2O; p = 0.007) as compared to diaphragmatic hernia-saline. In accordance with the results from lung function analysis, elastin staining of pulmonary tissue revealed a physiological distribution of elastic fiber to the tips of the secondary crests in the diaphragmatic hernia-perfluorooctylbromide group. Likewise, messenger RNA expression was induced in genes associated with extracellular matrix remodeling (matrix metalloproteinase-2, tissue inhibitor of metalloproteinase-1, and tissue inhibitor of metalloproteinase-2). Surfactant protein expression was similar in the diaphragmatic hernia-perfluorooctylbromide and diaphragmatic hernia-saline groups. Distal airway size, mean linear intercept, as well as airspace and tissue fractions were similar in diaphragmatic hernia-perfluorooctylbromide, diaphragmatic hernia-saline, and control groups. CONCLUSIONS Fetal perfluorooctylbromide treatment improves lung growth, lung mechanics, and extracellular matrix remodeling in hypoplastic lungs, most probably due to transient pulmonary stretch, preserved fetal breathing movements, and its physical characteristics. Perfluorooctylbromide instillation is a promising approach for prenatal therapy of lung hypoplasia.
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Sananès N, Ruano R, Weingertner AS, Regnard P, Salmon Y, Kohler A, Miry C, Mager C, Guerra F, Schneider A, Becmeur F, Leroy J, Dimarcq JL, Debry C, Favre R. Experimental fetal endoscopic tracheal occlusion in rhesus and cynomolgus monkeys: nonhuman primate models. J Matern Fetal Neonatal Med 2014; 28:1822-7. [DOI: 10.3109/14767058.2014.969234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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DeKoninck P, Gomez O, Sandaite I, Richter J, Nawapun K, Eerdekens A, Ramirez JC, Claus F, Gratacos E, Deprest J. Right-sided congenital diaphragmatic hernia in a decade of fetal surgery. BJOG 2014; 122:940-6. [DOI: 10.1111/1471-0528.13065] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2014] [Indexed: 12/01/2022]
Affiliation(s)
- P DeKoninck
- Fetal Medicine Unit; Department of Obstetrics and Gynaecology; University Hospitals Leuven; KU Leuven Leuven Belgium
- Department of Development and Regeneration; Cluster Organ Systems; KU Leuven Leuven Belgium
| | - O Gomez
- Maternal-Fetal Medicine Department; Institut Clínic de Ginecologia; Obstetrícia i Neonatologia (ICGON); Hospital Clínic; Institut d'Investigacions Biomédiques Augusto Pi i Sunyer (IDIBAPS); University of Barcelona; Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER); Barcelona Spain
| | - I Sandaite
- Fetal Medicine Unit; Department of Obstetrics and Gynaecology; University Hospitals Leuven; KU Leuven Leuven Belgium
- Department of Development and Regeneration; Cluster Organ Systems; KU Leuven Leuven Belgium
- Department of Radiology; University Hospitals Leuven; Leuven Belgium
| | - J Richter
- Fetal Medicine Unit; Department of Obstetrics and Gynaecology; University Hospitals Leuven; KU Leuven Leuven Belgium
- Department of Development and Regeneration; Cluster Organ Systems; KU Leuven Leuven Belgium
| | - K Nawapun
- Fetal Medicine Unit; Department of Obstetrics and Gynaecology; University Hospitals Leuven; KU Leuven Leuven Belgium
- Department of Development and Regeneration; Cluster Organ Systems; KU Leuven Leuven Belgium
| | - A Eerdekens
- Department of Paediatrics; University Hospitals Leuven; KU Leuven Leuven Belgium
- Department of Development and Regeneration; Cluster Organ Systems; KU Leuven Leuven Belgium
| | - JC Ramirez
- Maternal-Fetal Medicine Department; Institut Clínic de Ginecologia; Obstetrícia i Neonatologia (ICGON); Hospital Clínic; Institut d'Investigacions Biomédiques Augusto Pi i Sunyer (IDIBAPS); University of Barcelona; Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER); Barcelona Spain
| | - F Claus
- Department of Radiology; University Hospitals Leuven; Leuven Belgium
| | - E Gratacos
- Maternal-Fetal Medicine Department; Institut Clínic de Ginecologia; Obstetrícia i Neonatologia (ICGON); Hospital Clínic; Institut d'Investigacions Biomédiques Augusto Pi i Sunyer (IDIBAPS); University of Barcelona; Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER); Barcelona Spain
