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Puligandla P, Skarsgard E, Baird R, Guadagno E, Dimmer A, Ganescu O, Abbasi N, Altit G, Brindle M, Fernandes S, Dakshinamurti S, Flageole H, Hebert A, Keijzer R, Offringa M, Patel D, Ryan G, Traynor M, Zani A, Chiu P. Diagnosis and management of congenital diaphragmatic hernia: a 2023 update from the Canadian Congenital Diaphragmatic Hernia Collaborative. Arch Dis Child Fetal Neonatal Ed 2024; 109:239-252. [PMID: 37879884 DOI: 10.1136/archdischild-2023-325865] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/02/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE The Canadian Congenital Diaphragmatic Hernia (CDH) Collaborative sought to make its existing clinical practice guideline, published in 2018, into a 'living document'. DESIGN AND MAIN OUTCOME MEASURES Critical appraisal of CDH literature adhering to Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Evidence accumulated between 1 January 2017 and 30 August 2022 was analysed to inform changes to existing or the development of new CDH care recommendations. Strength of consensus was also determined using a modified Delphi process among national experts in the field. RESULTS Of the 3868 articles retrieved in our search that covered the 15 areas of CDH care, 459 underwent full-text review. Ultimately, 103 articles were used to inform 20 changes to existing recommendations, which included aspects related to prenatal diagnosis, echocardiographic evaluation, pulmonary hypertension management, surgical readiness criteria, the type of surgical repair and long-term health surveillance. Fifteen new CDH care recommendations were also created using this evidence, with most related to the management of pain and the provision of analgesia and neuromuscular blockade for patients with CDH. CONCLUSIONS The 2023 Canadian CDH Collaborative's clinical practice guideline update provides a management framework for infants and children with CDH based on the best available evidence and expert consensus.
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Affiliation(s)
- Pramod Puligandla
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Erik Skarsgard
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Baird
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Elena Guadagno
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Alexandra Dimmer
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Olivia Ganescu
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Nimrah Abbasi
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gabriel Altit
- Neonatology, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Mary Brindle
- Department of Surgery, Section of Pediatric Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Sairvan Fernandes
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shyamala Dakshinamurti
- Department of Pediatrics and Child Health, Section of Neonatology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Helene Flageole
- Department of Pediatric Surgery, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Audrey Hebert
- Department of Pediatrics, Division of Neonatology, Laval University, Quebec City, Quebec, Canada
| | - Richard Keijzer
- Department of Pediatric Surgery and Manitoba Institute of Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Dylan Patel
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Greg Ryan
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Michael Traynor
- Department of Anesthesia, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Augusto Zani
- Department of Surgery, Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Priscilla Chiu
- Department of Surgery, Division of Pediatric General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Wu F, Chen Y, Zhang X, Li Y, Chen Z, Liu Z, Dai W, Yang C, Liu H. Relative Mediastinal Displacement Index (RMDI): A Prenatal MRI Indicator of Adverse Events in Fetuses With Isolated Left Congenital Diaphragmatic Hernia. J Magn Reson Imaging 2024. [PMID: 38440902 DOI: 10.1002/jmri.29329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO), has partly improved congenital diaphragmatic hernia (CDH) outcomes, yet the overall morbidity and mortality remain high. Existing prenatal indicators for CDH fetuses are operator-dependent, time-consuming, or less accurate, a new simple and accurate indicator to indicate adverse events in CDH patients is needed. PURPOSE To propose and assess the association of a new MRI parameter, the relative mediastinal displacement index (RMDI), with adverse events including in-hospital deaths or the need for ECMO in fetuses with isolated left CDH (iLCDH). STUDY TYPE Retrospective analysis. SUBJECTS One hundred thirty-nine fetuses were included in the iLCDH group (24 with adverse events and 115 without) and 257 fetuses were included in the control group from two centers in Guangzhou. FIELD STRENGTH/SEQUENCE 3.0 T, T2WI-TRUFI; 1.5 T, T2WI-FIESTA. ASSESSMENT Three operators independently measured the→ DL $$ \underset{\mathrm{DL}}{\to } $$ ,→ DR $$ \underset{\mathrm{DR}}{\to } $$ , and DH on the axial images. The calculation formula of the RMDI was (→ DL $$ \underset{\mathrm{DL}}{\to } $$ + → DR $$ \underset{\mathrm{DR}}{\to } $$ )/DH . STATISTICAL TESTS The independent sample t test, Mann-Whitney U test, Chi-square test, Chi-square test continuity correction, Fisher's test, linear regression analysis, logistic regression analysis, intraclass correlation coefficient, receiver operating characteristic curve analysis, and Delong test. A P value <0.05 was considered statistically significant. RESULTS The RMDI did not change with gestational age in the iLCDH group (with [P = 0.189] and without [P = 0.567] adverse events) and the control group (P = 0.876). There were significant differences in RMDI between the iLCDH group (0.89 [0.65, 1.00]) and the control group (-0.23 [-0.34, -0.16]). In the iLCDH group, RMDI was the only indicator left for indicating adverse events, and the best cutoff value was 1.105. Moreover, there was a significant difference in diagnostic accuracy between the RMDI (AUC = 0.900) and MSA (AUC = 0.820), LHR (AUC = 0.753), o/e LHR (AUC = 0.709), and o/e TFLV (AUC = 0.728), respectively. DATA CONCLUSION The RMDI is expected to be a simple and accurate tool for indicating adverse events in fetuses with iLCDH. EVIDENCE LEVEL 4 TECHNICAL EFFICACY: Stage 1.
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Affiliation(s)
- Fan Wu
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | | | - Xin Zhang
- Guangzhou Medical University, Guangzhou, China
| | - Yuchao Li
- Guangzhou Medical University, Guangzhou, China
| | - Zhaoji Chen
- Guangzhou Medical University, Guangzhou, China
| | - Zhenqing Liu
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Wangchun Dai
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
| | - Chaoxiang Yang
- Department of Radiology, Guangdong Women and Children Hospital, Guangzhou, China
| | - Hongsheng Liu
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, China
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Narang K, Wyatt M, O'Leary P, Qureshi MY, Kolbe A, Stephens EH, Dearani JA, Ruano R. Novel approach to prenatal predictors of outcomes for fetuses with severe Ebstein anomaly. J Matern Fetal Neonatal Med 2023; 36:2271626. [PMID: 37904503 DOI: 10.1080/14767058.2023.2271626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 10/11/2023] [Indexed: 11/01/2023]
Abstract
OBJECTIVE Ebstein anomaly (EA) is a cardiac malformation with highly variable presentation and severity with limited perinatal management options. We present incorporation of fetal lung measurements into a multidisciplinary evaluation for counseling and predicting postnatal outcomes in patients with severe EA. METHODS Five fetuses with severe fetal EA were reviewed. Third trimester sonographic observed/expected total lung area (O/E TLA) and lung to head ratio (O/E LHR), fetal MRI total fetal lung volume ratio (O/E-TFLV), echocardiographic cardio-thoracic ratio (CT ratio), sonographic estimated fetal weight (EFW) by Hadlock formula and presence of hydrops, were used to guide perinatal management. RESULTS Three of five had appropriate fetal growth, were delivered at term in a cardiac operative suite, and underwent immediate intervention with good neonatal outcomes. Two had severe fetal growth restriction (FGR), CT ratios > 0.8 and O/E LHR and TLA < 25%. One of which delivered prematurely with neonatal demise and one suffered in utero demise at 34 weeks. CONCLUSIONS FGR, hydrops, increased CT ratio and reduced O/E LHR and TFLV are potential prognosticators of poor outcomes in severe EA, and should be validated in larger cohorts that would allow for a statistical analysis of the predictive utility of these measurements.
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Affiliation(s)
- Kavita Narang
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Michelle Wyatt
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Patrick O'Leary
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - M Yasir Qureshi
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Amy Kolbe
- Pediatric Radiology Division, Department of Radiology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Elizabeth H Stephens
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Rodrigo Ruano
- Division Chief of Maternal-Fetal Medicine, Director UHealth Jackson Fetal Care, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
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Whitby E, Gaunt T. Fetal lung MRI and features predicting post-natal outcome: a scoping review of the current literature. Br J Radiol 2023:20220344. [PMID: 37314838 DOI: 10.1259/bjr.20220344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023] Open
Abstract
The outcome for infants with fetal lung pathologies not only depends on the nature of the pathology, but the impact it has on the developing lungs. The main prognostic factor is the degree of pulmonary hypoplasia, but this is not detectable pre-natally. Imaging techniques aim to simulate these features with a variety of surrogate measurements, including lung volume and MRI signal intensity. Despite the complexity of the various research studies and lack of consistent methodology, this scoping review aims to summarise current applications, and promising techniques requiring further investigation.
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Affiliation(s)
- Elspeth Whitby
- University of Sheffield and Sheffield Teaching Hospitals NHS foundation Trust, England, United Kingdom
| | - Trevor Gaunt
- Department of Maternal and Fetal Medicine, University College London, London, United Kingdom
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
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Niemiec SM, Louiselle AE, Phillips R, Gien J, Zaretsky MV, Derderian SC, Liechty KW, Meyers ML. Third-trimester percentage predicted lung volume and percentage liver herniation as prognostic indicators in congenital diaphragmatic hernia. Pediatr Radiol 2023; 53:479-486. [PMID: 36289070 DOI: 10.1007/s00247-022-05538-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 09/13/2022] [Accepted: 10/14/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Over the last two decades, fetal imaging has greatly improved, and new prenatal imaging measurements have been developed to characterize congenital diaphragmatic hernia (CDH) severity. OBJECTIVE To determine the best prenatal imaging predictor of postnatal CDH outcomes, including use of extracorporeal membrane oxygenation (ECMO) and in-hospital mortality, with particular attention to the percentage of liver herniation (%LH) as a predictor. Additionally, we sought to guide best practices across hospital systems including improved models of prenatal risk assessment. MATERIALS AND METHODS We conducted a retrospective review of infants with left CDH who were prenatally diagnosed. We analyzed prenatal imaging measurements including observed-to-expected (O/E) lung-to-head ratio (LHR) on US, percentage predicted lung volume (PPLV) on MRI, and O/E total fetal lung volume (TFLV) and %LH on MRI. We compared prenatal imaging characteristics for infants with (1) in-hospital postnatal mortality and (2) use of ECMO. Then we performed multivariate logistic regression to determine independent predictors of postnatal outcomes. RESULTS We included 63 infants with a median gestation of 34 weeks at the time of prenatal MRI. Low O/E LHR (31.2 vs. 50, P < 0.0001), PPLV (14.7 vs. 22.6, P < 0.0001) and O/E TLFV (24.6 vs. 38.3, P < 0.0001) and high %LH (15.1 vs. 2.1, P = 0.0006) were associated with worse postnatal outcomes; however, only PPLV was predictive of survival and need for ECMO on multivariable analysis. PPLV survival to discharge model showed an area under the curve (AUC) of 0.93 (95% confidence interval [CI]: 0.86, 0.99), P < 0.0001; and an odds ratio of 68.7 (95% CI: 6.5-2,302), P = 0.003. PPLV need for ECMO model showed AUC = 0.87 (95% CI: 0.78, 0.96), P < 0.0001; and odds ratio = 20.1 (95% CI: 3.1-226.3), P = 0.011. CONCLUSION Low O/E LHR, PPLV and O/E TFLV and high %LH in the third trimester are associated with worse postnatal outcomes. PPLV most strongly predicted outcome using a logistic regression model. Percentage of liver herniation was not an independent predictor of outcomes.
