1
|
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.
Collapse
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
| |
Collapse
|
2
|
Papaioannou G, Caro-Domínguez P, Klein WM, Garel C, Cassart M. Indications for magnetic resonance imaging of the fetal body (extra-central nervous system): recommendations from the European Society of Paediatric Radiology Fetal Task Force. Pediatr Radiol 2023; 53:297-312. [PMID: 36161506 DOI: 10.1007/s00247-022-05495-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 07/06/2022] [Accepted: 08/25/2022] [Indexed: 02/04/2023]
Abstract
The indications for fetal body MRI are amplifying because of the expanding possibilities of fetal and perinatal therapy. However, huge heterogeneity regarding the indications for fetal body MRI is seen among different European countries that is mostly related to local use of US, but also to local fetal MRI expertise and legislation on pregnancy termination. The purpose of this article is to summarize the precise indications for fetal MRI, excluding the central nervous system. MRI indications arise from the sonographic findings, based on the operator's experience and the various practices in the countries and institutions represented on the European Society of Paediatric Radiology Fetal Task Force. We also highlight the strengths and weaknesses of fetal US and MRI of the fetal body.
Collapse
Affiliation(s)
- Georgia Papaioannou
- Department of Pediatric Radiology, Mitera Maternity and Children's Hospital, 6 Erythrou Stavrou str, Maroussi 15123, Athens, Greece.
| | - Pablo Caro-Domínguez
- Pediatric Imaging Unit, Department of Radiology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Willemijn M Klein
- Department of Medical Imaging, Radiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Catherine Garel
- Department of Radiology, Armand-Trousseau Hospital, Paris, France
| | - Marie Cassart
- Department of Radiology and Fetal Medicine, Iris South Hospitals, Brussels, Belgium
| |
Collapse
|
3
|
Olutoye Ii OO, Short WD, Gilley J, Hammond Ii JD, Belfort MA, Lee TC, King A, Espinoza J, Joyeux L, Lingappan K, Gleghorn JP, Keswani SG. The Cellular and Molecular Effects of Fetoscopic Endoluminal Tracheal Occlusion in Congenital Diaphragmatic Hernia. Front Pediatr 2022; 10:925106. [PMID: 35865706 PMCID: PMC9294219 DOI: 10.3389/fped.2022.925106] [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: 04/21/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a complex disease associated with pulmonary hypoplasia and pulmonary hypertension. Great strides have been made in our ability to care for CDH patients, specifically in the prenatal improvement of lung volume and morphology with fetoscopic endoluminal tracheal occlusion (FETO). While the anatomic effects of FETO have been described in-depth, the changes it induces at the cellular and molecular level remain a budding area of CDH research. This review will delve into the cellular and molecular effects of FETO in the developing lung, emphasize areas in which further research may improve our understanding of CDH, and highlight opportunities to optimize the FETO procedure for improved postnatal outcomes.
Collapse
Affiliation(s)
- Oluyinka O Olutoye Ii
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Walker D Short
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Jamie Gilley
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, United States
| | - J D Hammond Ii
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, United States
| | - Michael A Belfort
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, United States
| | - Timothy C Lee
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
| | - Alice King
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
| | - Jimmy Espinoza
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, United States
| | - Luc Joyeux
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
| | - Krithika Lingappan
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jason P Gleghorn
- Department of Biomedical Engineering, University of Delaware, Newark, DE, United States
| | - Sundeep G Keswani
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, United States
| |
Collapse
|
4
|
Varela MF, Peiro JL. EX-UTERO INTRAPARTUM TREATMENT (EXIT). REVISTA MÉDICA CLÍNICA LAS CONDES 2021. [DOI: 10.1016/j.rmclc.2021.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
5
|
Aoki H, Miyazaki O, Irahara S, Okamoto R, Tsutsumi Y, Miyasaka M, Sago H, Kanamori Y, Suzuki Y, Morimoto N, Nosaka S. Value of parametric indexes to identify tracheal atresia with or without fistula on fetal magnetic resonance imaging. Pediatr Radiol 2021; 51:2027-2037. [PMID: 33988754 DOI: 10.1007/s00247-021-05092-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/18/2021] [Accepted: 04/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tracheal atresia causes some secondary changes (dilated trachea, flattened/inverted diaphragm, hyperintense and hyperinflated lungs). They can be reduced if a high airway fistula is present. OBJECTIVE This study evaluated fetal MR images of tracheal atresia and the secondary changes, focusing on the presence of a fistula. MATERIALS AND METHODS We assessed fetal MR images of tracheal atresia without fistula (n=4, median 26 weeks), tracheal atresia with fistula (n=4, median 33 weeks) and controls (n=30, median 32 weeks). We evaluated airway obstruction using true-positive rate in tracheal atresia and false-positive rate in controls indicating they are likely normal variants. Tracheal diameter, craniocaudal-anteroposterior ratio of the right hemidiaphragm, lung-to-liver signal intensity ratio, and cardiothoracic ratio were compared among the three groups using the Kruskal-Wallis test followed by pairwise comparison using the Mann-Whitney U test. RESULTS True-positive rate was 100% in tracheal atresia, while false-positive rate was 20% in controls. The Kruskal-Wallis test showed differences among groups in craniocaudal-anteroposterior ratio and cardiothoracic ratio (P<0.001) but not in tracheal diameter (P=0.256) or lung-to-liver signal intensity ratio (P=0.082). The pairwise comparison in craniocaudal-anteroposterior ratio and cardiothoracic ratio showed differences between controls and tracheal atresia without fistula (P<0.01) and with fistula (P<0.05). CONCLUSION Fetal MRI is useful for the diagnosis of tracheal atresia, and detection of airway obstruction is essential. Lower craniocaudal-anteroposterior ratio and cardiothoracic ratio might be reliable measures even if a fistula is present.
Collapse
Affiliation(s)
- Hidekazu Aoki
- Department of Radiology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan. .,Department of Diagnostic Radiology, Tohoku University Hospital, Miyagi, Japan.
| | - Osamu Miyazaki
- Department of Radiology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Saho Irahara
- Department of Radiology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Reiko Okamoto
- Department of Radiology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Yoshiyuki Tsutsumi
- Department of Radiology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Mikiko Miyasaka
- Department of Radiology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yutaka Kanamori
- Division of Surgery, Department of Surgical Specialties, National Center for Child Health and Development, Tokyo, Japan
| | - Yasuyuki Suzuki
- Department of Critical Care and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
| | - Noriko Morimoto
- Division of Otolaryngology, Department of Surgical Specialties, National Center for Child Health and Development, Tokyo, Japan
| | - Shunsuke Nosaka
- Department of Radiology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| |
Collapse
|
6
|
Wiggins E, Zecevic M, Hippe DS, Moshiri M, Winter T, Dubinsky TJ. Magnetic Resonance Prediction of Lung Maturity in Fetuses With Congenital Diaphragmatic Hernia. Ultrasound Q 2021; 37:272-277. [PMID: 34478427 DOI: 10.1097/ruq.0000000000000567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT To determine if lung to liver MR T2 signal ratio is predictive of neonatal outcome in fetuses with congenital diaphragmatic hernia (CDH).After Interal Review Board approval, the PACS systems at the University of Washington and University of Utah were searched for cases having an in utero fetal MR examination diagnostic of CDH. Inclusion criteria were at least 1 prior ultrasound demonstrating a CDH and an MR obtained within 1 week of that prior ultrasound.A total of 69 patients from the University of Utah and 13 from the University of Washington satisfied the inclusion criteria for a total of 82. After adjusting for gestational age and contralateral lung volume, there was little apparent association between contralateral lung to liver MR T2 signal and 5-minute Apgar score and neonatal mortality When considering neonatal Apgar and mortality, increasing contralateral lung volume was significantly associated with lower risk (hazard ratio, 0.40 per doubling; 95% confidence interval, 0.24-0.69; P = 0.001) as expected.Our data demonstrate that the lung to liver MR signal ratio was not predictive of outcome. The measurement of contralateral lung area, and gestational age at the time of the examination (time of diagnosis) are still the best predictors of poor neonatal outcome.
Collapse
Affiliation(s)
- Eve Wiggins
- Department of Radiology, University of Washington School of Medicine, Seattle WA
| | - Mladen Zecevic
- Department of Radiology, University of Washington School of Medicine, Seattle WA
| | - Dan S Hippe
- Department of Radiology, University of Washington School of Medicine, Seattle WA
| | - Mariam Moshiri
- Department of Radiology, University of Washington School of Medicine, Seattle WA
| | - Tom Winter
- Department of Radiology, University of Utah, Salt Lake City, UT
| | - Theodore J Dubinsky
- Department of Radiology, University of Washington School of Medicine, Seattle WA
| |
Collapse
|
7
|
Masselli G, Cozzi D, Ceccanti S, Laghi F, Giancotti A, Brunelli R. Fetal body MRI for fetal and perinatal management. Clin Radiol 2021; 76:708.e1-708.e8. [PMID: 34112509 DOI: 10.1016/j.crad.2021.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 05/05/2021] [Indexed: 12/19/2022]
Abstract
Fetal magnetic resonance imaging (MRI) has become a valuable adjunct to ultrasound (US) in diagnosing fetal abnormalities. This review is intended to highlight the contribution of MRI in parental counselling and perinatal treatment. A state-of-the-art fetal MRI protocol with experts of maternal-fetal medicine present in the MRI suite allows emphasis on patient-centred care and maximises therapeutic options.