| | - J Deprest
- Fetal Medicine Unit; Department of Obstetrics and Gynaecology; University Hospitals Leuven; KU Leuven Leuven Belgium
- Department of Development and Regeneration; Cluster Organ Systems; KU Leuven Leuven Belgium
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Abstract
Congenital diaphragmatic hernia is an uncommon congenital anomaly of the diaphragm with pulmonary hypoplasia and persistent pulmonary hypertension as serious consequences. Despite recent advances in therapy, congenital diaphragmatic hernia remains a challenging condition. Best treatment strategies are still largely unknown, and practice strategies vary widely among different centres. Additionally, as congenital diaphragmatic hernia is a relatively uncommon condition, it is difficult to recruit sufficient numbers of patients for clinical trials. In recent years, survival rates of congenital diaphragmatic hernia patients appear to have increased. With the progressively improved survival rates, the long-term prognosis and quality of life of patients have become an increasingly important issue. Survivors have been shown to be at risk for many long-term morbidities, which highlights the importance of long-term follow-up of these children. The aim of this review is to give an overview of the current knowledge regarding congenital diaphragmatic hernia.
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Affiliation(s)
- Lisette Leeuwen
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia; Medical School, University of Groningen, Groningen, The Netherlands
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Ruano R, Lazar DA, Cass DL, Zamora IJ, Lee TC, Cassady CI, Mehollin-Ray A, Welty S, Fernandes CJ, Haeri S, Belfort MA, Olutoye OO. Fetal lung volume and quantification of liver herniation by magnetic resonance imaging in isolated congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:662-669. [PMID: 24127326 DOI: 10.1002/uog.13223] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 08/20/2013] [Accepted: 10/01/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To determine associations between fetal lung and liver herniation volumes measured by magnetic resonance imaging (MRI) and mortality/need for extracorporeal membrane oxygenation (ECMO) in cases of isolated congenital diaphragmatic hernia (CDH). A secondary objective was to compare prenatal MRI parameters with two-dimensional ultrasound lung measurements. METHODS A retrospective review of medical records of all fetuses with isolated CDH evaluated between January 2004 and July 2012 was performed. The following MRI parameters were measured at 20-32 weeks: observed/expected total fetal lung volume (o/e-TLV), predicted pulmonary volume (PPV), percentage of liver herniated into the fetal thorax (%LH) and the liver/thoracic volume ratio (LiTR). These were compared with the ultrasound-determined lung-to-head ratio (LHR) and the observed/expected LHR (o/e-LHR) in the same cohort. The predictive value of MRI and ultrasound parameters for mortality and the need for ECMO was evaluated by univariate, multivariate and factor analysis and by receiver-operating characteristics curves. RESULTS Eighty fetuses with isolated CDH were evaluated. Overall mortality was 18/80 (22.5%). Two newborns died a few hours after birth. ECMO was performed in 29/78 (37.2%) newborns, with a survival rate of 48.3% (14/29). The side of the diaphragmatic defect was not associated with mortality (P = 0.99) or the need for ECMO (P = 0.48). Good correlation was observed among o/e-TLV, PPV, LHR and o/e-LHR as well as between %LH and LiTR (r = 0.89; P < 0.01); however, fetal lung measurements and measures of liver herniation were not correlated (all P > 0.05). All parameters were statistically associated with mortality or the need for ECMO. The best combination of measurements to predict mortality was o/e-TLV and %LH, with 83% accuracy. CONCLUSION Mortality and the need for ECMO in neonates with isolated CDH can be best predicted using a combination of MRI o/e-TLV and %LH.