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Affiliation(s)
- Stephen M Niemiec
- Department of Surgery, Laboratory for Fetal and Regenerative Biology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.,Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amanda E Louiselle
- Department of Surgery, Laboratory for Fetal and Regenerative Biology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.,Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ryan Phillips
- Department of Surgery, Laboratory for Fetal and Regenerative Biology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.,Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jason Gien
- Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Department of Pediatrics Section of Neonatology, Children's Hospital of Colorado, Aurora, CO, USA.,Colorado Fetal Care Center, Children's Hospital of Colorado, Colorado Institute for Fetal & Maternal Health, Aurora, CO, USA
| | - Michael V Zaretsky
- Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Colorado Fetal Care Center, Children's Hospital of Colorado, Colorado Institute for Fetal & Maternal Health, Aurora, CO, USA
| | - Sarkis C Derderian
- Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Colorado Fetal Care Center, Children's Hospital of Colorado, Colorado Institute for Fetal & Maternal Health, Aurora, CO, USA
| | - Kenneth W Liechty
- Department of Surgery, Laboratory for Fetal and Regenerative Biology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.,Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA.,Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Colorado Fetal Care Center, Children's Hospital of Colorado, Colorado Institute for Fetal & Maternal Health, Aurora, CO, USA
| | - Mariana L Meyers
- Department of Radiology, Children's Hospital Colorado, 13123 E. 16th Ave., Aurora, CO, 80045, USA. .,Colorado Fetal Care Center, Children's Hospital of Colorado, Colorado Institute for Fetal & Maternal Health, Aurora, CO, USA. .,Department of Radiology, Division of Pediatric Radiology, University of Colorado School of Medicine, Aurora, CO, USA.
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Olutoye OO, Mehl SC, Moturu A, Pettit RW, Coleman RD, Vogel AM, Lee TC, Keswani SG, King A. Risk Stratification by Percent Liver Herniation in Congenital Diaphragmatic Hernia. J Surg Res 2023; 282:168-173. [PMID: 36306587 PMCID: PMC11132729 DOI: 10.1016/j.jss.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/15/2022] [Accepted: 09/07/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Congenital diaphragmatic hernia is associated with pulmonary hypoplasia, pulmonary hypertension, and significant neonatal morbidity. Although intrathoracic liver herniation (LH) >20% is associated with adverse outcomes, the relationship between LH <20% and outcomes is poorly characterized. METHODS A single-center retrospective cohort study was performed from 2011 to 2020 of 80 fetuses with left-sided congenital diaphragmatic hernia that were delivered and repaired at our institution. Perinatal, perioperative, and postoperative data were collected. We evaluated the association of %LH with outcomes as a stratified ordinal variable (0%-10% LH, 10%-19% LH, and >20% LH) and as a continuous variable. Data were analyzed by analysis of variance with Bonferroni post hoc analysis, chi-square analyses, and univariate logistic regression. RESULTS Extracorporeal membrane oxygenation (ECMO) (P < 0.001), repair on ECMO (P = 0.002), repair with patch (P < 0.001), length of stay (P = 0.002), inhaled nitric oxide use (P < 0.001), and sildenafil use at discharge (P < 0.001), showed significant differences among LH groups. There were no differences among the groups concerning survival (at discharge, 6 mo, and 1 y) and tracheostomy. On further analysis there was no difference between 10% and 19% LH and ≥20% LH patients concerning ECMO (P = 0.55), repair on ECMO (P = 0.54), repair with patch (P = 1.00), length of stay (P = 1.00), and inhaled nitric oxide use (P = 0.33). Logistic regression analysis displayed a significant association with LH and ECMO, repair on ECMO, repair with patch, inhaled nitric oxide use, and sildenafil use. CONCLUSIONS Our analysis displays no significant difference in perinatal management between patients with 10%-19% and ≥20% LH. These findings suggest that the historical cutoff of ≥20% LH may not be sufficient alone to guide perinatal counseling and decision-making.
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Affiliation(s)
- Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Steven C Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Anoosha Moturu
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Rowland W Pettit
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Ryan D Coleman
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Adam M Vogel
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas.
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Emam D, Aertsen M, Van der Veeken L, Fidon L, Patkee P, Kyriakopoulou V, De Catte L, Russo F, Demaerel P, Vercauteren T, Rutherford M, Deprest J. Longitudinal MRI Evaluation of Brain Development in Fetuses with Congenital Diaphragmatic Hernia around the Time of Fetal Endotracheal Occlusion. AJNR Am J Neuroradiol 2023; 44:205-211. [PMID: 36657946 PMCID: PMC9891331 DOI: 10.3174/ajnr.a7760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 12/10/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE Congenital diaphragmatic hernia is associated with high mortality and morbidity, including evidence suggesting neurodevelopmental comorbidities after birth. The aim of this study was to document longitudinal changes in brain biometry and the cortical folding pattern in fetuses with congenital diaphragmatic hernia compared with healthy fetuses. MATERIALS AND METHODS This is a retrospective cohort study including fetuses with isolated congenital diaphragmatic hernia between January 2007 and May 2019, with at least 2 MR imaging examinations. For controls, we used images from fetuses who underwent MR imaging for an unrelated condition that did not compromise fetal brain development and fetuses from healthy pregnant women. Biometric measurements and 3D segmentations of brain structures were used as well as qualitative and quantitative grading of the supratentorial brain. Brain development was correlated with disease-severity markers. RESULTS Forty-two fetuses were included, with a mean gestational age at first MR imaging of 28.0 (SD, 2.1) weeks and 33.2 (SD, 1.3) weeks at the second imaging. The mean gestational age in controls was 30.7 (SD, 4.2) weeks. At 28 weeks, fetuses with congenital diaphragmatic hernia had abnormal qualitative and quantitative maturation, more extra-axial fluid, and larger total skull volume. By 33 weeks, qualitative grading scores were still abnormal, but quantitative scoring was in the normal range. In contrast, the extra-axial fluid volume remained abnormal with increased ventricular volume. Normal brain parenchymal volumes were found. CONCLUSIONS Brain development in fetuses with congenital diaphragmatic hernia around 28 weeks appears to be delayed. This feature is less prominent at 33 weeks. At this stage, there was also an increase in ventricular and extra-axial space volume.
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Affiliation(s)
- D Emam
- From the Department of Development and Regeneration (D.E., L.V.d.V., L.D.C., F.R., J.D.), Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
- Department Obstetrics and Gynaecology (D.E., L.F.), Faculty of Medicine, Tanta University, Tanta, Egypt
| | - M Aertsen
- Department of Imaging and Pathology (M.A., P.D.), Clinical Department of Radiology, University Hospitals, KU Leuven, Leuven, Belgium
| | - L Van der Veeken
- From the Department of Development and Regeneration (D.E., L.V.d.V., L.D.C., F.R., J.D.), Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
- Clinical Department Obstetrics and Gynaecology (L.V.d.V., L.D.C., F.R., J.D.), University Hospitals Leuven, Leuven, Belgium
| | - L Fidon
- Department Obstetrics and Gynaecology (D.E., L.F.), Faculty of Medicine, Tanta University, Tanta, Egypt
- Division of Imaging Sciences and Biomedical Engineering, Perinatal Imaging and Health and School of Biomedical Engineering and Imaging Sciences (L.F., T.V., J.D.), King's College London, King's Health Partners, St. Thomas' Hospital, London, UK
| | - P Patkee
- Centre for the Developing Brain (P.P., V.K., M.R., J.D.)
| | | | - L De Catte
- From the Department of Development and Regeneration (D.E., L.V.d.V., L.D.C., F.R., J.D.), Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
- Clinical Department Obstetrics and Gynaecology (L.V.d.V., L.D.C., F.R., J.D.), University Hospitals Leuven, Leuven, Belgium
| | - F Russo
- From the Department of Development and Regeneration (D.E., L.V.d.V., L.D.C., F.R., J.D.), Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
- Clinical Department Obstetrics and Gynaecology (L.V.d.V., L.D.C., F.R., J.D.), University Hospitals Leuven, Leuven, Belgium
| | - P Demaerel
- Department of Imaging and Pathology (M.A., P.D.), Clinical Department of Radiology, University Hospitals, KU Leuven, Leuven, Belgium
| | - T Vercauteren
- Division of Imaging Sciences and Biomedical Engineering, Perinatal Imaging and Health and School of Biomedical Engineering and Imaging Sciences (L.F., T.V., J.D.), King's College London, King's Health Partners, St. Thomas' Hospital, London, UK
| | - M Rutherford
- Centre for the Developing Brain (P.P., V.K., M.R., J.D.)
| | - J Deprest
- From the Department of Development and Regeneration (D.E., L.V.d.V., L.D.C., F.R., J.D.), Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
- Clinical Department Obstetrics and Gynaecology (L.V.d.V., L.D.C., F.R., J.D.), University Hospitals Leuven, Leuven, Belgium
- Centre for the Developing Brain (P.P., V.K., M.R., J.D.)
- Division of Imaging Sciences and Biomedical Engineering, Perinatal Imaging and Health and School of Biomedical Engineering and Imaging Sciences (L.F., T.V., J.D.), King's College London, King's Health Partners, St. Thomas' Hospital, London, UK
- Institute for Women's Health (J.D.), University College London, London, UK
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Postnatal Imaging for Prediction of Outcome in Patients with Left-sided Congenital Diaphragmatic Hernia. J Pediatr 2022; 251:89-97.e3. [PMID: 35944713 DOI: 10.1016/j.jpeds.2022.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/17/2022] [Accepted: 07/28/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate associations between postnatal imaging features and outcome of left-sided congenital diaphragmatic hernia, as defined by overall survival and a requirement for extracorporeal membrane oxygenation (ECMO). STUDY DESIGN Newborns diagnosed prenatally with left-sided congenital diaphragmatic hernia between January 2013 and September 2021 were studied retrospectively. The esophageal deviation index was newly defined as the largest diameter from the midline to deviated gastric tube divided by the largest transverse diameter of the thoracic cavity on the radiograph. Regression analyses were performed to identify postnatal imaging features associated with overall survival and a requirement for ECMO. The predictive power (ie, area under the curve [AUC] of a time-dependent receiver operating characteristic curve) of prenatal, postnatal, and intraoperative findings for predicting survival were calculated. RESULTS Ninety-seven patients (54 males; mean gestational age, 38.3 ± 1.9 weeks; mean birth weight, 2956.5 ± 540.0 g) were analyzed. The esophageal deviation index (adjusted hazard ratio [HR], moderate [≥0.19 to <0.24], 6.427 [P = .029]; severe [≥0.24], 33.007 [P < .001]) and right pneumothorax (adjusted HR, 8.763; P = .002) were associated with overall survival and with a requirement for ECMO. Liver herniation on postnatal ultrasound also was associated with overall survival (P < .001) and need for ECMO (P = .001). In addition, the AUC for prediction of 1-year survival from postnatal ultrasound was comparable with that of prenatally or intraoperatively detected liver herniation (0.93; 95% CI, 0.88-0.97). CONCLUSIONS The esophageal deviation index, right pneumothorax, and liver herniation observed by postnatal imaging have prognostic value in patients with left-sided congenital diaphragmatic hernia.
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Masahata K, Yamoto M, Umeda S, Nagata K, Terui K, Fujii M, Shiraishi M, Hayakawa M, Amari S, Masumoto K, Okazaki T, Inamura N, Toyoshima K, Koike Y, Furukawa T, Yazaki Y, Yokoi A, Endo M, Tazuke Y, Okuyama H, Usui N. Prenatal predictors of mortality in fetuses with congenital diaphragmatic hernia: a systematic review and meta-analysis. Pediatr Surg Int 2022; 38:1745-1757. [PMID: 36102982 DOI: 10.1007/s00383-022-05232-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE This study aimed to evaluate prenatal predictors of mortality in fetuses with congenital diaphragmatic hernia (CDH). METHODS A systematic literature search was performed to identify relevant observational studies that evaluated the ability of lung-to-head ratio (LHR), observed-to-expected LHR (o/e-LHR), observed-to-expected total fetal lung volume (o/e-TFLV), lung-to-thorax transverse area ratio (L/T ratio), intrathoracic herniation of the liver and the stomach, and side of diaphragmatic hernia, using a threshold for the prediction of mortality in fetuses with CDH. Study quality was assessed using the QUADAS-2 tool. Hierarchical summary receiver operating characteristic curves were constructed. RESULTS A total of 50 articles were included in this meta-analysis. The QUADAS-2 tool identified a high risk of bias in more than one domain scored in all parameters. Among those parameters, the diagnostic odds ratio of mortality with o/e-LHR < 25%, o/e-TFLV < 25%, and L/T ratio < 0.08 were 11.98 [95% confidence interval (CI) 4.65-30.89], 11.14 (95% CI 5.19-23.89), and 10.28 (95% CI 3.38-31.31), respectively. The predictive values for mortality were similar between the presence of liver herniation and retrocardiac fetal stomach position. CONCLUSIONS This systematic review suggests that o/e-LHR, o/e-TFLV, and L/T ratio are equally good predictors of neonatal mortality in fetuses with isolated CDH.