Collapse
Affiliation(s)
- G Masselli
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome, Italy.
| | - D Cozzi
- Pediatric Surgery Unit, Sapienza University of Rome, Azienda Policlinico Umberto I, Rome, Italy
| | - S Ceccanti
- Pediatric Surgery Unit, Sapienza University of Rome, Azienda Policlinico Umberto I, Rome, Italy
| | - F Laghi
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - A Giancotti
- Department of Gynecological, Obstetrical, and Urological Sciences, Sapienza University, Rome, Italy
| | - R Brunelli
- Department of Gynecological, Obstetrical, and Urological Sciences, Sapienza University, Rome, Italy
| |
Collapse
|
8
|
Varela MF, Pinzon-Guzman C, Riddle S, Parikh R, McKinney D, Rutter M, Lim FY, Peiro JL. EXIT-to-airway: Fundamentals, prenatal work-up, and technical aspects. Semin Pediatr Surg 2021; 30:151066. [PMID: 34172204 DOI: 10.1016/j.sempedsurg.2021.151066] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Ex-utero intrapartum treatment (EXIT) is a delivery strategy developed to manage a variety of prenatally diagnosed conditions in the transition to newborn life. This procedure allows control and provides time for intervention in otherwise life-threatening malformations, such as congenital upper airway obstructions. EXIT-to-airway has changed the outcome of fetuses with these anomalies. The main purpose of this intervention is to improve the safety of establishing a reliable airway at birth. Maximal but controlled uterine relaxation to maintain feto-maternal perfusion and thus gas exchange, while keeping the fetal and maternal well-being are the paradigms of any type of EXIT. The most important aspect of fetal airway management is to consolidate a highly trained, well-coordinated, multidisciplinary team that is prepared for every contingency. A comprehensive prenatal assessment, including ultrasound, fetal echocardiogram, fetal MRI, and genetic testing is imperative for patient selection. Extensive preoperative planning, ad-hoc team meetings, and surgical simulations for challenging cases are critical strategies to achieve the best outcomes. This article outlines the prenatal work-up, decision making, technical aspects, and principles for a successful EXIT-to-airway procedure.
Collapse
Affiliation(s)
- Maria Florencia Varela
- The Center for Fetal and Placental Research, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, USA
| | - Carolina Pinzon-Guzman
- The Center for Fetal and Placental Research, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, USA; Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA
| | - Stefanie Riddle
- Division of Neonatology, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA.; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rupi Parikh
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David McKinney
- Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael Rutter
- Division of Pediatric Otolaryngology, Head and Neck Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jose L Peiro
- The Center for Fetal and Placental Research, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, USA; Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| |
Collapse
|
9
|
Perinatal outcome of fetuses with congenital high airway obstruction syndrome: a single-center experience. Obstet Gynecol Sci 2020; 64:52-61. [PMID: 33285045 PMCID: PMC7834760 DOI: 10.5468/ogs.20266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 10/21/2020] [Indexed: 11/17/2022] Open
Abstract
Objective To report our experience with management of fetuses with congenital high airway obstruction syndrome (CHAOS). Methods We retrospectively reviewed the cases of fetuses who were prenatally diagnosed and postnatally confirmed with CHAOS between 2010 and 2019 at Asan Medical Center, Seoul, Korea. Results Of 13 fetuses prenatally diagnosed with CHAOS, 7 were lost to follow-up and 6 were postnatally confirmed as having CHAOS. All fetuses, except one were delivered via cesarean section with an ex utero intrapartum treatment (EXIT) procedure. Two patients had coexisting congenital heart diseases requiring several cardiac surgeries following birth. Both of these patients demonstrated developmental delay; however, the remaining 4 had a normal development except for expressive language. Two infants died of respiratory complications, and the remaining 4 were alive at the end of the follow-up period. All 4 live patients underwent tracheostomy with planned reconstruction surgery. Three children are now able to phonate, and 1 can maintain a conservation. Conclusion The proper management of CHAOS using the EXIT procedure results in high survival and low hypoxemia-induced complication rates. Therefore, an accurate prenatal diagnosis is necessary for an appropriate perinatal management.
Collapse
|
10
|
Adams NC, Victoria T, Oliver ER, Moldenhauer JS, Adzick NS, Colleran GC. Fetal ultrasound and magnetic resonance imaging: a primer on how to interpret prenatal lung lesions. Pediatr Radiol 2020; 50:1839-1854. [PMID: 33252753 DOI: 10.1007/s00247-020-04806-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/01/2020] [Accepted: 08/10/2020] [Indexed: 12/22/2022]
Abstract
Fetal lung lesions include common lesions such as congenital pulmonary airway malformation (CPAM), bronchopulmonary sequestration (BPS) and combined CPAM-BPS hybrid lesions, as well as less common entities including congenital lobar emphysema/obstruction, bronchial atresia, bronchogenic cysts and rare malignant pulmonary lesions such as pleuropulmonary blastoma. Fetal lung lesions occur in approximately 1 in 15,000 live births and are thought to arise from a spectrum of abnormalities related to airway obstruction and malformation, with the lesion type depending on the timing of insult, level of bronchial tree involvement, and severity of obstruction. Lesions vary from small and asymptomatic to large and symptomatic with significant mass effect on surrounding structures. Accurate diagnosis and characterization of these anomalies is crucial for guiding patient counseling as well as perinatal and postnatal management. The goal of this review is to provide an overview of normal fetal lung appearance and imaging features of common and uncommon lesions on both ultrasound and MR imaging, and to discuss key aspects in reporting and evaluating the severity of these lesions.
Collapse
Affiliation(s)
- Niamh C Adams
- Department of Radiology, Children's Hospital of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | - Teresa Victoria
- Department of Radiology, Children's Hospital of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Edward R Oliver
- Department of Radiology, Children's Hospital of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Julie S Moldenhauer
- Department of Surgery, Children's Hospital of Pennsylvania, Philadelphia, PA, USA
| | - N Scott Adzick
- Department of Surgery, Children's Hospital of Pennsylvania, Philadelphia, PA, USA
| | - Gabrielle C Colleran
- Department of Radiology, National Maternity Hospital, Dublin, Ireland
- Department of Radiology, Children's Health Ireland at Temple Street, Dublin, Ireland
| |
Collapse
|
11
|
Williams EE, Dassios T, Murthy V, Greenough A. Anatomical deadspace during resuscitation of infants with congenital diaphragmatic hernia. Early Hum Dev 2020; 149:105150. [PMID: 32777695 DOI: 10.1016/j.earlhumdev.2020.105150] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/24/2020] [Accepted: 07/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) has a high mortality and morbidity related to pulmonary hypoplasia. AIMS To test the hypothesis that CDH infants who survived would have a greater anatomical deadspace reflecting less severe pulmonary hypoplasia. Furthermore, infants with CDH who had undergone feto-tracheal occlusion (FETO) would have a greater anatomical deadspace. STUDY DESIGN Infants were studied during resuscitation in the delivery suite. They were all intubated immediately at delivery, given a neuromuscular blocking agent and underwent respiratory monitoring. The anatomical deadspace was calculated from volumetric capnography measurements. SUBJECTS Thirty infants born at 32 weeks of gestation or greater and diagnosed antenatally with a CDH were studied. Eleven had undergone FETO and overall five died. OUTCOME MEASURES Anatomical deadspace (VdANA) and survival to discharge. RESULTS The median (IQR) gestational age of the infants was 38.1 (35.2-39.3) weeks and birthweight 2.8 (2.3-3.3) kg. The anatomical deadspace was higher in those infants who survived (2.9 (2.8-3.3) mls/kg) compared to those who died (2.2 (2.1-2.7) mls/kg; p = 0.003) and was higher in those who had undergone FETO (3.0 (2.8-3.8) mls/kg) compared to those who had not (2.8 (2.4-3.0) mls/kg; p = 0.032). In predicting survival to discharge, the anatomical deadspace had an AUC of 0.90 (p = 0.006). CONCLUSIONS CDH infants who survived had a larger anatomical deadspace than those who died suggesting they had less lung hypoplasia. In addition, infants who had undergone FETO had greater anatomical deadspace possibly reflecting distension of the conducting airways.