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Affiliation(s)
- R Ruano
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX, USA; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
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Zani A, Sellars M, Allen P, Tyraskis A, Nicolaides K, Greenough A, Patel S, Davenport M, Ade-Ajayi N. Tracheomegaly in infants with severe congenital diaphragmatic hernia treated with fetal endoluminal tracheal occlusion. J Pediatr 2014; 164:1311-5. [PMID: 24704300 DOI: 10.1016/j.jpeds.2014.02.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 12/09/2013] [Accepted: 02/10/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To measure and evaluate the effects of tracheal dimensions on survival and ventilation in a large series of infants with congenital diaphragmatic hernia (CDH) treated antenatally with fetal endoluminal tracheal occlusion (FETO). STUDY DESIGN Tracheal dimensions on chest radiograph (CR) were measured by 2 blinded radiologists. Survival, day 1 best oxygenation index and duration of ventilation, continuous positive airway pressure, and hospital stay were recorded. Survivors with a minimum 12-month follow-up were longitudinally compared for incidence of gastroesophageal reflux, chest infections, chest deformities, and hernia recurrence. RESULTS Seventy infants with CDH (41 who underwent FETO) were treated between 2004 and 2010. Hernia repair was performed in 26 infants without FETO (8 with patch repair) and 35 infants with FETO (26 with patch repair; P = .0015). Infants with FETO had a wider trachea than those without FETO at T1 (P < .0001) and between T1 and the carina (P < .0001). Tracheal diameter was similar in survivors and nonsurvivors in the FETO group. Tracheal size was not correlated with day 1 best oxygenation index in the FETO group (R2 = 0.17) or the non-FETO group (R2 = 0.07). There were no between-group differences in duration of mechanical ventilation (P = .30), continuous positive airway pressure (P = .20), or hospital stay (P = .30). In the longitudinal study, tracheal widths were larger on the last CR than on preoperative CR in patients without FETO (T1, P = .02; widest point, P = .001; carina, P = .0001), and for patients with FETO at the widest point (P < .0001) and at the carina (P < .0001), but not at T1 (P = .12). There were no differences in clinical variables between the FETO and non-FETO groups. CONCLUSION FETO has a significant impact on tracheal size of infants with CDH; however, tracheal size does not affect survival or the requirement for early respiratory support.
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Affiliation(s)
- Augusto Zani
- Department of Pediatric Surgery, King's College Hospital, London, United Kingdom
| | - Maria Sellars
- Department of Radiology, King's College Hospital, London, United Kingdom
| | - Pamela Allen
- Department of Radiology, King's College Hospital, London, United Kingdom
| | - Athanasios Tyraskis
- Department of Pediatric Surgery, King's College Hospital, London, United Kingdom
| | - Kypros Nicolaides
- Harris Birthright Research Center for Fetal Medicine, King's College Hospital, London, United Kingdom
| | - Anne Greenough
- Division of Asthma, Allergy, and Lung Biology, King's College London, London, United Kingdom
| | - Shailesh Patel
- Department of Pediatric Surgery, King's College Hospital, London, United Kingdom
| | - Mark Davenport
- Department of Pediatric Surgery, King's College Hospital, London, United Kingdom
| | - Niyi Ade-Ajayi
- Department of Pediatric Surgery, King's College Hospital, London, United Kingdom.