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Affiliation(s)
- Kazunori Masahata
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan.
| | - Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Satoshi Umeda
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Kouji Nagata
- Department of Pediatric Surgery, Kyushu University, Fukuoka, Japan
| | - Keita Terui
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Makoto Fujii
- Department of Health Science, Graduate School of Medicine, Osaka University, Suita, Japan
| | | | - Masahiro Hayakawa
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Shoichiro Amari
- Division of Neonatology, National Center for Child Health and Development, Tokyo, Japan
| | - Kouji Masumoto
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tadaharu Okazaki
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Noboru Inamura
- Department of Pediatrics, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Katsuaki Toyoshima
- Departments of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Yuki Koike
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Taizo Furukawa
- Department of Pediatric Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuta Yazaki
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Akiko Yokoi
- Departments of Pediatric Surgery, Kobe Children's Medical Center, Kobe, Japan
| | - Masayuki Endo
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuko Tazuke
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
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Antenatal Assessment of the Prognosis of Congenital Diaphragmatic Hernia: Ethical Considerations and Impact for the Management. Healthcare (Basel) 2022; 10:healthcare10081433. [PMID: 36011090 PMCID: PMC9408048 DOI: 10.3390/healthcare10081433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 11/17/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is associated with abnormal pulmonary development, which is responsible for pulmonary hypoplasia with structural and functional abnormalities in pulmonary circulation, leading to the failure of the cardiorespiratory adaptation at birth. Despite improvement in treatment options and advances in neonatal care, mortality remains high, at close to 15 to 30%. Several risk factors of mortality and morbidities have been validated in fetuses with CDH. Antenatal assessment of lung volume is a reliable way to predict the severity of CDH. The two most commonly used measurements are the observed/expected lung to head ratio (LHRo/e) and the total pulmonary volume (TPV) on MRI. The estimation of total pulmonary volume (TPVo/e) by means of prenatal MRI remains the gold standard. In addition to LHR and TPV measurements, the position of the liver (up, in the thorax or down, in the abdomen) also plays a role in the prognostic evaluation. This prenatal prognostic evaluation can be used to select fetuses for antenatal surgery, consisting of fetoscopic endoluminal tracheal occlusion (FETO). The antenatal criteria of severe CDH with an ascended liver (LHRo/e or TPVo/e < 25%) are undoubtedly associated with a high risk of death or significant morbidity. However, despite the possibility of estimating the risk in antenatal care, it is difficult to determine what is in the child’s best interest, as there still are many uncertainties: (1) uncertainty about individual short-term prognosis; (2) uncertainty about long-term prognosis; and (3) uncertainty about the subsequent quality of life, especially when it is known that, with a similar degree of disability, a child’s quality of life varies from poor to good depending on multiple factors, including family support. Nevertheless, as the LHR decreases, the foreseeable “burden” becomes increasingly significant, and the expected benefit is increasingly unlikely. The legal and moral principle of the proportionality of medical procedures, as well as the prohibition of “unreasonable obstinacy” in all investigations or treatments undertaken, is necessary in these situations. However, the scientific and rational basis for assessing the long-term individual prognosis is limited to statistical data that do not adequately reflect individual risk. The risk of self-fulfilling prophecies should be kept in mind. The information given to parents must take this uncertainty into account when deciding on the treatment plan after birth.
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Takeuchi Y, Inoue S, Odaka A, Muta Y, Beck Y. Anterolateral defect of left congenital diaphragmatic hernia with hepatic herniation. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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12
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Russo F, Benachi A, Gratacos E, Zani A, Keijzer R, Partridge E, Sananes N, De Coppi P, Aertsen M, Nicolaides KH, Deprest J. Antenatal Management of Congenital Diaphragmatic Hernia: what's next ? Prenat Diagn 2022; 42:291-300. [PMID: 35199368 DOI: 10.1002/pd.6120] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/19/2022] [Accepted: 02/20/2022] [Indexed: 11/07/2022]
Abstract
Congenital diaphragmatic hernia (CDH) can be diagnosed in the prenatal period and its severity can be measured by fetal imaging. There is now level I evidence that, in selected cases, Fetoscopic Endoluminal Tracheal Occlusion (FETO) increases survival to discharge from the neonatal unit as well as the risk for prematurity. Both effects are dependent on the time point of tracheal occlusion. FETO may also lead to iatrogenic death when done in unexperienced centres. The implementation of the findings from our clinical studies, may also vary based on local conditions. These may be different in terms of available skill set, access to fetal therapy, as well as outcome based on local neonatal management. We encourage prior benchmarking of local outcomes with optimal postnatal management, based on large enough numbers and using identical criteria as in the recent trials. We propose to work further on prenatal prediction methods, and the improvement of fetal intervention. In this manuscript, we describe a research agenda from a fetal medicine perspective. This research should be in parallel with innovation in neonatal and pediatric (surgical) management of this condition. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Francesca Russo
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven and Clinical Department of Obstetrics and Gynaecology, UZ Leuven, Leuven, Belgium
| | - Alexandra Benachi
- Department of Obstetrics and Gynaecology, Hospital Antoine Béclère, Université Paris Saclay, Clamart, France
| | | | - Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Richard Keijzer
- Department of Pediatric Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Emily Partridge
- Department of Pediatric Surgery, Children's Hospital of Philadelphia, PA, USA
| | - Nicolas Sananes
- Department Obstetrics and Gynaecology, University Hospitals Strasbourg, Strasbourg, France
| | | | - Michael Aertsen
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | | | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven and Clinical Department of Obstetrics and Gynaecology, UZ Leuven, Leuven, Belgium.,Institute of Women's Health, University College London, London, United Kingdom
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13
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Ott KC, Bi M, Scorletti F, Ranginwala SA, Marriott WS, Peiro JL, Kline-Fath BM, Alhajjat AM, Shaaban AF. The interplay between prenatal liver growth and lung development in congenital diaphragmatic hernia. Front Pediatr 2022; 10:983492. [PMID: 36225336 PMCID: PMC9548643 DOI: 10.3389/fped.2022.983492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/07/2022] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE Liver herniation is a known risk factor for increased severity in CDH and is associated with clinically significant pulmonary hypoplasia and pulmonary hypertension. Better studies are needed to understand the growth of the herniated liver compared to the liver that remains in the abdomen and how this liver growth then affects lung development. Serial hi-resolution fetal MRI enables characterization of liver growth throughout gestation and examination of macroscopic features that may regulate liver growth. Here, we hypothesized that the nature of liver herniation affects liver growth and, in turn, affects lung growth. METHODS Clinical data were retrospectively collected from consecutive cases of prenatally diagnosed isolated left-sided or right-sided CDH from June 2006 to August 2021. Only those cases with MRI lung volumetry for both mid-gestation and late-gestation time points were recruited for analysis. Cases with fetal chromosomal abnormalities and other major structural abnormalities were excluded. Fractional liver volume and liver growth was indexed to estimated fetal weight and compared to lung growth. RESULTS Data was collected from 28 fetuses with a left liver-down CDH (LLD), 37 left liver-up CDH (LLU) and 9 right liver-up CDH (RLU). Overall, RLU fetuses had greater overall and fractional (intra-thoracic vs. intra-abdominal) liver growth when compared to LLD and LLU fetuses. Additionally, intra-thoracic liver growth was consistently slower than intra-abdominal liver growth for either right- or left-sided CDH. When the liver was not herniated, a positive correlation was seen between liver growth and lung growth. However, when the liver was herniated above the diaphragm, this positive correlation was lost. CONCLUSION Right-sided CDH fetuses exhibit greater liver growth compared to left-sided CDH. Liver herniation disrupts the normal positive correlation between liver and lung growth that is seen when the liver is entirely within the abdomen.
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Affiliation(s)
- Katherine C Ott
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago Institute for Fetal Health, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Michael Bi
- Cincinnati Fetal Care Center, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Federico Scorletti
- Neonatal Surgical Unit, Medical and Surgical Department of the Fetus, Newborn and Infant, Bambino Gesù Children's Hospital, Rome, Italy
| | - Saad A Ranginwala
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago Institute for Fetal Health, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - William S Marriott
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago Institute for Fetal Health, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jose L Peiro
- Cincinnati Fetal Care Center, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Beth M Kline-Fath
- Cincinnati Fetal Care Center, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Amir M Alhajjat
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago Institute for Fetal Health, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Aimen F Shaaban
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago Institute for Fetal Health, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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14
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Amodeo I, Borzani I, Raffaeli G, Persico N, Amelio GS, Gulden S, Colnaghi M, Villamor E, Mosca F, Cavallaro G. The role of magnetic resonance imaging in the diagnosis and prognostic evaluation of fetuses with congenital diaphragmatic hernia. Eur J Pediatr 2022; 181:3243-3257. [PMID: 35794403 PMCID: PMC9395465 DOI: 10.1007/s00431-022-04540-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/23/2022] [Indexed: 11/04/2022]
Abstract
UNLABELLED In recent years, magnetic resonance imaging (MRI) has largely increased our knowledge and predictive accuracy of congenital diaphragmatic hernia (CDH) in the fetus. Thanks to its technical advantages, better anatomical definition, and superiority in fetal lung volume estimation, fetal MRI has been demonstrated to be superior to 2D and 3D ultrasound alone in CDH diagnosis and outcome prediction. This is of crucial importance for prenatal counseling, risk stratification, and decision-making approach. Furthermore, several quantitative and qualitative parameters can be evaluated simultaneously, which have been associated with survival, postnatal course severity, and long-term morbidity. CONCLUSION Fetal MRI will further strengthen its role in the near future, but it is necessary to reach a consensus on indications, methodology, and data interpretation. In addition, it is required data integration from different imaging modalities and clinical courses, especially for predicting postnatal pulmonary hypertension. This would lead to a comprehensive prognostic assessment. WHAT IS KNOWN • MRI plays a key role in evaluating the fetal lung in patients with CDH. • Prognostic assessment of CDH is challenging, and advanced imaging is crucial for a complete prenatal assessment and counseling. WHAT IS NEW • Fetal MRI has strengthened its role over ultrasound due to its technical advantages, better anatomical definition, superior fetal lung volume estimation, and outcome prediction. • Imaging and clinical data integration is the most desirable strategy and may provide new MRI applications and future research opportunities.
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Affiliation(s)
- Ilaria Amodeo
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | - Irene Borzani
- grid.414818.00000 0004 1757 8749Pediatric Radiology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Genny Raffaeli
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy ,grid.4708.b0000 0004 1757 2822Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Nicola Persico
- grid.4708.b0000 0004 1757 2822Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy ,grid.414818.00000 0004 1757 8749Department of Obstetrics and Gynecology, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Simeone Amelio
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | - Silvia Gulden
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | - Mariarosa Colnaghi
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | - Eduardo Villamor
- grid.412966.e0000 0004 0480 1382Department of Pediatrics, School for Oncology and Reproduction (GROW), Maastricht University Medical Center, University of Maastricht, MUMC+), Maastricht, the Netherlands
| | - Fabio Mosca
- grid.414818.00000 0004 1757 8749Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy ,grid.4708.b0000 0004 1757 2822Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122, Milan, Italy.