Collapse
Affiliation(s)
- Emma E Williams
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Science and Medicine, King's College London, SE5 9RS, United Kingdom
| | - Theodore Dassios
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Science and Medicine, King's College London, SE5 9RS, United Kingdom; Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London SE5 9RS, United Kingdom.
| | - Vadivelam Murthy
- Neonatal Intensive Care Centre, The Royal London Hospital-Barts Health NHS Foundation Trust, London E1 11B, United Kingdom
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Science and Medicine, King's College London, SE5 9RS, United Kingdom; Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, SE1 9RT, United Kingdom; NIHR Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust, King's College London, SE1 9RT, United Kingdom
| |
Collapse
|
12
|
Abstract
Fetal anesthesia teams must understand the pathophysiology and rationale for the treatment of each disease process. Treatment can range from minimally invasive procedures to maternal laparotomy, hysterotomy, and major fetal surgery. Timing may be in early, mid-, or late gestation. Techniques continue to be refined, and the anesthetic plans must evolve to meet the needs of the procedures. Anesthetic plans range from moderate sedation to general anesthesia that includes monitoring of 2 patients simultaneously, fluid restriction, invasive blood pressure monitoring, vasopressor administration, and advanced medication choices to optimize fetal cardiac function.
Collapse
Affiliation(s)
- Kha M Tran
- University of Pennsylvania Perelman School of Medicine, Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Debnath Chatterjee
- Children's Hospital Colorado, Anschutz Medical Campus, 13123 East 16th Avenue, Aurora, CO 80045, USA
| |
Collapse
|
13
|
Congenital High Airway Obstruction Syndrome (CHAOS): No Intervention, No Survival-A Case Report and Literature Review. Case Rep Radiol 2020; 2020:1036073. [PMID: 32685231 PMCID: PMC7336206 DOI: 10.1155/2020/1036073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 06/15/2020] [Indexed: 11/17/2022] Open
Abstract
Congenital high airway obstruction syndrome (CHAOS) is complete or partial obstruction of the fetal upper airway. CHAOS is a rare and fatal condition if no perinatal intervention is done. Antenatal sonographic imaging has typical findings that can help in an early diagnosis, which is important in deciding elective termination of the pregnancy or successful planning of appropriate perinatal management.
Collapse
|
14
|
Peiro JL, Nolan HR, Alhajjat A, Diaz R, Gil-Guevara E, Tabbah SM, Lim FY. A Technical Look at Fetoscopic Laser Ablation for Fetal Laryngeal Surgical Recanalization in Congenital High Airway Obstruction Syndrome. J Laparoendosc Adv Surg Tech A 2020; 30:695-700. [PMID: 32352856 DOI: 10.1089/lap.2019.0808] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background: Congenital high airway obstruction syndrome (CHAOS) is a rare condition characterized by complete obstruction of the upper fetal airways. Left untreated, it is uniformly fatal. Ex utero intrapartum treatment (EXIT) has been used to establish a surgical airway in affected fetuses during delivery. While this procedure benefits those fetuses that survive to delivery, high mortality in the prenatal period necessitates earlier innovative strategies. Herein, we report a novel technique for in utero intervention. Methods: A fetoscopic intervention was performed at 28 weeks on a 35-year-old G1P0 woman with fetal CHAOS from a laryngeal obstruction measuring 11 mm in length on prenatal imaging. Under ultrasound guidance, a 3.3-mm curved fetoscope was used to access the uterine cavity through a single subcentimeter maternal skin incision. The scope was driven through the fetal oral cavity and manipulated to attain a view of the vocal cords. A subglottic obstruction was observed. A 600-micron laser fiber was passed through the working channel of the scope and used to ablate the obstructed airway. Using the laser fiber and a guidewire, the ablated opening was traversed with the fetoscope to the level of the carina. Results: Postoperatively, the lungs became less hyperinflated. There was improvement in ascites and diaphragmatic eversion. At 31 1/7 weeks' gestation, the mother experienced preterm premature rupture of membranes with active labor and the fetus was delivered through EXIT to tracheostomy. The infant was managed on mechanical ventilation and is currently thriving at home with a tracheostomy at 2 years of age. Conclusion: Fetoscopy with laser ablation of the airway obstruction is an effective prenatal management strategy that offers the potential to alter the devastating natural course of CHAOS.
Collapse
Affiliation(s)
- Jose L Peiro
- Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
| | - Heather R Nolan
- Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
| | - Amir Alhajjat
- Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
| | - Ramiro Diaz
- Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
| | - Enrique Gil-Guevara
- Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
| | - Sammy M Tabbah
- Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
| | - Foong Y Lim
- Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
| |
Collapse
|
15
|
Kanamori Y, Tahara K, Ohno M, Tomonaga K, Yamada Y, Hishiki T, Fujino A, Miyazaki O, Nosaka S, Morimoto N, Sugibayashi R, Ozawa K, Wada S, Sago H, Tsukamoto K, Isayama T, Ito Y. Congenital high airway obstruction syndrome complicated with foregut malformation and high airway fistula to the alimentary tract – a case series with four distinct types. CASE REPORTS IN PERINATAL MEDICINE 2020. [DOI: 10.1515/crpm-2019-0064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Congenital high airway obstruction syndrome (CHAOS) is a rare disease and recently has been noticed to show typical prenatal images, such as hyperinflated lungs and flattened or inverted diaphragms. However, in some cases correct diagnosis may be difficult and in such cases the mortality rate increases.
Case presentation
We report four cases of CHAOS complicated with a high airway fistula to the alimentary tract and foregut malformation. The patients did not show the typical features of CHAOS in the fetus. This may be attributed to the high airway fistula acting as a decompression route for the accumulated lung fluids to the alimentary tract.
Conclusion
The combination of CHAOS, foregut malformation and a high airway fistula is very rare and classified into four distinct types: (1) CHAOS with a high airway fistula but not with a foregut malformation; (2) CHAOS with esophageal atresia and tracheoesophageal fistula; (3) CHAOS with a high airway fistula and duodenal atresia; and (4) CHAOS with esophageal atresia, tracheoesophageal fistula and duodenal atresia. It may be useful for treating physicians to be aware of these four distinct types and the typical characteristics of each type.
Collapse
Affiliation(s)
- Yutaka Kanamori
- Division of Surgery, Department of Surgical Specialties , National Center for Child Health and Development , 2-10-1 Okura Setagaya-ku , Tokyo 157-8535 , Japan , Tel.: +81-3-3416-0181, Fax: +81-3-3416-2222
| | - Kazunori Tahara
- Division of Surgery, Department of Surgical Specialties , National Center for Child Health and Development , Okura Setagaya-ku , Tokyo , Japan
| | - Michinobu Ohno
- Division of Surgery, Department of Surgical Specialties , National Center for Child Health and Development , Okura Setagaya-ku , Tokyo , Japan
| | - Kotaro Tomonaga
- Division of Surgery, Department of Surgical Specialties , National Center for Child Health and Development , Okura Setagaya-ku , Tokyo , Japan
| | - Yohei Yamada
- Division of Surgery, Department of Surgical Specialties , National Center for Child Health and Development , Okura Setagaya-ku , Tokyo , Japan
| | - Tomoro Hishiki
- Division of Surgery, Department of Surgical Specialties , National Center for Child Health and Development , Okura Setagaya-ku , Tokyo , Japan
| | - Akihiro Fujino
- Division of Surgery, Department of Surgical Specialties , National Center for Child Health and Development , Okura Setagaya-ku , Tokyo , Japan
| | - Osamu Miyazaki
- Department of Radiology , National Center for Child Health and Development , Tokyo , Japan
| | - Shunsuke Nosaka
- Department of Radiology , National Center for Child Health and Development , Tokyo , Japan
| | - Noriko Morimoto
- Division of Otolaryngology, Department of Surgical Specialties , National Center for Child Health and Development , Tokyo , Japan
| | - Rika Sugibayashi
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine , National Center for Child Health and Development , Tokyo , Japan
| | - Katsusuke Ozawa
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine , National Center for Child Health and Development , Tokyo , Japan
| | - Seiji Wada
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine , National Center for Child Health and Development , Tokyo , Japan
| | - Haruhiko Sago
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine , National Center for Child Health and Development , Tokyo , Japan
| | - Keiko Tsukamoto
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine , National Center for Child Health and Development , Tokyo , Japan
| | - Tetsuya Isayama
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine , National Center for Child Health and Development , Tokyo , Japan
| | - Yushi Ito
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine , National Center for Child Health and Development , Tokyo , Japan
| |
Collapse
|
16
|
Causes of death shortly after delivery and medical malpractice claims in congenital high airway obstruction syndrome: Review of the literature. Leg Med (Tokyo) 2019; 40:61-65. [PMID: 31442942 DOI: 10.1016/j.legalmed.2019.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 06/07/2019] [Accepted: 07/29/2019] [Indexed: 11/23/2022]
Abstract
Congenital High Airway Obstruction Syndrome is a rare pathology that may conduct the baby to death shortly after delivery. This outcome may cause emotional distress in the parents but it may also generate expensive medical malpractice claims about the reasons why the syndrome was not identified and/or correctly treated. The authors conducted a review of the cases in which Congenital High Airway Obstruction Syndrome caused death of the baby shortly after delivery. Then, they pointed out these ultrasonographic and anatomical reasons why the syndrome may be not identified and/or correctly treated: negative prenatal ultrasonography, recurrence of non-specific findings at prenatal ultrasonography, connection of respiratory and gastrointestinal tracts, tracheal agenesis or atresia, parent's refuse of post-partum therapeutic procedures, multiple malformations of the fetus/child. In conclusion, the authors highlighted that death shortly after delivery is usually caused by specific conditions that are not influenced by healthcare team's practice.