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Jani JC, Cannie MM. Re: comparison of ultrasound and magnetic resonance imaging parameters in predicting survival in isolated left-sided congenital diaphragmatic hernia. M. Bebbington, T. Victoria, E. Danzer, J. Moldenhauer, N. Khalek, M. Johnson, H. Hedrick and N. S. Adzick. Ultrasound Obstet Gynecol 2014; 43: 670-674. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:609-610. [PMID: 24888742 DOI: 10.1002/uog.13392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- J C Jani
- Department of Obstetrics and Gynaecology, University Hospital Brugmann, Brussels, Belgium
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Zamora IJ, Olutoye OO, Cass DL, Fallon SC, Lazar DA, Cassady CI, Mehollin-Ray AR, Welty SE, Ruano R, Belfort MA, Lee TC. Prenatal MRI fetal lung volumes and percent liver herniation predict pulmonary morbidity in congenital diaphragmatic hernia (CDH). J Pediatr Surg 2014; 49:688-93. [PMID: 24851749 DOI: 10.1016/j.jpedsurg.2014.02.048] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 02/13/2014] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this study was to determine whether prenatal imaging parameters are predictive of postnatal CDH-associated pulmonary morbidity. METHODS The records of all neonates with CDH treated from 2004 to 2012 were reviewed. Patients requiring supplemental oxygen at 30 days of life (DOL) were classified as having chronic lung disease (CLD). Fetal MRI-measured observed/expected total fetal lung volume (O/E-TFLV) and percent liver herniation (%LH) were recorded. Receiver operating characteristic (ROC) curves and multivariate regression were applied to assess the prognostic value of O/E-TFLV and %LH for development of CLD. RESULTS Of 172 neonates with CDH, 108 had fetal MRIs, and survival was 76%. 82% (89/108) were alive at DOL 30, 46 (52%) of whom had CLD. Neonates with CLD had lower mean O/E-TFLV (30 vs.42%; p=0.001) and higher %LH (21.3±2.8 vs.7.1±1.8%; p<0.001) compared to neonates without CLD. Using ROC analysis, the best cutoffs in predicting CLD were an O/E-TFLV<35% (AUC=0.74; p<0.001) and %LH>20% (AUC=0.78; p<0.001). On logistic regression, O/E-TFLV<35% and a %LH>20% were highly associated with indicators of long-term pulmonary sequelae. On multivariate analysis, %LH was the strongest predictor of CLD in patients with CDH (OR: 10.96, 95%CI: 2.5-48.9, p=0.002). CONCLUSION Prenatal measurement of O/E-TFLV and %LH is predictive of CDH pulmonary morbidity and can aid in establishing parental expectations of postnatal outcomes.
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Affiliation(s)
- Irving J Zamora
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Oluyinka O Olutoye
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Darrell L Cass
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Sara C Fallon
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - David A Lazar
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Christopher I Cassady
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA; Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Amy R Mehollin-Ray
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA; Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Stephen E Welty
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA; Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, TX, USA
| | - Rodrigo Ruano
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Michael A Belfort
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Timothy C Lee
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
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141
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Kehl S, Siemer J, Brunnemer S, Weiss C, Eckert S, Schaible T, Sütterlin M. Prediction of postnatal outcomes in fetuses with isolated congenital diaphragmatic hernias using different lung-to-head ratio measurements. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:759-767. [PMID: 24764330 DOI: 10.7863/ultra.33.5.759] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES The purpose of this study was to compare different methods for measuring the fetal lung area-to-head circumference ratio and to investigate their prediction of postpartum survival and the need for neonatal extracorporeal membrane oxygenation (ECMO) therapy in fetuses with isolated congenital diaphragmatic hernias. METHODS This prospective study included 118 fetuses of at least 20 weeks' gestation with isolated left-sided congenital diaphragmatic hernias. The lung-to-head ratio was measured with 3 different methods (longest diameter, anteroposterior diameter, and tracing). To eliminate the influence of gestational age, the observed-to-expected lung-to-head ratio was calculated. Receiver operating characteristic (ROC) curves were calculated for the statistical prediction of survival and need for ECMO therapy by the observed-to-expected lung-to-head ratio measured with the different methods. RESULTS For survival and ECMO necessity 118 and 102 cases (16 neonates were not eligible for ECMO) were assessed, respectively. For prediction of postpartum survival and ECMO necessity, the areas under the ROC curves and 95% confidence intervals showed very similar results for the 3 methods for prediction of survival (tracing, 0.8445 [0.7553-0.9336]; longest diameter, 0.8248 [0.7360-0.9136]; and anteroposterior diameter, 0.8002 [0.7075-0.8928]) and for ECMO necessity (tracing, 0.7344 [0.6297-0.8391]; longest diameter, 0.7128 [0.6027-0.8228]; and anteroposterior diameter, 0.7212 [0.6142-0.8281]). Comparisons between the areas under the ROC curves showed that the tracing method was superior to the anteroposterior diameter method in predicting postpartum survival (P = .0300). CONCLUSIONS Lung-to-head ratio and observed-to-expected lung-to-head ratio measurements were shown to accurately predict postnatal survival and the need for ECMO therapy in fetuses with left-sided congenital diaphragmatic hernias. Tracing the limits of the lungs seems to be the favorable method for calculating the fetal lung area.