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Predicting Perinatal Outcomes in Fetuses with Congenital Diaphragmatic Hernia Using Ultrasound and Magnetic Resonance Imaging. MATERNAL-FETAL MEDICINE 2021. [DOI: 10.1097/fm9.0000000000000103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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16
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Cordier AG, Laup L, Letourneau A, Le Sache N, Fouquet V, Senat MV, Perrotin F, Rosenblatt J, Sananes N, Jouannic JM, Benoist G, Jani JC, Benachi A. Prenatal stomach position predicts gastrointestinal morbidity at 2 years in fetuses with left-sided congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:959-967. [PMID: 32462707 DOI: 10.1002/uog.22086] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 05/02/2020] [Accepted: 05/10/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE The long-term morbidity associated with isolated left-sided congenital diaphragmatic hernia (CDH) has been described previously. However, antenatal criteria impacting gastrointestinal morbidity (GIM) are not yet defined. The objective of this study was to evaluate the effect of fetal stomach position on the risk of GIM at 2 years of age in children with left-sided CDH. METHODS This was a retrospective, observational multicenter cohort study of data obtained from January 2010 to January 2014, that included patients whose fetus had isolated left-sided CDH, with or without fetal endoscopic tracheal occlusion (FETO). Prenatal maternal, fetal and pediatric data were collected. Fetal stomach position was evaluated a posteriori by two observers, using ultrasound images at the level of the four-chamber view of the heart that had been obtained to calculate the observed-to-expected lung-area-to-head-circumference ratio (O/E-LHR). Fetal stomach position was graded as follows: Grade 1, stomach not visualized; Grade 2, stomach visualized anteriorly, next to the apex of the heart, with no structure in between the stomach and the sternum; Grade 3, stomach visualized alongside the left ventricle of the heart, and abdominal structures anteriorly; or Grade 4, as Grade 3 but with stomach posterior to the level of the atrioventricular heart valves. The primary outcome was GIM at 2 years of age, assessed in a composite manner, including the occurrence of gastroesophageal reflux disease, need for gastrostomy, duration of parenteral and enteral nutrition and persistence of oral aversion. Regression analysis was performed in order to investigate the effect of O/E-LHR, stomach position and FETO on various GIM outcome variables. RESULTS Forty-seven patients with fetal left-sided CDH were included in the analysis. Thirteen (27.7%) infants did not meet the criterion of exclusive oral feeding at 2 years of age. Fetal stomach position grade was associated significantly and independently with the duration of parenteral nutrition (odds ratio (OR), 19.86; P = 0.031) and persistence of oral aversion at 2 years (OR, 3.40; P = 0.006). On multivariate analysis, O/E-LHR was predictive of the need for prosthetic patch repair, but not for GIM. FETO did not seem to affect the risk of GIM at 2 years. CONCLUSION In isolated left-sided CDH, fetal stomach position is the only factor that is predictive of GIM at 2 years of age. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A G Cordier
- Department of Gynecology and Obstetrics, Antoine Béclère Hospital, Paris-Sud University, Clamart, France
- Reference Center for Rare Diseases: Congenital Diaphragmatic Hernia, Clamart, France
| | - L Laup
- Department of Gynecology and Obstetrics, Antoine Béclère Hospital, Paris-Sud University, Clamart, France
| | - A Letourneau
- Department of Gynecology and Obstetrics, Antoine Béclère Hospital, Paris-Sud University, Clamart, France
- Reference Center for Rare Diseases: Congenital Diaphragmatic Hernia, Clamart, France
| | - N Le Sache
- Reference Center for Rare Diseases: Congenital Diaphragmatic Hernia, Clamart, France
- Department of Neonatal Pediatrics, Bicêtre Hospital, Paris-Sud University, Le Kremlin-Bicêtre, France
| | - V Fouquet
- Reference Center for Rare Diseases: Congenital Diaphragmatic Hernia, Clamart, France
- Department of Pediatric Surgery, Bicêtre Hospital, Paris-Sud University, Le Kremlin-Bicêtre, France
| | - M V Senat
- Reference Center for Rare Diseases: Congenital Diaphragmatic Hernia, Clamart, France
- Department of Gynecology and Obstetrics, Bicêtre Hospital, Paris-Sud University, Le Kremlin-Bicêtre, France
| | - F Perrotin
- Department of Obstetrics, Gynecology and Fetal Medicine, Regional University Hospital, Francois Rabelais University, Tours, France
| | - J Rosenblatt
- Department of Obstetrics and Gynecology, Robert Debré Hospital, APHP, Paris, France
| | - N Sananes
- Department of Maternal-Fetal Medicine, Strasbourg University Hospital, Strasbourg, France
| | - J M Jouannic
- Department of Fetal Medicine, Trousseau Hospital, APHP Sorbonne, Sorbonne University, Paris, France
| | - G Benoist
- Department of Obstetrics and Gynecology, Caen University Hospital, Caen, France
| | - J C Jani
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - A Benachi
- Department of Gynecology and Obstetrics, Antoine Béclère Hospital, Paris-Sud University, Clamart, France
- Reference Center for Rare Diseases: Congenital Diaphragmatic Hernia, Clamart, France
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Attar I, Chaara H, Jayi S, Alaoui FZF, Melhouf MA. [Understanding and guidelines for the management of antenatal diagnosis of diaphragmatic hernia: prognostic factors]. Pan Afr Med J 2021; 39:9. [PMID: 34178237 PMCID: PMC8197053 DOI: 10.11604/pamj.2021.39.9.28895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/06/2021] [Indexed: 11/11/2022] Open
Abstract
Nous avons mené une étude portée sur cinq cas d´hernie de la coupole diaphragmatique fœtale (HCD) sur deux ans au sein de notre unité de diagnostic anténatal afin de faire un rappel sur les repères généraux concernant cette pathologie et sa prise en charge toute en soulignant les actualités en matière d'évaluation prénatale du pronostic néonatale à l´aide du calcul du Lung over Head Ratio (LHR): échographie versus imagerie par résonance magnétique (IRM) dans les pays du tiers-monde. Le but de notre travail est de clarifier le devenir de ces nouveau-nés et d'assurer un accompagnement au couple d'un fœtus portant une hernie de la coupole diaphragmatique.
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Affiliation(s)
- Imane Attar
- Service de Gynécologie et d´Obstétrique II, CHU Hassan II, Fès, Maroc
| | - Hekmat Chaara
- Service de Gynécologie et d´Obstétrique II, CHU Hassan II, Fès, Maroc
| | - Sofi Jayi
- Service de Gynécologie et d´Obstétrique II, CHU Hassan II, Fès, Maroc
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Abbasi N, Ryan G, Ruano R, Sanz Cortes M, Ye XY, Shah PS, Filly R, Benachi A, Johnson A. Interrater agreement for sonographic stomach position classification in fetal diaphragmatic hernia across the North American Fetal Therapy Network. Prenat Diagn 2021; 42:348-356. [PMID: 33817814 DOI: 10.1002/pd.5949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 03/29/2021] [Accepted: 03/15/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To evaluate inter-rater agreement for sonographic classification of stomach position (as a surrogate for liver herniation) in fetal left congenital diaphragmatic hernia (LCDH) among: (i) fetal medicine specialists from the North American Fetal Therapy Network (NAFTNet) centers within and without the fetal endoscopic tracheal occlusion (FETO) consortium and in comparison to an expert external reviewer (ER1); and (iii) among two expert ERs (ER1 and ER2). METHODS Forty-eight physicians from 26 NAFTNet centers and 2 ERs were asked to assess 13 sonographic clips of isolated LCDH and classify stomach position as "intra-abdominal," "anterior left chest," "mid to posterior left chest," or "retro-cardiac" based on the classification published by Basta et al.8 Interrater agreement was assessed by determining proportion of stomach position ratings concordant amongst NAFTNet participants and ER1. Agreement for stomach position between ERs was calculated using kappa statistics. RESULTS Agreement for stomach position was 69% (39%-85%; n = 19) and 54% (23%-92%; n = 29) among FETO and non-FETO NAFTNet participants, respectively, when compared to ER1. Most disagreement in stomach position was related to a discrepancy of one position. ERs were in agreement for stomach position in 5 of 13 cases (38.5%) and inter-rater agreement was highest for "anterior" stomach position. CONCLUSION Interrater agreement for stomach position assessment in CDH was poor across NAFTNet and indeed amongst expert reviewers.
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Affiliation(s)
- Nimrah Abbasi
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, Mayo College of Medicine, Rochester, Minnesota, USA
| | - Magda Sanz Cortes
- Department of Obstetrics and Gynecology, Texas Children's Fetal Center, Baylor College of Medicine, Houston, Texas, USA
| | - Xiang Y Ye
- Maternal-Infant Care (MiCare) Center, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Prakesh S Shah
- Maternal-Infant Care (MiCare) Center, Mount Sinai Hospital, Toronto, Ontario, Canada.,Deparment of Paediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Roy Filly
- University of California San Francisco Fetal Treatment Center, San Francisco, California, USA.,Department of Radiology and Biomedical Imaging, University of California San Francisco Medical Center, San Francisco, California, USA
| | - Alexandra Benachi
- Centre Maladie Rare: Hernie de Coupole Diaphragmatique, Hôpital Antoine-Béclère, Clamart, France.,Service de Gynécologie-Obstétrique, AP-HP, Hôpital Antoine Béclère, Université Paris-Sud, Clamart, France
| | - Anthony Johnson
- The Fetal Center, Children's Memorial Hermann Hospital, University of Texas Health Science Center, Houston, Texas, USA
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19
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Shetty S, Arattu Thodika FMS, Greenough A. Managing respiratory complications in infants and newborns with congenital diaphragmatic hernia. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1865915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
| | | | - Anne Greenough
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London, UK
- Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, UK
- Asthma UK Centre in Allergic Mechanisms of Asthma, King’s College London, London, UK
- NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, UK
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20
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Russo FM, Debeer A, De Coppi P, Devriendt K, Crombag N, Hubble T, Power B, Benachi A, Deprest J. What should we tell parents? Congenital diaphragmatic hernia. Prenat Diagn 2020; 42:398-407. [PMID: 33599313 DOI: 10.1002/pd.5880] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/13/2020] [Accepted: 11/30/2020] [Indexed: 12/18/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is characterized by a defect in the muscle dividing the thoracic and abdominal cavities. This leads to herniation of the abdominal organs into the thorax and a disturbance of lung development. Two-thirds of cases are identified by prenatal ultrasound in the second trimester, which should prompt referral to a tertiary center for prognosis assessment and counseling by a multidisciplinary team familiar with this condition. In this review, we summarize evidence on prenatal diagnosis and postnatal management of CDH. There is a focus on information that should be provided to expecting parents during prenatal counseling.
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Affiliation(s)
- Francesca M Russo
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - Anne Debeer
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Paolo De Coppi
- Neonatal and Paediatric Surgery Unit, Great Ormond Street Hospital, London, UK.,Stem Cells & Regenerative Medicine Section, NIHR Biomedical Research Center, UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Neeltje Crombag
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - Talia Hubble
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Medical Sciences Division, University of Oxford, Oxford, UK
| | | | - Alexandra Benachi
- Department of Obstetrics and Gynecology, Hôpital Antoine Béclère, AP-HP, Université Paris Saclay, Clamart, France.,Centre Référence Maladie Rare: Hernie de Coupole Diaphragmatique, Clamart, France
| | - Jan Deprest
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, UK
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21
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Abstract
Congenital diaphragmatic hernia (CDH) is a potentially severe anomaly that should be referred to a fetal care center with expertise in multidisciplinary evaluation and management. The pediatric radiologist plays an important role in the evaluation of CDH, both in terms of anatomical description of the anomaly and in providing detailed prognostic information for use in caring for the fetus and pregnant mother as well as planning for delivery and postnatal care. This article reviews the types of hernias, including distinguishing features and imaging clues. The most common methods of predicting severity are covered, and current fetal and postnatal therapies are explained. The author of this paper provides a handy reference for pediatric radiologists presented with a case of CDH as part of their daily practice.
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22
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Abstract
Congenital diaphragmatic hernia (CDH) is a rare developmental defect of the diaphragm, characterized by herniation of abdominal contents into the chest that results in varying degrees of pulmonary hypoplasia and pulmonary hypertension (PH). Significant advances in the prenatal diagnosis and identification of prognostic factors have resulted in the continued refinement of the approach to fetal therapies for CDH. Postnatally, protocolized approaches to lung-protective ventilation, nutrition, prevention of infection, and early aggressive management of PH have led to improved outcomes in infants with CDH. Advances in our understanding of the associated left ventricular (LV) hypoplasia and myocardial dysfunction in infants with severe CDH have allowed for the optimization of hemodynamics and management of PH. This article provides a comprehensive review of CDH for the anesthesiologist, focusing on the complex pathophysiology, advances in prenatal diagnosis, fetal interventions, and optimal postnatal management of CDH.