Collapse
|
17
|
Nicolas CT, Lynch-Salamon D, Bendel-Stenzel E, Tibesar R, Luks F, Eyerly-Webb S, Lillegard JB. Fetoscopy-Assisted Percutaneous Decompression of the Distal Trachea and Lungs Reverses Hydrops Fetalis and Fetal Distress in a Fetus with Laryngeal Atresia. Fetal Diagn Ther 2019; 46:75-80. [PMID: 31238308 DOI: 10.1159/000500455] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 04/16/2019] [Indexed: 11/19/2022]
Abstract
We present a case of prenatal hydrops secondary to congenital high airway obstruction syndrome (CHAOS) that was treated with fetoscopy-assisted needle decompression. A 22-year-old G3P2 woman presented after a 21-week ultrasound demonstrated CHAOS. The fetus developed hydrops at 25 weeks, characterized by abdominal ascites, pericardial effusion, and scalp edema. Fetal MRI showed complete obstruction of the glottis and subglottic airway, suggestive of laryngeal atresia. At 27 weeks, due to the progression of the hydrops, operative fetoscopy was proposed and performed. Fetal laryngoscopy confirmed fusion of the vocal cords and laryngeal atresia. The atretic segment was a solid cartilaginous block, preventing intubation. Using the fetoscope to stabilize the fetal head and neck, we performed ultrasound-guided percutaneous needle drainage of the cervical trachea through the anterior fetal neck. We removed 17 mL of viscous fluid from the lower trachea, resulting in immediate lung decompression. Two weeks later, ultrasound confirmed hydrops resolution. The patient was delivered and tracheostomy performed at 30 weeks via an ex utero intrapartum treatment (EXIT) procedure after progression of preterm labor. At 27 days of life, the infant was stable on minimal ventilator support. To our knowledge, this is the first successful report of an ultrasound-guided percutaneous tracheal decompression through the anterior neck of a fetus with CHAOS secondary to laryngeal atresia.
Collapse
Affiliation(s)
- Clara T Nicolas
- Children's Hospital of Minnesota, Midwest Fetal Care Center, Minneapolis, Minnesota, USA.,Mayo Clinic, Division of Surgery Research, Rochester, Minnesota, USA
| | - David Lynch-Salamon
- Children's Hospital of Minnesota, Midwest Fetal Care Center, Minneapolis, Minnesota, USA
| | - Ellen Bendel-Stenzel
- Children's Hospital of Minnesota, Midwest Fetal Care Center, Minneapolis, Minnesota, USA.,Minnesota Neonatal Physicians, Minneapolis, Minnesota, USA
| | - Robert Tibesar
- Children's Hospital of Minnesota, Midwest Fetal Care Center, Minneapolis, Minnesota, USA
| | - Francois Luks
- Hasbro Children's Hospital and The Fetal Treatment Program of New England, Providence, Rhode Island, USA
| | - Stephanie Eyerly-Webb
- Children's Hospital of Minnesota, Midwest Fetal Care Center, Minneapolis, Minnesota, USA
| | - Joseph B Lillegard
- Children's Hospital of Minnesota, Midwest Fetal Care Center, Minneapolis, Minnesota, USA, .,Mayo Clinic, Division of Surgery Research, Rochester, Minnesota, USA, .,Pediatric Surgical Associates, Minneapolis, Minnesota, USA,
| |
Collapse
|
18
|
Fayoux P, Devisme L. Histoanatomical structures of laryngeal atresia: Functional considerations. Laryngoscope 2019; 130:252-256. [DOI: 10.1002/lary.27855] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2019] [Indexed: 11/12/2022]
Affiliation(s)
- Pierre Fayoux
- Department of Pediatric Otolaryngology–Head Neck SurgeryJeanne de Flandre Hospital–CHU Lille Lille France
- CERIM EA2694Lille University Lille France
| | - Louise Devisme
- Department of Anatomy and Pathology–CHU Lille Lille France
| |
Collapse
|
19
|
Smitthimedhin A, Whitehead MT, Bigdeli M, Nino G, Perez G, Otero HJ. MRI determination of volumes for the upper airway and pharyngeal lymphoid tissue in preterm and term infants. Clin Imaging 2018; 50:51-56. [DOI: 10.1016/j.clinimag.2017.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/28/2017] [Accepted: 12/14/2017] [Indexed: 10/18/2022]
|
20
|
Dethe V, Lamghare P, Bagale S, Agarwal V. Creating Order Out of Chaos - Role of Antenatal Ultrasound in Diagnosis. Pol J Radiol 2018; 82:463-465. [PMID: 29662573 PMCID: PMC5894023 DOI: 10.12659/pjr.901757] [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: 09/28/2016] [Accepted: 11/25/2016] [Indexed: 11/09/2022] Open
Abstract
Background Congenital high airway obstruction syndrome (CHAOS) is a rare fetal anomaly characterized by obstruction of the higher fetal airway. This could be either complete or incomplete and is more commonly seen at the subglottic level, resulting in a spectrum of characteristic secondary features. Case Report In this case study, we report two cases of CHAOS with one showing laryngeal atresia and the other, tracheal atresia. Both these cases showed characteristic findings on a detailed, meticulous USG examination which led to this diagnosis. Conclusions Early and accurate diagnosis offers a window of opportunity for parental counseling and management using procedures such as EXIT (ex-utero intrapartum procedure). Earlier, CHAOS was thought to be incompatible with life; however, with the advent of ex-utero intrapartum procedure, a few cases of post-natal survival have been noted in the literature. In this article, we emphasize the sonographic findings found in CHAOS. Early diagnosis offers an opportunity for a intrauterine fetal intervention in potentially lethal cases.
Collapse
Affiliation(s)
- Vaibhav Dethe
- Department of Radiology, Byramjee Jeejeebhoy Medical College and Sassoon General Hospital, Pune, Maharashtra, India
| | - Purnachandra Lamghare
- Department of Radiology, Byramjee Jeejeebhoy Medical College and Sassoon General Hospital, Pune, Maharashtra, India
| | - Sachin Bagale
- Department of Radiology, Byramjee Jeejeebhoy Medical College and Sassoon General Hospital, Pune, Maharashtra, India
| | - Vasudha Agarwal
- Department of Radiology, Byramjee Jeejeebhoy Medical College and Sassoon General Hospital, Pune, Maharashtra, India
| |
Collapse
|
21
|
Abstract
Fetal MRI is a level III diagnostic tool performed subsequently a level II prenatal ultrasound (US), in cases of inconclusive ultrasonographic diagnosis or when a further investigation is required to confirm or improve the diagnosis, to plan an appropriate pregnancy management. Fetal MRI plays an increasingly important role in the prenatal diagnosis of fetal neck, chest and abdominal malformations, even if its role has been amply demonstrated, especially, in the field of fetal CNS anomalies. Due to its multiparametricity and multiplanarity, MRI provides a detailed evaluation of the whole fetal respiratory, gastrointestinal and genitourinary systems, especially on T2-weighted (W) images, with a good tissue contrast resolution. In the evaluation of the digestive tract, T1-W sequences are very important in relation to the typical hyperintensity of the large intestine, due to the presence of meconium. The objective of this review is to focus on the application of fetal MRI in neck, chest and abdominal diseases.
Collapse
|
22
|
Gowda M, Gupta S, Ali A, Paranthaman S. Locating the Level and Extent of Congenital High Airway Obstruction: Fluid in the Airway Tract as Reference Points. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:2179-2185. [PMID: 28586146 DOI: 10.1002/jum.14273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 02/20/2017] [Indexed: 06/07/2023]
Abstract
Described here are a series of four cases of congenital high airway obstruction in the fetus. All of the patients presented in the second trimester and all had hydrops fetalis. Three cases had bilateral hyperinflated lungs, midline shift of heart, flattening or inversion of the diaphragm, and fetal ascites. Autopsy was performed in one of these three and showed laryngeal atresia. In one fetus, there was only a unilateral huge enlargement of the lung with mediastinal shift. On autopsy, this fetus had atresia of right main bronchus. All parents had terminated the pregnancy following the prenatal diagnosis. Laryngeal atresia is an extremely rare fetal anomaly with dismal prognosis. It is important to differentiate the condition from other lesions with a more favorable prognosis, such as congenital adenomatoid malformation of the lung. Much research is needed in the future to explore the therapeutic options, including fetoscopic intervention or transplantation of stem cell-derived airways.