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Affiliation(s)
- Sven Kehl
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
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142
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Cordier AG, Cannie MM, Guilbaud L, De Laveaucoupet J, Martinovic J, Nowakowska D, Milejska-Lewandowska M, Rodó C, Viaris de Lesegno B, Votino C, Senat MV, Jani JC, Benachi A. Stomach position versus liver-to-thoracic volume ratio in left-sided congenital diaphragmatic hernia. J Matern Fetal Neonatal Med 2014; 28:190-5. [DOI: 10.3109/14767058.2014.906576] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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143
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Cundy TP, Gardener GJ, Andersen CC, Kirby CP, McBride CA, Teague WJ. Fetoscopic endoluminal tracheal occlusion (FETO) for congenital diaphragmatic hernia in Australia and New Zealand: are we willing, able, both or neither? J Paediatr Child Health 2014; 50:226-33. [PMID: 24372875 DOI: 10.1111/jpc.12457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2013] [Indexed: 12/01/2022]
Abstract
AIM An estimated 140 pregnancies are diagnosed with congenital diaphragmatic hernia (CDH) in Australia and New Zealand each year, with these fetuses having a less than even chance of 1-year survival. Fetoscopic endoluminal tracheal occlusion (FETO) is a relatively new technique that offers a prenatal interventional strategy for selective cases of CDH. This is not routinely offered in Australia or New Zealand. The aim of this systematic review is to critically appraise controlled clinical trials investigating the role of FETO in moderate and severe isolated CDH and explore whether this treatment is justified within our region. METHODS A systematic literature search of multiple electronic databases was undertaken, with restrictions to human subjects and controlled clinical trials. RESULTS Nine relevant studies were identified. No current evidence was found in favour of FETO for moderate severity CDH. For severe CDH, the most recent evidence demonstrates significantly improved survival following FETO performed using contemporary percutaneous minimally invasive techniques. Optimum timing for balloon insertion, removal and occlusion duration remains conjectural. Substantial variation in survival rates observed among control groups highlights the impact of post-natal care in prenatally diagnosed CDH. CONCLUSION Until recently, evidence to support a role for FETO in prenatal CDH management was weak. Recently reported and ongoing controlled trials give cause for optimism, with improved FETO safety and increased survival reported for severe CDH cases. Should Australasia embrace FETO for selected CDH cases, a co-ordinated, evidence-informed service should be established under the guidance of experienced international partnerships.
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Affiliation(s)
- Thomas P Cundy
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
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144
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Engels AC, Van Calster B, Richter J, DeKoninck P, Lewi L, De Catte L, Devlieger R, Deprest JA. Collagen plug sealing of iatrogenic fetal membrane defects after fetoscopic surgery for congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:54-59. [PMID: 23801588 DOI: 10.1002/uog.12547] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/11/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To investigate the efficacy of collagen plugs at reducing the risk of preterm premature rupture of membranes (PPROM) after fetoscopic surgery for congenital diaphragmatic hernia (CDH). METHODS This was a single-center cohort study on all consecutive cases undergoing fetoscopic endoluminal tracheal occlusion (FETO) for severe or moderate CDH, between April 2002 and May 2011 (n = 141). Cases either received a collagen plug for sealing the fetal membrane defect after FETO or did not, depending on the operating surgeon. The principal outcome measure was the time from fetal surgery to PPROM, further referred to as 'latency'. A multivariable Cox regression model was used to investigate the association between collagen plug and latency while adjusting for risk factors for PPROM. RESULTS Of the 141 cases, 54 (38%) received a collagen plug and 87 (62%) did not. Sixty cases experienced PPROM, 26 among cases with and 34 among cases without a plug (48 vs 39%). The hazard ratio of plug use was 1.29 (95% CI, 0.76-2.19), which does not exclude a potentially increased risk for PPROM when a collagen plug is used. For cases with a plug, 24% had PPROM before balloon removal and 24% had PPROM after elective balloon removal. For cases without a plug, these rates were 30 and 9%, respectively. Perinatal outcomes were similar in both groups. CONCLUSIONS No evidence was found that collagen plugs reduce the risk of PPROM after FETO for CDH.