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Affiliation(s)
| | | | - Jason Gien
- Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
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23
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Dütemeyer V, Cordier AG, Cannie MM, Bevilacqua E, Huynh V, Houfflin-Debarge V, Verpillat P, Olivier C, Benachi A, Jani JC. Prenatal prediction of postnatal survival in fetuses with congenital diaphragmatic hernia using MRI: lung volume measurement, signal intensity ratio, and effect of experience. J Matern Fetal Neonatal Med 2020; 35:1036-1044. [PMID: 32212880 DOI: 10.1080/14767058.2020.1740982] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objective: To evaluate various signal intensity ratios in isolated congenital diaphragmatic hernia (CDH) and to compare their potential in predicting survival with that of the observed-to-expected (O/E) ratio of total fetal lung volume (TFLV) using magnetic resonance imaging (MRI) measurements. Our second objective was to evaluate the impact of operator's experience in comparing the prediction of postnatal survival by O/E-TFLV.Methods: In 75 conservatively managed CDH fetuses and in 50 who underwent fetoscopic endoluminal tracheal occlusion (FETO), the fetal lung-to-amniotic fluid, lung-to-liver, lung-to-muscle, lung-to-spinal fluid signal intensity ratios, respectively LAFSIR, LLSIR, LMSIR, and LSFSIR, were measured, as was O/E-TFLV. Receiver operating characteristic (ROC) curves were constructed and used to compare the various signal intensity ratios with O/E-TFLV in the prediction of postnatal survival. In 72 MRI lung volumes assessed by the referring radiologists in Paris and Lille and secondarily by our expert radiologist in Brussels (M.M.C.) using the same MRI examinations, ROC curves were constructed and used to compare the value of O/E-TFLV determined by the two centers in the prediction of postnatal survival.Results: In the total cohort of CDH fetuses, O/E-TFLV and LLSIR were predictive of postnatal survival whereas in the conservatively managed group O/E-TFLV, LLSIR, and LMSIR predicted postnatal survival. O/E-TFLV predicted postnatal survival far better than the signal intensity ratios: area under the ROC curve for prediction by O/E-TFLV in the total cohort was 0.866 (p < .001; standard error = 0.031). The area under the ROC curve for prediction of postnatal survival using O/E-TFLV by MRI evaluated at the referral centers was 0.640 (p = 102; standard error = 0.085), and with O/E-TFLV reevaluated by M.M.C., it was 0.872 (p < .001; standard error = 0.061). Pairwise comparison showed a significant difference between the areas under the ROC curves (difference = 0.187, p = .012; standard error = 0.075).Conclusion: In fetuses with CDH with/without FETO, LLSIR was significantly correlated with the prediction of postnatal survival. However, measurement of O/E-TFLV was far better in predicting postnatal outcome. Operator experience in measurement of lung volumes using MRI seem to play a role in the predictive value of the technique.
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Affiliation(s)
- Vivien Dütemeyer
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Vrije Universiteit Brussel, Brussels, Belgium
| | - Anne-Gael Cordier
- Department of Gynecology and Obstetrics, Bicêtre Hospital, Paris Sud University, Le Kremlin Bicêtre, France.,Reference Center for Rare Diseases: Congenital Diaphragmatic Hernia, Clamart, France
| | - Mieke M Cannie
- Department of Radiology, University Hospital Brugmann, Brussels, Belgium.,Department of Radiology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Elisa Bevilacqua
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Vrije Universiteit Brussel, Brussels, Belgium
| | - Van Huynh
- Department of Paediatric Radiology, Bicêtre Hospital, Paris Sud University, Le Kremlin Bicêtre, France
| | | | | | - Camille Olivier
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Vrije Universiteit Brussel, Brussels, Belgium
| | - Alexandra Benachi
- Reference Center for Rare Diseases: Congenital Diaphragmatic Hernia, Clamart, France.,Department of Obstetrics and Gynaecology, Antoine Béclère Hospital, Paris Sud University, Clamart, France
| | - Jacques C Jani
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Vrije Universiteit Brussel, Brussels, Belgium
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24
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Cordier AG, Russo FM, Deprest J, Benachi A. Prenatal diagnosis, imaging, and prognosis in Congenital Diaphragmatic Hernia. Semin Perinatol 2020; 44:51163. [PMID: 31439324 DOI: 10.1053/j.semperi.2019.07.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Antenatal ultrasound screening identifies more than 60% of Congenital Diaphragmatic Hernia (CDH) cases and provides the opportunity for in utero referral to a tertiary care center for expert assessment and perinatal management. Prenatal assessment of fetuses with CDH has tremendously improved over the past ten years. The outcome may be predicted prenatally by medical imaging and advanced genetic testing. The combination of lung size and liver position determination by ultrasound measurements and MRI are widely accepted methods to stratify fetuses into groups that correlate not only with neonatal mortality but also with morbidity. Notwithstanding this, prediction of persistent pulmonary hypertension of the newborn still needs to be improved.
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Affiliation(s)
- Anne-Gael Cordier
- Department of Obstetrics and Gynecology, Hôpital Antoine Béclère, AP-HP, Université Paris Sud, 157 rue de la porte de Trivaux, 92140 CLAMART, APHP, Clamart, France; Centre Référence Maladie Rare, Hernie de Coupole Diaphragmatique, Clamart, France.
| | - Francesca M Russo
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium; Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - Jan Deprest
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium; Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium; Institute for Women's Health, University College London, London, UK
| | - Alexandra Benachi
- Department of Obstetrics and Gynecology, Hôpital Antoine Béclère, AP-HP, Université Paris Sud, 157 rue de la porte de Trivaux, 92140 CLAMART, APHP, Clamart, France; Centre Référence Maladie Rare, Hernie de Coupole Diaphragmatique, Clamart, France
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25
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Abstract
Congenital diaphragmatic hernia (CDH) is a condition that results from incomplete diaphragm formation during embryogenesis. The diaphragmatic defect allows for herniation of abdominal viscera into the chest, and the resulting pulmonary hypoplasia and pulmonary hypertension can lead to cardiorespiratory failure in the neonatal period. There is a wide spectrum of disease severity in CDH, and while advances in neonatal care and the introduction of extracorporeal membrane oxygenation have improved outcomes in many cases, the most severe defects are still associated with high morbidity and mortality. Improvements in prenatal diagnostic and prognostic capabilities have created an opportunity to select high risk patients for fetal intervention. Three decades of refinements in the fetal surgical therapy for CDH have led to the current technique of Fetoscopic Endoluminal Tracheal Occlusion (FETO). Herein, we review the current considerations for selecting patients for fetal intervention, and the contemporary fetal surgical operation for CDH, FETO, with a focus on early outcomes and ongoing studies.
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Affiliation(s)
- Mark L Kovler
- Johns Hopkins Hospital, Division of General Pediatric Surgery, Baltimore, MD, United States
| | - Eric B Jelin
- Johns Hopkins Hospital, Division of General Pediatric Surgery, Baltimore, MD, United States.
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26
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Novoa Y Novoa VA, Sutton LF, Neis AE, Marroquin AM, Coleman TM, Praska KA, Freimund TA, Ruka KL, Warzala VL, Sangi-Haghpeykar H, Ruano R. Reproducibility of Liver-to-Thorax Area Ratio Ultrasound Measurements in Congenital Diaphragmatic Hernia. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:1477-1482. [PMID: 30244491 DOI: 10.1002/jum.14826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 08/02/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES The aim of this study was to investigate the reproducibility of a standardized method to assess the ultrasound liver-to-thoracic area ratio in fetuses with congenital diaphragmatic hernia. METHODS We selected 24 images of 9 fetuses diagnosed with left-sided at our institution between January 2010 and December 2017. Eight operators (1 maternal-fetal medicine specialist and 7 sonographers) reviewed the selected images and assessed the ultrasound liver-to-thoracic area ratio according to a standardized protocol. We evaluated the correlation between operators using the intraclass correlation coefficient and compared agreement between the sonographers and a physician with experience in measuring the ultrasound liver-to-thoracic area ratio using a Bland-Altman analysis. RESULTS Good intraoperator reproducibility was observed for the standardized ultrasound liver-to-thoracic area ratio (intraclass correlation coefficient, 0.78). Good agreement among sonographers and the physician was also observed for the standardized measurements (bias, 0.01; precision, 0.03; limits of agreement, -0.05 to + 0.07). CONCLUSIONS We demonstrated that good intraoperator and interoperator reproducibility of ultrasound liver-to-thoracic area ratio assessment is feasible after standardizing the method in our center.
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Affiliation(s)
- Victoria Arruga Novoa Y Novoa
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Laura F Sutton
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Allan E Neis
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Amber M Marroquin
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Tracey M Coleman
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Kathleen A Praska
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Tamara A Freimund
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Krystal L Ruka
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Vicki L Warzala
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Haleh Sangi-Haghpeykar
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Rodrigo Ruano
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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27
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Burgos CM, Frenckner B, Luco M, Harting MT, Lally PA, Lally KP. Prenatally versus postnatally diagnosed congenital diaphragmatic hernia - Side, stage, and outcome. J Pediatr Surg 2019; 54:651-655. [PMID: 29753526 DOI: 10.1016/j.jpedsurg.2018.04.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/02/2018] [Accepted: 04/04/2018] [Indexed: 11/19/2022]
Abstract
AIM To compare outcomes between prenatally and postnatally diagnosed CDH in a large multicenter database of prospectively collected data and evaluate factors associated with poorer outcome for prenatally diagnosed CDH. MATERIAL AND METHODS We used information from the multicenter, multinational CDH Study Group database on patients born between 2007 and 2015. We compared differences between prenatally and postnatally diagnosed CDH with respect to survival, side, size, ECMO needs, associated major cardiac malformations and liver position. RESULTS 3746 cases of CDH were entered in the registry between 2007 and 2015, with an overall survival of 71%. Of those, 68% had a prenatal diagnosis. Survival rates were significantly better in the postnatally diagnosed group, 83 vs 65%. There was a higher proportion of bigger defect sizes, C and D, in the prenatally diagnosed group, but the survival rates were similar when patients were stratified by defect size. The rate of ECMO utilization was higher overall in the prenatally diagnosed group, 33 vs 22%, but it was similar within similar defect sizes. Right-sided defects are more commonly missed at prenatal screening than left-sided CDH, 53 vs 35% (p < 0.0001). CONCLUSIONS Prenatally diagnosed CDH is associated with larger defect sizes compared to those with a postnatal diagnosis, and consequently have higher morbidity and mortality. Right-sided CDH are more often missed at prenatal ultrasound. The increasing rate of prenatal detection requires a clear understanding of accurate risk stratification, in order to counsel families and to provide appropriate perinatal management. LEVEL OF EVIDENCE I for a Prognosis Study - This is a high-quality, prospective cohort study with 99% of patients followed to the study end point (death or discharge).
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Affiliation(s)
| | - Björn Frenckner
- Department of Pediatric Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Matias Luco
- Department of Neonatology, School of Medicine Pontificia Universidad Católica de, Chile
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at UT Health and Children's Memorial Hermann Hospital, Houston, TX, US
| | - Pamela A Lally
- Department of Pediatric Surgery, McGovern Medical School at UT Health and Children's Memorial Hermann Hospital, Houston, TX, US
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at UT Health and Children's Memorial Hermann Hospital, Houston, TX, US
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Aydin E, Lim FY, Kingma P, Haberman B, Rymeski B, Burns P, Peiro JL. Congenital diaphragmatic hernia: the good, the bad, and the tough. Pediatr Surg Int 2019; 35:303-313. [PMID: 30680439 DOI: 10.1007/s00383-019-04442-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2019] [Indexed: 01/06/2023]
Abstract
OBJECTIVES We aim to determine factors that are associated with better outcomes of CDH patients. METHODS A retrospective review was performed on all CDH patients admitted to our institution between 2003 and 2016. This study was performed at a single institution which has a fetal care center. Patients admitted with CDH with at least 1-year follow-up during the analysis were included in the study. RESULTS Twenty-six (13.8%) patients had a hernia sac, 124 (59%) patients had liver herniation, and 56 (25.1%) patients had an accompanying syndrome. Overall survival to discharge was 73.1% while overall survival to date was 69.5%. The presence of a hernia sac, liver herniation, and accompanying syndromes showed as independent predictors influencing the survival, B 1.968, p = 0.04, OR 7.158, 95% CI 0.907-56.485, B - 1.178, p = 0.01, OR 3.932, 95% CI 1.798-8.602 and B - 1.032, p = 0.05, OR 2.795, 95% CI 0.976-7.764, respectively. CONCLUSION In our CDH cohort, the presence of a hernia sac was proven to be associated with better outcomes, while thoracic herniation of the liver was associated with worse outcomes. The accompanying syndromes although being more difficult to manage had a little effect on the outcome of the disease itself.