Collapse
Affiliation(s)
- Mamatha Gowda
- Department of Obstetrics and Gynecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Shilpa Gupta
- Department of Obstetrics and Gynecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Ashraf Ali
- Department of Obstetrics and Gynecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Shanthi Paranthaman
- Department of Obstetrics and Gynecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| |
Collapse
|
23
|
D'Eufemia MD, Cianci S, Di Meglio F, Di Meglio L, Di Meglio L, Vitale SG, Laganà AS, Chiofato B, Rapisarda AMC, Padula F, La Rosa V, Coco C, Vascone C. Congenital high airway obstruction syndrome (CHAOS): discussing the role and limits of prenatal diagnosis starting from a single-center case series. J Prenat Med 2016; 10:4-7. [PMID: 28725339 DOI: 10.11138/jpm/2016.10.1.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES we aimed to report our experience about congenital high airway obstruction syndrome (CHAOS) that is a rare and fatal congenital anomaly; laryngeal atresia is the most frequent cause. Sonographic findings are enlarged echogenic lungs, dilated trachea, and ascites. METHODS we performed a single-center case series analysis collecting antenatally through ultrasound examination, and some of them confirmed by autopsy. RESULTS we report six cases of CHAOS diagnosed by antenatal ultrasonography between 2007 and 2013. CONCLUSION to date literature provides very few individual case reports. This work describes typical sonographic findings of this syndrome and it underlines the importance of early prenatal diagnosis to improve prognosis thought an ex utero intrapartum treatment, that seems to be the only chance of survival for the affected fetus.
Collapse
Affiliation(s)
- Maria Diletta D'Eufemia
- Department of Woman, Child and General and Specialistics Surgery, Second University of Naples, Italy
| | - Stefano Cianci
- Department of Medical Surgical Specialties, Gynecology and Obstetrics Section, University of Catania, Italy
| | - Filippo Di Meglio
- Department of Gynaecological-Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Italy
| | - Letizia Di Meglio
- Clinical Department of Gynaecology and Obstetrics of Physiopathology Reproduction, "Federico II" University of Naples, Italy
| | - Lavinia Di Meglio
- Clinical Department of Gynaecology and Obstetrics of Physiopathology Reproduction, "Federico II" University of Naples, Italy
| | - Salvatore Giovanni Vitale
- Unit of Gynaecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood "Gaetano Barresi", University of Messina, Italy
| | - Antonio Simone Laganà
- Unit of Gynaecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood "Gaetano Barresi", University of Messina, Italy
| | - Benito Chiofato
- Unit of Gynaecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood "Gaetano Barresi", University of Messina, Italy
| | | | - Francesco Padula
- Department of Prenatal Diagnosis, Altamedica Fetal Maternal Medical Centre, Rome, Italy
| | - Valentina La Rosa
- Unit of Psychodiagnostics and Clinical Psychology, University of Catania, Italy
| | - Claudio Coco
- Department of Prenatal Diagnosis, Altamedica Fetal Maternal Medical Centre, Rome, Italy
| | - Carmine Vascone
- Department of Woman, Child and General and Specialistics Surgery, Second University of Naples, Italy
| |
Collapse
|
24
|
VanKoevering KK, Morrison RJ, Prabhu SP, Torres MFL, Mychaliska GB, Treadwell MC, Hollister SJ, Green GE. Antenatal Three-Dimensional Printing of Aberrant Facial Anatomy. Pediatrics 2015; 136:e1382-5. [PMID: 26438708 PMCID: PMC4621796 DOI: 10.1542/peds.2015-1062] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2015] [Indexed: 01/17/2023] Open
Abstract
Congenital airway obstruction poses a life-threatening challenge to the newborn. We present the first case of three-dimensional (3D) modeling and 3D printing of complex fetal maxillofacial anatomy after prenatal ultrasound indicated potential upper airway obstruction from a midline mass of the maxilla. Using fetal MRI and patient-specific computer-aided modeling, the craniofacial anatomy of the fetus was manufactured using a 3D printer. This model demonstrated the mass to be isolated to the upper lip and maxilla, suggesting the oral airway to be patent. The decision was made to deliver the infant without a planned ex utero intrapartum treatment procedure. The neonate was born with a protuberant cleft lip and palate deformity, without airway obstruction, as predicted by the patient-specific model. The delivery was uneventful, and the child was discharged without need for airway intervention. This case demonstrates that 3D modeling may improve prenatal evaluation of complex patient-specific fetal anatomy and facilitate the multidisciplinary approach to perinatal management of complex airway anomalies.
Collapse
Affiliation(s)
| | | | - Sanjay P. Prabhu
- Department of Radiology, Harvard Medical School, Boston, Massachusetts;,Department of Radiology, Boston Children’s Hospital, Boston, Massachusetts
| | | | | | - Marjorie C. Treadwell
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Fetal Diagnosis and Treatment Center, University of Michigan, Ann Arbor, Michigan; and
| | | | - Glenn E. Green
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
25
|
Zucker EJ, Epelman M, Newman B. Perinatal Thoracic Mass Lesions: Pre- and Postnatal Imaging. Semin Ultrasound CT MR 2015; 36:501-21. [PMID: 26614133 DOI: 10.1053/j.sult.2015.05.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Chest masses present a common problem in the perinatal period. Advances in prenatal ultrasound, supplemented by fetal magnetic resonance imaging, now allow early detection and detailed characterization of many thoracic lesions in utero. As such, in asymptomatic infants, assessment with postnatal computed tomography or magnetic resonance imaging can often be delayed for several months until the time at which surgery is being contemplated. Bronchopulmonary malformations comprise most of the thoracic masses encountered in clinical practice. However, a variety of other pathologies can mimic their appearances or produce similar effects such as hypoplasia of a lung or both lungs. Understanding of the key differentiating clinical and imaging features can assist in optimizing prognostication and timely management.
Collapse
Affiliation(s)
- Evan J Zucker
- Department of Radiology, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, CA.
| | - Monica Epelman
- Department of Medical Imaging, Nemours Children's Hospital, Orlando, FL
| | - Beverley Newman
- Department of Radiology, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, CA
| |
Collapse
|
26
|
Bel S, Sananes N, Gaudineau A, Akladios C, Favre R. Treatment of a Fetal Tracheal Obstruction by Fetoscopy and Laser. Fetal Diagn Ther 2015; 40:63-6. [PMID: 25660567 DOI: 10.1159/000371705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 12/16/2014] [Indexed: 11/19/2022]
Abstract
We report below a case of in utero tracheoscopy with laser collapse of a bronchogenic cyst obstructing the fetal trachea. The patient was referred for ultrasonography at 24 weeks of gestation because of fetal hydrops. Tracheoscopy was performed via fetoscopic approach using a single trocar under local anesthesia with lidocaine and ultrasound guidance. This revealed an image suggestive of a cyst obstructing the middle third at the anterior base of the trachea. Coagulation using a diode laser enabled us to collapse this fluid-filled cyst with three 10-watt bursts (3 times 3 s) and to visualize a completely unobstructed tracheobronchial tree with significant pulmonary fluid reflux on removal of the obstacle. The fetal condition improved markedly within 48 h after the procedure. To the best of our knowledge, this is the first described case of in utero treatment of a tracheal obstruction by tracheoscopy and laser. In severe cases of obstruction of the fetal airways, whether the obstacle is situated in a high or low position, fetal endoscopy is of diagnostic and potentially therapeutic utility.
Collapse
Affiliation(s)
- Sandra Bel
- Department of Obstetrics and Gynecology, Strasbourg University Teaching Hospital, Strasbourg, France
| | | | | | | | | |
Collapse
|
27
|
Postmortem magnetic resonance appearances of congenital high airway obstruction syndrome. Pediatr Radiol 2015; 45:556-61. [PMID: 25190454 PMCID: PMC4381089 DOI: 10.1007/s00247-014-3133-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 06/24/2014] [Accepted: 07/16/2014] [Indexed: 10/31/2022]
Abstract
BACKGROUND Congenital high airway obstruction syndrome (CHAOS) is a rare life-threatening condition characterised by complete or near-complete developmental obstruction of the foetal airway. Although antenatal imaging findings have been described, the postmortem MRI findings have not been reported. OBJECTIVE To present postmortem MRI features of CHAOS. MATERIALS AND METHODS We retrospectively reviewed our hospital pathology and imaging databases for cases of CHAOS over a 2-year period. RESULTS We identified two cases of CHAOS. In both cases, postmortem plain radiographs demonstrated gross abdominal distension with distortion and splaying of the rib cage. Both foetuses had characteristic postmortem MRI findings including large-volume fluid-filled lungs on T2-weighted imaging, diaphragmatic eversion, fluid-filled airway dilatation below the level of obstruction, centrally positioned and compressed heart, and massive ascites. One foetus had an associated limb abnormality. CONCLUSION Postmortem MRI in foetuses suspected of having CHAOS allows confirmation of the diagnosis, determination of the anatomical level of the atresia or stenosis, and identification of associated abnormalities without the need for invasive autopsy.