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Affiliation(s)
- A C Engels
- KU Leuven, Centre for Surgical Technologies, Leuven, Belgium
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145
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Ruano R, Cass DL, Rieger M, Javadian P, Shamshirsaz AA, Olutoye OO, Belfort MA. Fetal laryngoscopy to evaluate vocal folds in a fetus with congenital high airway obstruction syndrome (CHAOS). ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:102-103. [PMID: 23939717 DOI: 10.1002/uog.13191] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 07/28/2013] [Accepted: 08/02/2013] [Indexed: 06/02/2023]
Affiliation(s)
- R Ruano
- Pavilion for Women Texas Children's Fetal Center, Suite F1020, 6651 Main Street, Houston, Texas, 77030, USA
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146
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Alves da Rocha L, Byrne FA, Keller RL, Miniati D, Brook MM, Silverman NH, Moon-Grady AJ. Left Heart Structures in Human Neonates with Congenital Diaphragmatic Hernia and the Effect of Fetal Endoscopic Tracheal Occlusion. Fetal Diagn Ther 2013; 35:36-43. [DOI: 10.1159/000356437] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 10/13/2013] [Indexed: 11/19/2022]
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147
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Lapillonne A, Benachi A, de Lagausie P, Mokthari M, Storme L, Granier M. [Neonatal thoracic and abdominal wall surgery: an update]. Arch Pediatr 2013; 20 Suppl 1:S1-4. [PMID: 23992831 DOI: 10.1016/s0929-693x(13)71402-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- A Lapillonne
- Université Paris Descartes, 12 rue de l'École-de-Médecine, 75006 Paris, France; AP-HP, Hôpital Necker-Enfants malades, 149 rue de Sèvres, 75015 Paris, France; CNRC, Baylor College of Medicine, 1 Baylor Plaza, Houston, Texas 77030, États-Unis.
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148
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Ruano R, Peiro JL, da Silva MM, Campos JADB, Carreras E, Tannuri U, Zugaib M. Early fetoscopic tracheal occlusion for extremely severe pulmonary hypoplasia in isolated congenital diaphragmatic hernia: preliminary results. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:70-76. [PMID: 23349059 DOI: 10.1002/uog.12414] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Revised: 12/20/2012] [Accepted: 12/21/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To evaluate the effect of early fetoscopic tracheal occlusion (FETO) (22-24 weeks' gestation) on pulmonary response and neonatal survival in cases of extremely severe isolated congenital diaphragmatic hernia (CDH). METHODS This was a multicenter study involving fetuses with extremely severe CDH (lung-to-head ratio < 0.70, liver herniation into the thoracic cavity and no other detectable anomalies). Between August 2010 and December 2011, eight fetuses underwent early FETO. Data were compared with nine fetuses that underwent standard FETO and 10 without fetoscopic procedure from January 2006 to July 2010. FETO was performed under maternal epidural anesthesia, supplemented with fetal intramuscular anesthesia. Fetal lung size and vascularity were evaluated by ultrasound before and every 2 weeks after FETO. Postnatal therapy was equivalent for both treated fetuses and controls. Primary outcome was infant survival to 180 days and secondary outcome was fetal pulmonary response. RESULTS Maternal and fetal demographic characteristics and obstetric complications were similar in the three groups (P > 0.05). Infant survival rate was significantly higher in the early FETO group (62.5%) compared with the standard group (11.1%) and with controls (0%) (P < 0.01). Early FETO resulted in a significant improvement in fetal lung size and pulmonary vascularity when compared with standard FETO (P < 0.01). CONCLUSIONS Early FETO may improve infant survival by further increases of lung size and pulmonary vascularity in cases with extremely severe pulmonary hypoplasia in isolated CDH. This study supports formal testing of the hypothesis with a randomized controlled trial.