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Affiliation(s)
- Emrah Aydin
- Division of Pediatric General and Thoracic Surgery, The Center for Fetal Cellular and Molecular Therapy, Cincinnati Fetal Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA.
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery, The Center for Fetal Cellular and Molecular Therapy, Cincinnati Fetal Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Paul Kingma
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Beth Haberman
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Beth Rymeski
- Division of Pediatric General and Thoracic Surgery, The Center for Fetal Cellular and Molecular Therapy, Cincinnati Fetal Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Patricia Burns
- Division of Pediatric General and Thoracic Surgery, The Center for Fetal Cellular and Molecular Therapy, Cincinnati Fetal Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
| | - Jose L Peiro
- Division of Pediatric General and Thoracic Surgery, The Center for Fetal Cellular and Molecular Therapy, Cincinnati Fetal Center, 3333 Burnet Avenue, MLC 11025, Cincinnati, OH, 45229-3039, USA
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29
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Basurto D, Russo FM, Van der Veeken L, Van der Merwe J, Hooper S, Benachi A, De Bie F, Gomez O, Deprest J. Prenatal diagnosis and management of congenital diaphragmatic hernia. Best Pract Res Clin Obstet Gynaecol 2019; 58:93-106. [PMID: 30772144 DOI: 10.1016/j.bpobgyn.2018.12.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 12/31/2018] [Indexed: 12/13/2022]
Abstract
Congenital diaphragmatic hernia is characterized by failed closure of the diaphragm, thereby allowing abdominal viscera to herniate into the thoracic cavity and subsequently interfering with normal lung development. At birth, pulmonary hypoplasia leads to respiratory insufficiency and persistent pulmonary hypertension (PHT), that is lethal in up to 32% of patients. In isolated cases, the outcome may be predicted prenatally by medical imaging and advanced genetic testing. In those fetuses with a predicted poor outcome, fetoscopic endoluminal tracheal occlusion may be offered. This procedure is currently being evaluated in a global randomized clinical trial (www.TOTALtrial.eu). We are currently investigating alternative strategies including transplacental sildenafil administration to reduce the occurrence of persistent PHT.
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Affiliation(s)
- David Basurto
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium
| | - Francesca Maria Russo
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium; Clinical Department of Obstetrics & Gynaecology, KU Leuven, Leuven, Belgium
| | - Lennart Van der Veeken
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium; Clinical Department of Obstetrics & Gynaecology, KU Leuven, Leuven, Belgium
| | - Johannes Van der Merwe
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium; Clinical Department of Obstetrics & Gynaecology, KU Leuven, Leuven, Belgium
| | - Stuart Hooper
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Alexandra Benachi
- Obstetrics and Gynaecology Department, Centre de Référence Maladie Rare: Hernie de Coupole Diaphragmatique, Hôpital Antoine Béclère, Université Paris Sud, AP-HP, Clamart, France; European Reference Network on Rare and Inherited Congenital Anomalies "ERNICA"
| | - Felix De Bie
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium
| | - Olga Gomez
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Fetal I+D Fetal Medicine Research Center, Institut Clinic de Ginecologia, Obstetricia I Neonatologia, IDIBAPS, CIBER-ER, University of Barcelona, Spain
| | - Jan Deprest
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium; Clinical Department of Obstetrics & Gynaecology, KU Leuven, Leuven, Belgium; Institute for Women's Health, University College London, London, UK; European Reference Network on Rare and Inherited Congenital Anomalies "ERNICA".
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Lee HS, Dickinson JE, Tan JK, Nembhard W, Bower C. Congenital diaphragmatic hernia: Impact of contemporary management strategies on perinatal outcomes. Prenat Diagn 2018; 38:1004-1012. [PMID: 30346634 DOI: 10.1002/pd.5376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 08/21/2018] [Accepted: 10/12/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This study aims to review temporal changes in perinatal management and 1-year survival outcomes of cases of congenital diaphragmatic hernia (CDH) from 1996 to 2015 in Western Australia (WA). METHOD This research is a retrospective study of all cases of CDH in WA from 1996 to 2015 identified from five independent databases within the WA health network. Detailed information pertaining to pregnancy and survival outcomes were obtained from review of maternal and infant medical records. RESULTS There were 215 cases of CDH with 164 diagnosed prenatally. Between 1996 and 2010, a decline in live birth rates for CDH-affected pregnancies was observed, reaching a nadir of 5.3 per 10 000 births before increasing to a peak of 9.73 per 10 000 births in 2011-2015. A corresponding decline was seen in the number of pregnancies terminated in the same period from 8.3 to 4.6 per 10 000 births (P = 0.14) and an increase in survival of live births from 38.9% to 81.3% (P = 0.01). CONCLUSION The improved overall survival rate in infants with CDH over the last 20 years may have resulted in an increased tendency for women to continue their pregnancy with a concomitant decline in termination rates. Information from this study will help in the counselling of women following prenatal detection of CDH.
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Affiliation(s)
| | | | - Jason Kg Tan
- Princess Margaret Hospital for Children, Perth, Australia
| | - Wendy Nembhard
- Princess Margaret Hospital for Children, Perth, Australia.,The Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Antenatal sildenafil administration to prevent pulmonary hypertension in congenital diaphragmatic hernia (SToP-PH): study protocol for a phase I/IIb placenta transfer and safety study. Trials 2018; 19:524. [PMID: 30261903 PMCID: PMC6161420 DOI: 10.1186/s13063-018-2897-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 08/31/2018] [Indexed: 01/28/2023] Open
Abstract
Background Congenital diaphragmatic hernia is an orphan disease with high neonatal mortality and significant morbidity. An important cause for this is pulmonary hypertension, for which no effective postnatal therapy is available to date. An innovative strategy aiming at treating or preventing pulmonary hypertension more effectively is urgently needed. Prenatal sildenafil administration to expectant mothers prevented fetal and neonatal vascular changes leading to pulmonary hypertension in several animal models, and is, therefore, a promising approach. Before transferring this antenatal medical approach to the clinic, more information is needed on transplacental transfer and safety of sildenafil in humans. Methods This is a randomized, investigator-blinded, double-armed, parallel-group, phase I/IIb study with as a primary objective to measure the in-vivo transplacental transfer of sildenafil in women in the second and early third trimester of pregnancy (sub-study 1; weeks: 20.0–32.6) and at term (sub-study 2; weeks: 36.6–40). Participants will be randomized to two different sildenafil doses: 25 or 75 mg. In sub-study 1, a single dose of the investigational product will be administered to women undergoing termination of pregnancy, and maternal and fetal blood samples will be collected for determination of sildenafil concentrations. In sub-study 2, sildenafil will be administered three times daily from 3 days before planned delivery until actual delivery, following which maternal and umbilical cord samples will be collected. Proxies of maternal and fetal tolerance as well as markers of fetal pulmonary vasodilation will also be measured. Discussion This is the first study evaluating in-vivo transplacental passage of sildenafil in humans. Trial registration EU Clinical Trials Register 2016–002619-17, validated on 12 August 2016. Trial sponsor: UZ Leuven, Herestraat 49, 3000 Leuven. Electronic supplementary material The online version of this article (10.1186/s13063-018-2897-8) contains supplementary material, which is available to authorized users.
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Russo FM, Cordier AG, De Catte L, Saada J, Benachi A, Deprest J. Proposal for standardized prenatal ultrasound assessment of the fetus with congenital diaphragmatic hernia by the European reference network on rare inherited and congenital anomalies (ERNICA). Prenat Diagn 2018; 38:629-637. [PMID: 29924391 DOI: 10.1002/pd.5297] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/02/2018] [Accepted: 06/08/2018] [Indexed: 12/13/2022]
Abstract
Congenital diaphragmatic hernia is a rare disease associated with high mortality and morbidity. Antenatal ultrasound screening identifies more than 70% of cases, providing the opportunity for in utero referral to a tertiary care center for expert assessment and perinatal management. Additional genetic and morphologic assessment may be used to rule out associated anomalies. In isolated cases, the outcome may be predicted prenatally by medical imaging. The combination of lung size and liver herniation is a widely accepted method to stratify fetuses into groups with an increasing degree of pulmonary hypoplasia and corresponding mortality rates. Ultrasound measurement of the observed to expected lung-to-head ratio (o/e LHR) is most widely used. The o/e LHR is an independent predictor of survival and short-term morbidity. Finally, evaluation of stomach position has recently been introduced as an indirect method to estimate severity of the disease in left-sided defects, as it has been shown to correlate with the proportion of intrathoracic liver. Herein, we propose a protocol for the standardized ultrasound assessment of fetuses with isolated CDH and individualized prediction of neonatal outcome.
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Affiliation(s)
- Francesca Maria Russo
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - Anne-Gael Cordier
- Department of Obstetrics and Gynecology, Hôpital Antoine Béclère, AP-HP, Université Paris Sud, Clamart, France
| | - Luc De Catte
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - Julien Saada
- Centre Référence Maladie Rare: Hernie de Coupole Diaphragmatique, Clamart, France
| | - Alexandra Benachi
- Department of Obstetrics and Gynecology, Hôpital Antoine Béclère, AP-HP, Université Paris Sud, Clamart, France.,Centre Référence Maladie Rare: Hernie de Coupole Diaphragmatique, Clamart, France
| | - Jan Deprest
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, UK
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Volpe N, Mazzone E, Muto B, Suprani A, Fanelli T, Kaihura CT, Dall'Asta A, Pedrazzi G, Del Rossi C, Silini EM, Magnani C, Volpe P, Ghi T, Frusca T. Three-dimensional assessment of umbilical vein deviation angle for prediction of liver herniation in left-sided congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:214-218. [PMID: 28078737 DOI: 10.1002/uog.17406] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 01/05/2017] [Accepted: 01/08/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To introduce a new sonographic marker of intrathoracic liver herniation in fetuses with left-sided congenital diaphragmatic hernia (CDH). METHODS In a consecutive series of fetuses with isolated CDH, an ultrasound volume of the fetal abdomen was acquired. On this volume, offline calculation of the angle formed by the midline of the abdomen (joining the center of the vertebral body to the abdominal insertion of the umbilical cord) and a second line joining the center of the vertebral body to the intra-abdominal convexity of the umbilical vein was carried out to give the umbilical vein deviation angle (UVDA). The UVDA was measured in a group of normal fetuses selected as controls. At follow-up, the presence of liver herniation was investigated in all cases of CDH. UVDA values were compared between the CDH group and controls, and between CDH 'liver-up' vs 'liver-down' cases. A receiver-operating characteristics (ROC) curve was constructed to identify a cut-off value of the UVDA with the highest accuracy in predicting liver herniation in the CDH group. RESULTS Between 2009 and 2015, 22 cases of left-sided CDH were included in the study group, of which nine cases had liver herniation. Eighty-eight normal fetuses were recruited as controls. The UVDA was significantly higher in the cases vs controls (15.25 ± 7.91° vs 7.68 ± 1.55°; P < 0.0001). Moreover, the UVDA was significantly increased in CDH fetuses with liver-up vs liver-down (21.77 ± 8.79° vs 10.75 ± 2.10°; P < 0.0001). On ROC curve analysis the UVDA showed good prediction of liver herniation (area under the ROC curve, 0.94; P < 0.0001) with the best cut-off of 15.2°, yielding a sensitivity of 89% and a specificity of 100% (P < 0.0001). CONCLUSIONS In fetuses with CDH, umbilical vein bowing may be quantified by measuring the UVDA using three-dimensional ultrasound. This sonographic marker seems to be an accurate predictor of liver herniation in left-sided CDH. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- N Volpe
- Obstetrics and Gynecology Unit, Department of Medicine and Surgery, Unit of Surgical Sciences, Maggiore Hospital, University of Parma, Parma, Italy
| | - E Mazzone
- Obstetrics and Gynecology Unit, Department of Medicine and Surgery, Unit of Surgical Sciences, Maggiore Hospital, University of Parma, Parma, Italy
| | - B Muto
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, ASL BA, Bari, Italy
| | - A Suprani
- Obstetrics and Gynecology Unit, Department of Medicine and Surgery, Unit of Surgical Sciences, Maggiore Hospital, University of Parma, Parma, Italy
| | - T Fanelli
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, ASL BA, Bari, Italy
| | - C T Kaihura
- Obstetrics and Gynecology Unit, Department of Medicine and Surgery, Unit of Surgical Sciences, Maggiore Hospital, University of Parma, Parma, Italy
| | - A Dall'Asta
- Obstetrics and Gynecology Unit, Department of Medicine and Surgery, Unit of Surgical Sciences, Maggiore Hospital, University of Parma, Parma, Italy
| | - G Pedrazzi
- Department of Neuroscience, University of Parma, Parma, Italy
| | - C Del Rossi
- Paediatric Hospital 'P. Barilla', Paediatric Surgery Unit, University of Parma, Parma, Italy
| | - E M Silini
- Department of Biomedical, Biotechnological and Translational Sciences, Pathological Anatomy and Histology Unit, University of Parma, Parma, Italy
| | - C Magnani
- Paediatric Hospital 'P. Barilla', Neonatology Unit, University of Parma, Parma, Italy
| | - P Volpe
- Fetal Medicine Unit, Di Venere and Sarcone Hospitals, ASL BA, Bari, Italy
| | - T Ghi
- Obstetrics and Gynecology Unit, Department of Medicine and Surgery, Unit of Surgical Sciences, Maggiore Hospital, University of Parma, Parma, Italy
| | - T Frusca
- Obstetrics and Gynecology Unit, Department of Medicine and Surgery, Unit of Surgical Sciences, Maggiore Hospital, University of Parma, Parma, Italy
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Yamoto M, Iwazaki T, Takeuchi K, Sano K, Fukumoto K, Takahashi T, Nomura A, Ooyama K, Sekioka A, Yamada Y, Urushihara N. The fetal lung-to-liver signal intensity ratio on magnetic resonance imaging as a predictor of outcomes from isolated congenital diaphragmatic hernia. Pediatr Surg Int 2018; 34:161-168. [PMID: 29018962 DOI: 10.1007/s00383-017-4184-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE We investigated the developmental changes in the unaffected contralateral lungs of patients with isolated left-sided congenital diaphragmatic hernia (CDH) using signal intensity ratios on prenatal magnetic resonance imaging (MRI) and determined whether these changes correlated with clinical outcomes. METHODS We performed 47 fetal MRI screens on 30 patients with isolated left-sided CDH. A cohort of 88 fetuses was selected as the control. We calculated the lung-to-liver signal intensity ratio (LLSIR) using region of interest analysis and compared LLSIR between the groups and between those in the CDH group with good and poor prognoses. RESULTS In the control group, LLSIR increased as pregnancy progressed [regression line = 2.232 + 0.135 × (GW-23), r = 0.669]. In the CDH group, especially in the poor prognosis group, LLSIR did not significantly increase as pregnancy progressed [regression line for good prognosis = 1.827 + 0.092 × (gestational week-23), r = 0.733; regression line for poor prognosis = 1.731 + 0.025 × (gestational week-23), r = 0.634]. CONCLUSION Fetal LLSIR on T2-weighted MRI is an accurate marker of fetal lung maturity that correlates with postnatal survival and can potentially be used as a prognostic parameter in CDH management.