Collapse
|
28
|
|
29
|
Ruano R, Cass DL, Rieger M, Javadian P, Shamshirsaz AA, Olutoye OO, Belfort MA. Fetal laryngoscopy to evaluate vocal folds in a fetus with congenital high airway obstruction syndrome (CHAOS). ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:102-103. [PMID: 23939717 DOI: 10.1002/uog.13191] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 07/28/2013] [Accepted: 08/02/2013] [Indexed: 06/02/2023]
Affiliation(s)
- R Ruano
- Pavilion for Women Texas Children's Fetal Center, Suite F1020, 6651 Main Street, Houston, Texas, 77030, USA
| | | | | | | | | | | | | |
Collapse
|
30
|
Garcia-Peña P, Coma A, Enríquez G. Congenital lung malformations: radiological findings and clues for differential diagnosis. Acta Radiol 2013; 54:1086-95. [PMID: 23436824 DOI: 10.1177/028418511305400901] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Congenital lung malformations encompass a wide spectrum of conditions with a broadly varying clinical presentation. They are often a source of morbidity in infants and children. Their management depends on the type of malformation and its clinical presentation. Usually, the diagnosis requires an imaging evaluation. Classifications of bronchopulmonary malformations have undergone significant revision in recent years and several theories have attempted to explain their confusing pathogenesis. There are considerable degrees of overlapping and hybrid conditions are common, with interrelated malformations showing various radiologic and pathologic features. Attending to the pathophysiological mechanisms and structures involved, lung malformations can be divided into three categories: bronchopulmonary anomalies, combined lung and vascular abnormalities, and vascular anomalies. The purpose of this article is to review the current imaging techniques for evaluating lung malformations in pediatric patients and their characteristic imaging findings. Moreover, this review discusses a useful classification and offers some clues to facilitate the differential diagnosis.
Collapse
Affiliation(s)
- Pilar Garcia-Peña
- Pediatric Radiology Department, Hospital Universitari
Matemo-lnfantil Vail d'Hebron, Barcelona, Spain
| | - Ana Coma
- Pediatric Radiology Department, Hospital Universitari
Matemo-lnfantil Vail d'Hebron, Barcelona, Spain
| | - Goya Enríquez
- Pediatric Radiology Department, Hospital Universitari
Matemo-lnfantil Vail d'Hebron, Barcelona, Spain
| |
Collapse
|
31
|
Coleman AM, Merrow AC, Elluru RG, Polzin WJ, Lim FY. Tracheal agenesis with tracheoesophageal fistulae: fetal MRI diagnosis with confirmation by ultrasound during an ex utero intrapartum therapy (EXIT) delivery and postdelivery MRI. Pediatr Radiol 2013; 43:1385-90. [PMID: 23567909 DOI: 10.1007/s00247-013-2679-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 02/12/2013] [Accepted: 02/22/2013] [Indexed: 10/27/2022]
Abstract
Tracheal agenesis is a rare and essentially lethal anomaly with divergent prenatal imaging findings depending on the presence or absence of a tracheoesophageal fistula. All prenatally diagnosed cases of tracheal agenesis reported to date have not had a tracheoesophageal fistula and presented with thoracoabdominal findings similar to congenital high airway obstruction syndrome. We present the case of a 32-week gestation fetus with rapid onset of polyhydramnios and no persistent findings of congenital high airway obstruction syndrome that was ultimately diagnosed with tracheal agenesis plus tracheoesophageal fistula by fetal MRI. Additionally, we present the novel uses of intraoperative US during a staged ex utero intrapartum therapy delivery and postdelivery MRI, facilitated by proximity within the neonatal ICU, to confirm diagnosis and direct patient management while minimizing unnecessary investigations.
Collapse
Affiliation(s)
- Alan M Coleman
- Fetal Care Center of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | | | | |
Collapse
|
32
|
Liberty G, Boldes R, Shen O, Shaul C, Cohen SM, Yagel S. The fetal larynx and pharynx: structure and development on two- and three-dimensional ultrasound. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:140-148. [PMID: 23239522 DOI: 10.1002/uog.12358] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/14/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To present a systematic approach for evaluating the fetal pharynx and larynx based on two- and three-dimensional ultrasound (2D-US and 3D-US) modalities, describing the sonographic appearance and function of the fetal upper respiratory tract and measuring the anatomical components of the pharynx and larynx. METHODS Gravidae presenting from the late first trimester to mid-gestation for routine booked examinations with structurally normal singleton fetuses of confirmed gestational age were enrolled. Transabdominal 2D-US was performed for anatomical and functional evaluation of the pharynx and larynx. Color Doppler was used to show fluid motion in the target area. 3D-US (Voluson® E6 with RAB-4-8-D transducer) scans of the fetal neck were acquired during fetal quiescence and in the absence of movements of the pharynx and larynx. Multiplanar reconstruction (MPR) in post-processing allowed adjustment of the volume to obtain the coronal plane. After a learning period to understand the sonographic anatomy of the target area, we measured the pharynx width and height, the upper, middle and lower larynx width and the larynx height. Render mode was applied for spatial evaluation of the target area. We developed a new methodological approach for structured evaluation of the fetal pharynx and larynx based on five spatial planes: posterior and anterior coronal planes and high, mid and low axial planes. RESULTS We examined 582 fetuses during the second trimester of pregnancy; target anatomy was imaged successfully in 218 patients at 11-24 gestational weeks. Acquisition added approximately 1 min to examination time. Rates of successful visualization and measurements increased significantly as pregnancy progressed, being 23% (46/194) at 11-13 weeks, 29% (69/240) at 14-16 weeks, 35% (18/51) at 17-19 weeks and 88% (85/97) at 20-24 weeks (P < 0.01). Pharynx components identified were: the sphenoid bone, pterygoid processes, constrictor muscles, piriform recesses and uvula. Larynx components identified were: the epiglottis, aryepiglottic folds, corniculate cartilages, arytenoid cartilages, cricoid cartilage, thyroid cartilage and vocal cords. MPR showed the biconcave shape of the uvula, which may explain the 'equals sign' observed on 2D-US. We observed the bilateral mode of movements of the constrictor muscles, aryepiglottic folds and vocal cords, and the bidirectional fluid jet flows through the larynx. Scatterplots of measured structures vs gestational age were created. Pharynx width ranged from 0.11 to 0.93 (mean ± SD, 0.48 ± 0.17) cm; pharynx height ranged from 0.23 to 2.01 (mean ± SD, 0.94 ± 0.34) cm; upper larynx width ranged from 0.04 to 0.37 (mean ± SD, 0.15 ± 0.07) cm; middle larynx width ranged from 0.08 to 0.77 (mean ± SD, 0.34 ± 0.16) cm; lower larynx width ranged from 0.05 to 0.64 (mean ± SD, 0.24 ± 0.11) cm; and larynx height ranged from 0.20 to 1.83 (mean ± SD, 0.71 ± 0.31) cm. All measurements were positively correlated with gestational age. CONCLUSIONS The fetal larynx and pharynx can be evaluated thoroughly using 2D- and 3D-US modalities. Knowledge of normal anatomy, function and biometry may prove useful in the evaluation of anatomical or functional pathology involving the fetal upper respiratory tract. Recognition of anatomical anomalies may enhance fetal intervention such as balloon placement in cases of diaphragmatic hernia.
Collapse
Affiliation(s)
- G Liberty
- Department of Obstetrics and Gynecology, Barzilai Medical Center, Ashkelon, Israel.
| | | | | | | | | | | |
Collapse
|
33
|
Ruano R, Peiro JL, da Silva MM, Campos JADB, Carreras E, Tannuri U, Zugaib M. Early fetoscopic tracheal occlusion for extremely severe pulmonary hypoplasia in isolated congenital diaphragmatic hernia: preliminary results. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:70-76. [PMID: 23349059 DOI: 10.1002/uog.12414] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Revised: 12/20/2012] [Accepted: 12/21/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To evaluate the effect of early fetoscopic tracheal occlusion (FETO) (22-24 weeks' gestation) on pulmonary response and neonatal survival in cases of extremely severe isolated congenital diaphragmatic hernia (CDH). METHODS This was a multicenter study involving fetuses with extremely severe CDH (lung-to-head ratio < 0.70, liver herniation into the thoracic cavity and no other detectable anomalies). Between August 2010 and December 2011, eight fetuses underwent early FETO. Data were compared with nine fetuses that underwent standard FETO and 10 without fetoscopic procedure from January 2006 to July 2010. FETO was performed under maternal epidural anesthesia, supplemented with fetal intramuscular anesthesia. Fetal lung size and vascularity were evaluated by ultrasound before and every 2 weeks after FETO. Postnatal therapy was equivalent for both treated fetuses and controls. Primary outcome was infant survival to 180 days and secondary outcome was fetal pulmonary response. RESULTS Maternal and fetal demographic characteristics and obstetric complications were similar in the three groups (P > 0.05). Infant survival rate was significantly higher in the early FETO group (62.5%) compared with the standard group (11.1%) and with controls (0%) (P < 0.01). Early FETO resulted in a significant improvement in fetal lung size and pulmonary vascularity when compared with standard FETO (P < 0.01). CONCLUSIONS Early FETO may improve infant survival by further increases of lung size and pulmonary vascularity in cases with extremely severe pulmonary hypoplasia in isolated CDH. This study supports formal testing of the hypothesis with a randomized controlled trial.