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MESH Headings
- Abnormalities, Multiple/metabolism
- Abnormalities, Multiple/mortality
- Abnormalities, Multiple/physiopathology
- Abnormalities, Multiple/surgery
- Balloon Occlusion/methods
- Female
- Fetoscopy/methods
- Fetoscopy/mortality
- Gestational Age
- Hernia, Diaphragmatic/metabolism
- Hernia, Diaphragmatic/mortality
- Hernia, Diaphragmatic/physiopathology
- Hernia, Diaphragmatic/surgery
- Hernias, Diaphragmatic, Congenital
- Humans
- Lung/abnormalities
- Lung/metabolism
- Lung/physiopathology
- Lung/surgery
- Lung Diseases/metabolism
- Lung Diseases/mortality
- Lung Diseases/physiopathology
- Lung Diseases/surgery
- Minimally Invasive Surgical Procedures
- Pregnancy
- Severity of Illness Index
- Survival Rate
- Trachea/embryology
- Trachea/physiopathology
- Treatment Outcome
- Ultrasonography, Doppler, Color
- Ultrasonography, Prenatal/methods
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Affiliation(s)
- R Ruano
- Obstetrics Department, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
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149
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Zamora IJ, Ethun CG, Evans LM, Olutoye OO, Ivey RT, Haeri S, Belfort MA, Lee TC, Cass DL. Maternal morbidity and reproductive outcomes related to fetal surgery. J Pediatr Surg 2013; 48:951-5. [PMID: 23701766 DOI: 10.1016/j.jpedsurg.2013.02.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 02/03/2013] [Indexed: 11/19/2022]
Abstract
PURPOSE The purpose of this manuscript was to examine the maternal morbidity and reproductive outcomes following maternal-fetal surgery with an emphasis on the EXIT procedure. METHODS The medical records of all women who underwent an ex-utero intrapartum treatment (EXIT) procedure or mid-gestation open maternal fetal surgery (OMFS) at our center from December 2001 to December 2011 were reviewed retrospectively. Future reproductive outcomes were obtained via telephone questionnaire. RESULTS Thirty-three women underwent maternal-fetal surgery. Twenty-six had EXIT, and seven had OMFS. The questionnaire response was 82% (27/33). Eighty-one percent (17/21) of the EXIT cohort desired future pregnancy. All who attempted (13/13) were successful. The majority (85%) conceived spontaneously and within 2.5 years on average. In the OMFS group, 40% experienced complications. One had uterine dehiscence, and another had uterine rupture requiring urgent delivery at 36 weeks. In subsequent pregnancies, 20% of OMFS cases were complicated by uterine rupture, and 8% of EXIT patients had uterine dehiscence. All had good maternal-fetal outcome. CONCLUSION Future reproductive capacity and complication rates in subsequent pregnancies following EXIT procedure are similar to those seen in the general population. In contrast, mid-gestation OMFS remains associated with relatively morbid complications. This evidence can help guide in counseling expectant mothers who are faced with the challenge of considering fetal surgery.
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Affiliation(s)
- Irving J Zamora
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA
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150
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Spaggiari E, Stirnemann J, Bernard JP, De Saint Blanquat L, Beaudoin S, Ville Y. Prognostic value of a hernia sac in congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 41:286-290. [PMID: 22605546 DOI: 10.1002/uog.11189] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/30/2012] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To investigate the prognostic value of a hernia sac in isolated congenital diaphragmatic hernia (CDH). METHODS Our database was searched to identify all consecutive cases of CDH referred to our fetal medicine unit between January 2004 and August 2011. Presence or absence of a hernia sac was assessed in liveborn cases using surgery or postnatal autopsy reports. We studied the correlation between the presence of a hernia sac and prenatal findings and perinatal morbidity and mortality. RESULTS Over the study period, there were 70 cases with isolated CDH born alive in which either a surgery or autopsy report was available. Neonatal death, either preoperative or postoperative, occurred in 1/18 (5.6%) infants with a hernia sac and in 17/52 (32.7%) cases without a hernia sac (P = 0.03). Patients with a hernia sac had a significantly higher observed to expected pulmonary volume on prenatal magnetic resonance imaging (51.9 vs 39.3%, P = 0.01). Neonatal morbidity in surviving infants was lower in the group with a hernia sac, although not significantly. CONCLUSION The presence of a hernia sac is associated with a higher pulmonary volume and a better overall prognosis for CDH.
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Affiliation(s)
- E Spaggiari
- Department of Obstetrics and Maternal-Fetal Medicine, GHU Necker Enfants-Malades, AP-HP and Université Paris Descartes, Paris, France
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