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Affiliation(s)
- Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan.
| | - Teruo Iwazaki
- Department of Radiology, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Kasumi Takeuchi
- Department of Radiology, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Kyouhei Sano
- Department of Radiology, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Koji Fukumoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Toshiaki Takahashi
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Akiyoshi Nomura
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Kei Ooyama
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Akinori Sekioka
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Yutaka Yamada
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
| | - Naoto Urushihara
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8660, Japan
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Done E, Gucciardo L, Van Mieghem T, Devriendt K, Allegaert K, Brady P, Devlieger R, De Catte L, Lewi L, Deprest J. Clinically relevant discordances identified after tertiary reassessment of fetuses with isolated congenital diaphragmatic hernia. Prenat Diagn 2017; 37:883-888. [PMID: 28453870 DOI: 10.1002/pd.5060] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/14/2017] [Accepted: 04/21/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Fetoscopic endoluminal tracheal occlusion (FETO) may improve outcome of severe isolated congenital diaphragmatic hernia (iCDH). We aimed to identify any discrepancy between initial assessment at the referring hospital and the evaluation at the fetal surgery center, and to document parental decisions following counseling for fetal surgery. DESIGN Single center retrospective study on patients with presumed iCDH either referred for assessment and counseling or referred for fetal surgery. Discordant findings were defined as either a >10% difference in lung size, discordant liver position or associated anomalies. RESULTS Outcomes from 129 consecutive assessments over 24 months were analyzed. Among fetal surgery referrals, 2% did not have CDH, and 10% had undiagnosed associated anomalies. Liver position was discordant in 7%. Thirty-three per cent had discordant lung size. Ninety-four per cent of patients eligible for surgery underwent FETO. In patients referred because of suspicion of CDH, associated anomalies were found in 14%. Fetal liver and lung assessments were discordant in 50% resp. 38%. Of those patients eligible for FETO, 26% requested termination. For three patients, the postnatal course was marked by a genetic or syndromic additional diagnosis. CONCLUSION Discordances between initial assessment before referral and evaluation in our institution were frequent, some of them clinically relevant. © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Elisa Done
- Division of Woman and Child, Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, Clinical Specialties Research Groups, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Leonardo Gucciardo
- Division of Woman and Child, Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, Clinical Specialties Research Groups, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Tim Van Mieghem
- Division of Woman and Child, Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, Clinical Specialties Research Groups, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Koen Devriendt
- Centre for Medical Genetics, University Hospitals Leuven, Leuven, Belgium
| | - Karel Allegaert
- Department of Development and Regeneration, Clinical Specialties Research Groups, Faculty of Medicine, KU Leuven, Leuven, Belgium.,Department of Neonatology, University Hospitals Leuven, Leuven, Belgium
| | - Paul Brady
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium
| | - Roland Devlieger
- Division of Woman and Child, Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, Clinical Specialties Research Groups, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Luc De Catte
- Division of Woman and Child, Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, Clinical Specialties Research Groups, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Liesbeth Lewi
- Division of Woman and Child, Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, Clinical Specialties Research Groups, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Jan Deprest
- Division of Woman and Child, Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, Clinical Specialties Research Groups, Faculty of Medicine, KU Leuven, Leuven, Belgium.,UCL Institute for Women's Health, University College London, London, UK
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Snoek KG, Peters NCJ, van Rosmalen J, van Heijst AFJ, Eggink AJ, Sikkel E, Wijnen RM, IJsselstijn H, Cohen-Overbeek TE, Tibboel D. The validity of the observed-to-expected lung-to-head ratio in congenital diaphragmatic hernia in an era of standardized neonatal treatment; a multicenter study. Prenat Diagn 2017; 37:658-665. [PMID: 28453882 PMCID: PMC5518227 DOI: 10.1002/pd.5062] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 04/03/2017] [Accepted: 04/21/2017] [Indexed: 01/06/2023]
Abstract
Objective To assess the predictive value of observed‐to‐expected lung‐to‐head ratio (O/E LHR) for survival and chronic lung disease (CLD) in survivors of left‐sided congenital diaphragmatic hernia (CDH) in an era of standardized neonatal treatment, and to evaluate the predictive value of the O/E LHR trajectory for survival. Methods This retrospective cohort study was performed in two high‐volume CDH centers in the Netherlands in prenatally detected, isolated left‐sided CDH patients born between 2008 and 2014. O/E LHR and liver position were determined using 2D‐ultrasonography at three time points during gestation from 19 weeks onwards. Ultrasound measurements were performed on stored ultrasound data by one single experienced operator blinded to postnatal outcome. Results Of the 122 included cases, 77.9% survived of whom 38.9% developed CLD. A significant association was found between the first measured O/E LHR and survival and development of CLD in survivors. Prenatal liver position did not have additional predictive value. No significant association was found between the trajectory of the O/E LHR and survival. Conclusion In an era of standardized neonatal treatment for neonates with CDH, the first measured O/E LHR per patient significantly predicts survival and development of CLD in survivors in isolated left‐sided CDH infants. © 2017 The Authors. Prenatal Diagnosis published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Kitty G Snoek
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital University Medical Center Rotterdam, The Netherlands
| | - Nina C J Peters
- Department of Obstetrics and Prenatal Medicine, Erasmus MC-Sophia Children's Hospital University Medical Center Rotterdam, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus University Medical Center Rotterdam, The Netherlands
| | - Arno F J van Heijst
- Department of Neonatology, Radboud University Medical Centre Nijmegen, The Netherlands
| | - Alex J Eggink
- Department of Obstetrics and Prenatal Medicine, Erasmus MC-Sophia Children's Hospital University Medical Center Rotterdam, The Netherlands
| | - Esther Sikkel
- Department of Obstetrics and Gynecology, Radboud University Medical Centre Nijmegen, The Netherlands
| | - René M Wijnen
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital University Medical Center Rotterdam, The Netherlands
| | - Hanneke IJsselstijn
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital University Medical Center Rotterdam, The Netherlands
| | - Titia E Cohen-Overbeek
- Department of Obstetrics and Prenatal Medicine, Erasmus MC-Sophia Children's Hospital University Medical Center Rotterdam, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital University Medical Center Rotterdam, The Netherlands
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Abstract
In congenital diaphragmatic hernia (CDH), herniation of the abdominal organs into the fetal chest causes pulmonary hypoplasia and pulmonary hypertension, the main causes of neonatal mortality. As antenatal ultrasound screening improves, the risk of postnatal death can now be better predicted, allowing for the identification of fetuses that might most benefit from a prenatal intervention. Fetoscopic tracheal occlusion is being evaluated in a large international randomized controlled trial. We present the antenatal imaging approaches that can help identify fetuses that might benefit from antenatal therapy, and review the evolution of fetal surgery for CDH to date.
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Affiliation(s)
- Titilayo Oluyomi-Obi
- Section of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, University of Calgary, 1403 29 Street NW, Calgary, Alberta.
| | - Tim Van Mieghem
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Sananes N, Britto I, Akinkuotu AC, Olutoye OO, Cass DL, Sangi-Haghpeykar H, Lee TC, Cassady CI, Mehollin-Ray A, Welty S, Fernandes C, Belfort MA, Lee W, Ruano R. Improving the Prediction of Neonatal Outcomes in Isolated Left-Sided Congenital Diaphragmatic Hernia by Direct and Indirect Sonographic Assessment of Liver Herniation. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:1437-1443. [PMID: 27208195 DOI: 10.7863/ultra.15.07020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 10/14/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Liver herniation can be assessed sonographically by either a direct (liver-to-thoracic area ratio) or an indirect (stomach position) method. Our objective was to evaluate the utility of those methods to assess liver herniation for the prediction of neonatal outcomes in patients with isolated left-sided congenital diaphragmatic hernia (CDH). METHODS We conducted a retrospective cohort study of all patients with CDH who had prenatal assessment and were delivered at Texas Children's Hospital between January 2004 and April 2014. The predictive value of sonographic parameters for mortality and the need for extracorporeal membrane oxygenation was evaluated by univariate, multivariate, and factor analysis and by receiver operating characteristics curves. RESULTS A total of 77 fetuses with isolated left-sided CDH were analyzed. The lung-to-head ratio, liver-to-thorax ratio, and stomach position (according to the classifications of Kitano et al [Ultrasound Obstet Gynecol 2011; 37:277-282] and Cordier et al [J Matern Fetal Neonatal Med 2015; 28:190-195]) were significantly associated with both neonatal outcomes (P < .03). Significant correlations were observed between all of these sonographic parameters. A combination of the liver-to-thorax ratio and stomach position (Kitano) or stomach position (Cordier) with the lung-to-head ratio increased the area under the receiver operating characteristic curve of the lung-to-head ratio for mortality prediction (0.86 [95% confidence interval, 0.74-0.98], 0.83 [0.72-0.95], and 0.83 [0.74-0.92], respectively). CONCLUSIONS Sonographic measurements of liver herniation (liver-to-thorax ratio and stomach position) are predictive of neonatal outcomes in isolated left-sided congenital diaphragmatic hernia. Our study shows that the combination of those sonographic measurements of liver herniation and lung size improves the accuracy of predicting mortality in those fetuses.