Collapse
MESH Headings
- Abnormalities, Multiple/metabolism
- Abnormalities, Multiple/mortality
- Abnormalities, Multiple/physiopathology
- Abnormalities, Multiple/surgery
- Balloon Occlusion/methods
- Female
- Fetoscopy/methods
- Fetoscopy/mortality
- Gestational Age
- Hernia, Diaphragmatic/metabolism
- Hernia, Diaphragmatic/mortality
- Hernia, Diaphragmatic/physiopathology
- Hernia, Diaphragmatic/surgery
- Hernias, Diaphragmatic, Congenital
- Humans
- Lung/abnormalities
- Lung/metabolism
- Lung/physiopathology
- Lung/surgery
- Lung Diseases/metabolism
- Lung Diseases/mortality
- Lung Diseases/physiopathology
- Lung Diseases/surgery
- Minimally Invasive Surgical Procedures
- Pregnancy
- Severity of Illness Index
- Survival Rate
- Trachea/embryology
- Trachea/physiopathology
- Treatment Outcome
- Ultrasonography, Doppler, Color
- Ultrasonography, Prenatal/methods
Collapse
Affiliation(s)
- R Ruano
- Obstetrics Department, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
| | | | | | | | | | | | | |
Collapse
|
34
|
Martínez J, Castañón M, Gómez O, Prat J, Eixarch E, Bennasar M, Puerto B, Gratacós E. Evaluation of Fetal Vocal Cords to Select Candidates for Successful Fetoscopic Treatment of Congenital High Airway Obstruction Syndrome: Preliminary Case Series. Fetal Diagn Ther 2013; 34:77-84. [DOI: 10.1159/000350697] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Accepted: 03/07/2013] [Indexed: 11/19/2022]
|
35
|
Ren S, Bhavsar T, Wurzel J. CHAOS in the mirror: Ballantyne (mirror) syndrome related to congenital high upper airway obstruction syndrome. Fetal Pediatr Pathol 2012; 31:360-4. [PMID: 22468720 DOI: 10.3109/15513815.2012.659400] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In the mirror syndrome, maternal edema mirrors fetal edema. The pathogenesis is unknown. The most common etiologic associations are rhesus isoimmunization, twin-twin transfusion syndrome, and viral infections. Less than 10% of reported cases are associated with congenital anomalies. We report a case due to congenital laryngeal stenosis, which also caused congenital high airway obstruction syndrome (CHAOS), characterized by pulmonary hyperplasia and edema or anasarca, related to airway abnormality. The fetal manifestations of the mirror syndrome and CHAOS overlap, but occurrence of the two in the same patient does not seem to have been reported.
Collapse
Affiliation(s)
- Shuyue Ren
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, Pennsylvania 19140, USA.
| | | | | |
Collapse
|
36
|
Colby CE, Carey WA, Blumenfeld YJ, Hintz SR. Infants with prenatally diagnosed anomalies: special approaches to preparation and resuscitation. Clin Perinatol 2012; 39:871-87. [PMID: 23164184 DOI: 10.1016/j.clp.2012.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
When a fetal anomaly is suspected, a multidisciplinary approach to diagnosis, counseling, pregnancy management, surveillance, delivery planning, and neonatal care is critical to creating a comprehensive management plan. This article provides a basic framework for integrating prenatal diagnostic and maternal-fetal care considerations, delivery planning, special resuscitation needs, and immediate and later neonatal care and evaluation into developing a thoughtful management plan for infants with prenatally diagnosed complex anomalies including congenital heart disease, intrathoracic masses, fetal airway obstruction, neural tube defects, abdominal wall defects, and skeletal dysplasia.
Collapse
Affiliation(s)
- Christopher E Colby
- Department of Pediatrics, Neonatal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | | | | | | |
Collapse
|
37
|
Sanford E, Saadai P, Lee H, Slavotinek A. Congenital high airway obstruction sequence (CHAOS): A new case and a review of phenotypic features. Am J Med Genet A 2012; 158A:3126-36. [DOI: 10.1002/ajmg.a.35643] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Accepted: 07/25/2012] [Indexed: 12/22/2022]
|
38
|
Tracheobronchomegaly following intrauterine tracheal occlusion for congenital diaphragmatic hernia. Pediatr Radiol 2012; 42:916-22. [PMID: 22644455 DOI: 10.1007/s00247-012-2362-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Revised: 12/18/2011] [Accepted: 12/30/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND Fetuses with severe congenital diaphragmatic hernia (CDH) and pulmonary hypoplasia may benefit from fetal endoluminal tracheal occlusion (FETO). Enlargement of the main bronchi and trachea appears to be a common complication of FETO. OBJECTIVE To retrospectively evaluate the trachea and main bronchi of infants who underwent FETO for CDH and compare diameters with age-matched references. MATERIAL AND METHODS Postnatal and follow-up chest radiographs were performed in seven children with unilateral CDH treated by FETO. Additional CT was performed in six of these (one neonate died before CT could be performed). Images were acquired from 3 days to 23 months of age. For each child, radiographs and CT images with optimal visualisation of the airways were selected for retrospective analysis. Tracheal and bronchial morphology was assessed by two experienced paediatric radiologists, and the diameters of these structures measured and compared with age-matched references. RESULTS Mean diameters of the trachea and main bronchi were above the age-matched normal range in all patients, regardless of the side of the hernia or the degree of lung hypoplasia. CONCLUSION Enlargement of the trachea and main bronchi appears following FETO and persists at least to the age of 5 years.
Collapse
|
39
|
Gray FL, Turner CG, Ahmed A, Calvert CE, Zurakowski D, Fauza DO. Prenatal tracheal reconstruction with a hybrid amniotic mesenchymal stem cells-engineered construct derived from decellularized airway. J Pediatr Surg 2012; 47:1072-9. [PMID: 22703772 DOI: 10.1016/j.jpedsurg.2012.03.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Accepted: 03/05/2012] [Indexed: 12/15/2022]
Abstract
PURPOSE This study was aimed at examining an airway construct engineered from autologous amniotic mesenchymal stem cells (aMSCs) and a xenologous decellularized airway scaffold as a means for tracheal repair. METHODS Fetal lambs (N = 13) with a tracheal defect were divided into 2 groups. One group (acellular, n = 6) was repaired with a decellularized leporine tracheal segment. The other group (engineered, n = 7) received an identical graft seeded with expanded/labeled autologous aMSCs. Newborns were euthanized for multiple analyses. RESULTS Eleven lambs survived to term, 10 of which could breathe at birth. Engineered grafts showed a significant increase in diameter in vivo (P = .04) unlike acellular grafts (P = .62), although variable stenosis was present in all implants. Engineered constructs exhibited full epithelialization, compared with none of the acellular grafts (P = .002). Engineered grafts had a significantly greater degree of increase in elastin levels after implantation than acellular implants (P = .04). No such differences were noted in collagen and glycosaminoglycan contents. Donor cells were detected in engineered grafts, which displayed a pseudostratified columnar epithelium. CONCLUSIONS Constructs engineered from aMSCs and decellularized airway undergo enhanced remodeling and epithelialization in vivo when compared with equivalent acellular implants. Amniotic mesenchymal stem cell-engineered airways may become an alternative for perinatal airway repair.
Collapse
Affiliation(s)
- Fabienne L Gray
- Department of Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
| | | | | | | | | | | |
Collapse
|
40
|
Long-term outcomes after fetal therapy for congenital high airway obstructive syndrome. J Pediatr Surg 2012; 47:1095-100. [PMID: 22703776 DOI: 10.1016/j.jpedsurg.2012.03.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Accepted: 03/05/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND/PURPOSE Congenital high airway obstructive syndrome (CHAOS) is a rare and devastating condition that is uniformly fatal without fetal intervention. We sought to describe fetal treatment and long-term outcomes of CHAOS at a single referral center. METHODS The medical records of patients with fetal CHAOS evaluated at our center between 1993 and 2011 were reviewed. Maternal history, radiographic findings, antenatal management, and postnatal outcomes were compared. RESULTS Twelve fetuses with CHAOS were identified. Eleven had concomitant hydrops at diagnosis. Six were electively terminated, and 2 had intra- or peripartum demise. Four patients underwent fetal intervention. Two underwent delivery via ex utero intrapartum treatment (EXIT) procedure with tracheostomy placement only, and 2 underwent fetal bronchoscopy with attempted wire tracheoplasty followed by EXIT with tracheostomy at delivery. All 4 patients who underwent EXIT were alive at last follow-up. One patient was ventilator and tracheostomy free and feeding by mouth. CONCLUSION Long-term and tracheostomy-free survival is possible with appropriate fetal intervention even in the presence of hydrops. Fetal intervention earlier in pregnancy may improve long-term outcomes, but patient selection for intervention remains challenging. Magnetic resonance imaging may help select those patients for whom fetal intervention before EXIT delivery may be beneficial.