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Affiliation(s)
- Nicolas Sananes
- Department of Obstetrics and Gynecology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA
| | - Ingrid Britto
- Department of Obstetrics and Gynecology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA
| | - Adesola C Akinkuotu
- Michael E. DeBakey Department of Surgery, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA
| | - Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA
| | - Darrell L Cass
- Michael E. DeBakey Department of Surgery, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA
| | - Haleh Sangi-Haghpeykar
- Department of Obstetrics and Gynecology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA
| | - Christopher I Cassady
- Department of Radiology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA
| | - Amy Mehollin-Ray
- Department of Radiology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA
| | - Stephen Welty
- Department of Pediatrics, Section of Neonatology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA
| | - Caraciolo Fernandes
- Department of Pediatrics, Section of Neonatology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA
| | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA
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Predictive Value of MRI Findings for the Identification of a Hernia Sac in Fetuses With Congenital Diaphragmatic Hernia. AJR Am J Roentgenol 2016; 205:1121-5. [PMID: 26496561 DOI: 10.2214/ajr.15.14476] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to identify MRI features of diaphragmatic hernia sac, as well as to assess the accuracy of diagnosing a sac prenatally. MATERIALS AND METHODS All fetal MRI examinations performed for intrapleural congenital diaphragmatic hernia (CDH) from 2004 to 2013 were retrospectively reviewed by two pediatric radiologists blinded to the hernia sac status (defined intraoperatively or at autopsy). Reviewers noted whether a sac was present on the basis of identification of the following four MRI findings: 1, meniscus of lung posterior or apical to the hernia contents; 2, encapsulated appearance of hernia contents, exerting less than expected mass effect on the heart and mediastinum; 3, presence of pleural fluid outlining a sac from above; and 4, presence of ascites outlining a sac from below. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each finding and for various combinations. Contingency tables, chi-square testing, and logistic regression were applied to calculate the probability of a sac. RESULTS Ninety patients were included: 21 with and 69 without a sac. The first three MRI findings correlated with the presence of a sac. Logistic regression yielded high predicted probability of a sac when one finding was identified (finding 1, 94.4%; finding 2, 96.2%). Adding a second and a third finding improved the probability to 99.7% and 99.9%, respectively. Sensitivity and specificity for the presence of a sac were 0.43 and 0.97, respectively. PPV and NPV were 83.8% and 80%, respectively. CONCLUSION On fetal MRI, presence of a hernia sac in CDH can be diagnosed with high specificity when indicative findings are present.
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Engels AC, Brady PD, Kammoun M, Finalet Ferreiro J, DeKoninck P, Endo M, Toelen J, Vermeesch JR, Deprest J. Pulmonary transcriptome analysis in the surgically induced rabbit model of diaphragmatic hernia treated with fetal tracheal occlusion. Dis Model Mech 2016; 9:221-8. [PMID: 26744354 PMCID: PMC4770142 DOI: 10.1242/dmm.021626] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 12/29/2015] [Indexed: 01/25/2023] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a malformation leading to pulmonary hypoplasia, which can be treated in utero by fetal tracheal occlusion (TO). However, the changes of gene expression induced by TO remain largely unknown but could be used to further improve the clinically used prenatal treatment of this devastating malformation. Therefore, we aimed to investigate the pulmonary transcriptome changes caused by surgical induction of diaphragmatic hernia (DH) and additional TO in the fetal rabbit model. Induction of DH was associated with 378 upregulated genes compared to controls when allowing a false-discovery rate (FDR) of 0.1 and a fold change (FC) of 2. Those genes were again downregulated by consecutive TO. But DH+TO was associated with an upregulation of 157 genes compared to DH and controls. When being compared to control lungs, 106 genes were downregulated in the DH group and were not changed by TO. Therefore, the overall pattern of gene expression in DH+TO is more similar to the control group than to the DH group. In this study, we further provide a database of gene expression changes induced by surgical creation of DH and consecutive TO in the rabbit model. Future treatment strategies could be developed using this dataset. We also discuss the most relevant genes that are involved in CDH. Summary: Rabbit fetuses with induced diaphragmatic hernia and treated with prenatal tracheal occlusion have a similar pulmonary transcriptome as unaffected controls. This study describes a valuable database of gene expressions in this model.
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Affiliation(s)
- Alexander C Engels
- Department of Development and Regeneration, Organ System Cluster, Faculty of Medicine, KU Leuven, 3000 Leuven, Belgium Clinical Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals KU Leuven, 3000 Leuven, Belgium
| | - Paul D Brady
- Department of Human Genetics, Centre for Human Genetics, University Hospitals KU Leuven, 3000 Leuven, Belgium
| | - Molka Kammoun
- Department of Human Genetics, Centre for Human Genetics, University Hospitals KU Leuven, 3000 Leuven, Belgium
| | - Julio Finalet Ferreiro
- Department of Human Genetics, Centre for Human Genetics, University Hospitals KU Leuven, 3000 Leuven, Belgium
| | - Philip DeKoninck
- Department of Development and Regeneration, Organ System Cluster, Faculty of Medicine, KU Leuven, 3000 Leuven, Belgium Clinical Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals KU Leuven, 3000 Leuven, Belgium
| | - Masayuki Endo
- Department of Development and Regeneration, Organ System Cluster, Faculty of Medicine, KU Leuven, 3000 Leuven, Belgium
| | - Jaan Toelen
- Department of Development and Regeneration, Organ System Cluster, Faculty of Medicine, KU Leuven, 3000 Leuven, Belgium Clinical Department of Pediatrics, Division Woman and Child, University Hospitals KU Leuven, 3000 Leuven, Belgium
| | - Joris R Vermeesch
- Department of Human Genetics, Centre for Human Genetics, University Hospitals KU Leuven, 3000 Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, Organ System Cluster, Faculty of Medicine, KU Leuven, 3000 Leuven, Belgium Clinical Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals KU Leuven, 3000 Leuven, Belgium
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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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Garabedian C, Jouannic JM, Benachi A, Sénat MV, Favre R, Houfflin-Debarge V. Thérapie fœtale et fœtoscopie : une réalité clinique en 2015. ACTA ACUST UNITED AC 2015; 44:597-604. [DOI: 10.1016/j.jgyn.2015.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 05/11/2015] [Accepted: 06/03/2015] [Indexed: 10/23/2022]
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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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Nawapun K, Eastwood M, Sandaite I, DeKoninck P, Claus F, Richter J, Rayyan M, Deprest J. Correlation of observed-to-expected total fetal lung volume with intrathoracic organ herniation on magnetic resonance imaging 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; 46:162-167. [PMID: 25331381 DOI: 10.1002/uog.14701] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Revised: 09/24/2014] [Accepted: 10/10/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To assess using fetal magnetic resonance imaging (MRI) the relationship between the position of the stomach as well as the volume of herniation of organs into the thorax, and the observed-to-expected total fetal lung volume (o/e-TFLV), as a measure of pulmonary hypoplasia, in fetuses with isolated left-sided congenital diaphragmatic hernia (LCDH). METHODS This was a single-center retrospective study using archived MR images from fetuses > 20 weeks' gestation evaluated for isolated LCDH over an 11-year period between July 2002 and September 2013. We retrieved data on the gestational age at MRI, o/e-TFLV and liver position. Images were also reviewed by a single operator to determine retrospectively the position of the stomach as well as the proportion of the total thorax volume occupied by the herniated fetal liver, stomach and other viscera. Following confirmation of reproducibility, we assessed the correlation of intrathoracic organ volumes and stomach position with o/e-TFLV. RESULTS The study included 205 fetuses which underwent a total of 259 MR examinations. The reproducibility of organ volume measurements was excellent (intraclass correlation coefficient range, 0.928-0.997). The average time spent to obtain intrathoracic organ volumes ranged from 2.28 to 5.13 min. Of all herniated organ-to-thoracic volume ratios, the liver-to-thoracic volume ratio had the strongest correlation with o/e-TFLV (ρ = -0.429, P<0.0001). Stomach volume did not correlate, although, when categorized by the position and extent of stomach herniation, there was an inverse relationship to o/e-TFLV. No intrathoracic organ-to-thoracic volume ratio was related to gestational age. CONCLUSIONS We observed in fetuses with isolated LCDH an inverse relationship between lung volume and the amount of liver herniated as well as the position of the stomach in the chest.
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Affiliation(s)
- K 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
| | - M Eastwood
- Cluster Organ Systems, Department of Development and Regeneration, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - I Sandaite
- Cluster Organ Systems, Department of Development and Regeneration, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
- Division of Medical Imaging, Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - P DeKoninck
- 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
| | - F Claus
- Division of Medical Imaging, Department of Radiology, University Hospitals Leuven, Leuven, Belgium
- Department of Radiology, Onze Lieve Vrouw Hospital Aalst, Aalst, Belgium
| | - J Richter
- 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
| | - M Rayyan
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium
| | - J 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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Spaggiari E, Stirnemann JJ, Sonigo P, Khen-Dunlop N, De Saint Blanquat L, Ville Y. Prenatal prediction of pulmonary arterial hypertension in congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:572-577. [PMID: 24976012 DOI: 10.1002/uog.13450] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 06/12/2014] [Accepted: 06/19/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate the role of prenatal prognostic markers obtained routinely by ultrasound examination and magnetic resonance imaging (MRI) in the prediction of development of postnatal pulmonary arterial hypertension (PAH) in isolated congenital diaphragmatic hernia (CDH). METHODS One hundred and ten cases of isolated CDH were referred to our fetal medicine unit between January 2004 and April 2013. Mortality and morbidity rates were reviewed for those presenting with postnatal PAH. The following prenatal markers were evaluated as potential predictive factors of PAH: liver position, side of the CDH defect, lung area to head circumference ratio (LHR) and observed/expected LHR (o/e-LHR), which were measured by ultrasound, and observed/expected total fetal lung volume (o/e-TFLV), which was measured by MRI. Univariable logistic regression was used to assess associations. RESULTS PAH was significantly associated with perinatal mortality and morbidity (P < 0.001). The occurrence of PAH decreased significantly with an increasing LHR, o/e-LHR and o/e-TFLV and was significantly increased for cases with an intrathoracic liver, but not for those with right-sided defects. Univariable regression revealed that o/e-TFLV (odds ratio (OR), 0.9 (95% CI, 0.86-0.95); P < 0.05 for percentage unit change in o/e), LHR (OR, 0.19 (95% CI, 0.09-0.40); P < 0.05 for unit change), o/e-LHR (OR, 0.95 (95% CI, 0.93-0.98); P < 0.05 for percentage unit change in o/e) and liver position (OR, 2.82 (95% CI, 1.13-7.00); P < 0.05 for intrathoracic liver) were significant predictors of subsequent PAH. No differences were found after adjusting for gestational age at delivery. The areas under the receiver-operating characteristics curve were 0.80 and 0.75 for o/e-TFLV and o/e-LHR, respectively. CONCLUSION In cases of CDH, PAH is associated with high rates of mortality and morbidity. Routinely obtained prenatal markers, usually used for the assessment of pulmonary hypoplasia, are also relevant for the postnatal prediction of PAH.
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MESH Headings
- Female
- Gestational Age
- Head
- Hernias, Diaphragmatic, Congenital/diagnosis
- Hernias, Diaphragmatic, Congenital/embryology
- Hernias, Diaphragmatic, Congenital/pathology
- Humans
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/embryology
- Hypertension, Pulmonary/pathology
- Infant, Newborn
- Liver/embryology
- Liver/pathology
- Lung/embryology
- Lung/pathology
- Lung Volume Measurements/methods
- Predictive Value of Tests
- Pregnancy
- Prognosis
- Survival Rate
- Ultrasonography, Prenatal
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Affiliation(s)
- E Spaggiari
- Department of Obstetrics and Maternal-Fetal Medicine, Necker-Enfants Malades Hospital, AP-HP, Paris, France; University Paris Descartes, Sorbonne Paris-Cité, Paris, France
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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
Over the past 20 years, prenatal detection of congenital diaphragmatic hernia (CDH) has improved worldwide, reaching up to 60% in Europe. Pulmonary hypoplasia and persistent pulmonary hypertension are the two main determinants of neonatal mortality and morbidity, so new tools have been focused on their evaluation. Fetal surgery for severe cases requires proper evaluation of the prognosis of fetuses with CDH. Observed-to-expected lung-to-head ratio, liver position, and total lung volume measured by magnetic resonance are the prognostic factors most often used, and have been shown to correlate not only with neonatal mortality but also with morbidity. In daily practice, pulmonary hypertension by itself, although most often associated with lung hypoplasia, is more difficult to predict.
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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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