Collapse
|
41
|
Joshi P, Satija L, George R, Chatterjee S, D'Souza J, Raheem A. Congenital high airway obstruction syndrome-antenatal diagnosis of a rare case of airway obstruction using multimodality imaging. Med J Armed Forces India 2012; 68:78-80. [PMID: 24669041 DOI: 10.1016/s0377-1237(11)60111-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 09/19/2011] [Indexed: 11/17/2022] Open
Affiliation(s)
- Piyush Joshi
- Classified Specialist (Radiodiagnosis), Command Hospital (SC), Pune - 40
| | - Lovleen Satija
- Senior Advisor (Radiodiagnosis), Command Hospital (CC), Lucknow
| | - Ra George
- Senior Advisor (Radiodiagnosis), Military Hospital, Mhow
| | - S Chatterjee
- Associate Professor, Department of Radiology, AFMC, Pune - 40
| | - J D'Souza
- Consultant (Radiology), INHS Asvini, Mumbai
| | - Abdul Raheem
- Graded Specialist (Radiology), 5 Air Force Hospital, Jorhat
| |
Collapse
|
42
|
Tracheal agenesis: approach towards this severe diagnosis. Case report and review of the literature. Eur J Pediatr 2012; 171:425-31. [PMID: 21918809 PMCID: PMC3284653 DOI: 10.1007/s00431-011-1563-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 08/31/2011] [Indexed: 12/20/2022]
Abstract
Tracheal agenesis (TA) is a severe congenital disorder with often an unexpected emergency presentation. There is complete or partial absence of the trachea below the larynx, with presence or absence of a tracheoesophageal fistula (TOF). A neonate with TA is described, and another 48 cases found in literature are reviewed. Due to absence of a TOF, five cases were diagnosed prenatally because of congenital high airway obstruction syndrome (CHAOS). When a TOF is present, polyhydramnion and several other congenital malformations seen on the ultrasound examination should alert clinicians of potential tracheal problems. Prenatal magnetic resonance imaging (MRI) may provide a definitive diagnosis. Postnatal diagnosis is based on recognition of specific clinical signs in the newborn with TA: respiratory distress with breathing movement without appropriate air entry, no audible cry, and failed endotracheal intubation. Despite progress in surgical interventions, mortality remains high. Prenatal diagnosis of TA is possible, but only if a TOF is absent resulting in CHAOS. Prenatal diagnosis of polyhydramnion and other congenital malformation should alert clinicians of potential tracheal problems. Prenatal MRI may provide a definitive diagnosis.
Collapse
|
43
|
Castellote A, Mencho S, Carreras E, Higueras T, Cadavid L, Piqueras J, Enriquez G. Correlation between US and MRI for prenatal lung volumetry in diaphragmatic hernia, and use of Doppler to identify the ipsilateral lung cap. Pediatr Radiol 2011; 41:1569-77. [PMID: 21938506 DOI: 10.1007/s00247-011-2200-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 03/28/2011] [Accepted: 05/16/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pulmonary hypoplasia is a common cause of neonatal death. OBJECTIVE To describe the correlation between relative fetal lung volume (RFLV) and lung-to-head ratio (LHR) in fetuses with unilateral diaphragmatic hernia. Additionally, to describe identification of the ipsilateral lung cap by power Doppler. MATERIALS AND METHODS Single-institution study of consecutive fetuses with diaphragmatic hernia. LHR (by US) and RFLV (by MRI) were correlated in fetuses with and without an ipsilateral lung cap seen at MRI. In four, color/power Doppler was used to follow the pulmonary artery of the ipsilateral lung to identify the compressed cap. RESULTS The study included 48 fetuses of 20-38 weeks' gestational age (mean, 26 weeks). Mean LHR was 1.52 (range, 0.6-3) in fetuses with a lung cap and 1.15 (range, 0.6-2.58) in fetuses without (P = 0.043). Mean RFLV was 47.4% (range, 18-80%) in fetuses with and 32.9% (range, 14-57%) in fetuses without a lung cap (P = 0.005). RFLV and LHR correlated (r = 0.41, P = 0.01 in those with a cap; r = 0.50, P = 0.05 in those without). Power Doppler identified the ipsilateral lung cap and pulsed Doppler confirmed pulmonary vascularization in four of four fetuses. CONCLUSION LHR underestimates lung volume in fetuses with an ipsilateral lung cap. Power Doppler may be useful for identifying the cap.
Collapse
Affiliation(s)
- Amparo Castellote
- Department of Pediatric Radiology, University Children's Hospital Vall d'Hebron, Ps. Vall d'Hebron 119-129, 08035 Barcelona, Spain.
| | | | | | | | | | | | | |
Collapse
|
44
|
Hourrier S, Salomon LJ, Bault JP, Dumez Y, Ville Y. Malformations pulmonaires congénitales : diagnostic et prise en charge anténataux. Rev Mal Respir 2011; 28:1017-24. [DOI: 10.1016/j.rmr.2011.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 04/18/2011] [Indexed: 11/25/2022]
|
45
|
Bulas D, Egloff AM. Fetal Chest Ultrasound and Magnetic Resonance Imaging: Recent Advances and Current Clinical Applications. Radiol Clin North Am 2011; 49:805-23. [DOI: 10.1016/j.rcl.2011.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|
46
|
Biyyam DR, Chapman T, Ferguson MR, Deutsch G, Dighe MK. Congenital Lung Abnormalities: Embryologic Features, Prenatal Diagnosis, and Postnatal Radiologic-Pathologic Correlation. Radiographics 2010; 30:1721-38. [PMID: 21071385 DOI: 10.1148/rg.306105508] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Deepa R Biyyam
- Department of Radiology, University of Washington Medical Center, Seattle, WA 98195, USA.
| | | | | | | | | |
Collapse
|
47
|
Roybal JL, Liechty KW, Hedrick HL, Bebbington MW, Johnson MP, Coleman BG, Adzick NS, Flake AW. Predicting the severity of congenital high airway obstruction syndrome. J Pediatr Surg 2010; 45:1633-9. [PMID: 20713212 DOI: 10.1016/j.jpedsurg.2010.01.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Revised: 01/17/2010] [Accepted: 01/18/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Congenital high airway obstruction syndrome (CHAOS) is caused by complete or near-complete obstruction of the fetal airway. Obstruction sets in motion a sequence of events that can ultimately lead to fetal demise. However, on rare occasions in utero airway decompression occurs, reversing syndromic findings and improving the prognosis. In our relatively large series of CHAOS patients, we have observed a spectrum of clinical severity. The aim of this study was to identify the prenatal characteristics of CHAOS predictive of a milder postnatal course. METHODS The medical charts of all fetuses observed at our institution with the diagnosis of CHAOS were reviewed for radiologic findings, delivery information, perinatal course, autopsy or discharge report, and long-term follow-up. RESULTS Between 1996 and 2008, 12 fetuses with CHAOS were identified. Four fetuses had no evidence of hydrops on initial imaging. Of the 8 fetuses displaying hydrops, 3 were terminated, 2 died in utero, and 1 with multiple anomalies died at birth. Six fetuses were delivered via the ex utero intrapartum therapy procedure for attempted salvage, and 5 of the 6 survived the neonatal period including all 4 fetuses without hydrops. Serial prenatal imaging demonstrated less severe signs of CHAOS in 3 fetuses, and in 2 of them, direct laryngoscopy revealed a tiny opening in the airway. All 3 fetuses that showed improvement on serial imaging survived the neonatal period and were discharged home by 2-10 weeks of age. CONCLUSIONS Although the natural history of CHAOS is variable, trends in prenatal ultrasound findings are highly predictive of postnatal outcome and are a valuable guide to prenatal counseling.
Collapse
Affiliation(s)
- Jessica L Roybal
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA 19104-4318, USA.
| | | | | | | | | | | | | | | |
Collapse
|
48
|
Daltro P, Werner H, Gasparetto TD, Domingues RC, Rodrigues L, Marchiori E, Gasparetto EL. Congenital chest malformations: a multimodality approach with emphasis on fetal MR imaging. Radiographics 2010; 30:385-95. [PMID: 20228324 DOI: 10.1148/rg.302095113] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Congenital chest malformations can range from small and asymptomatic entities to large space-occupying masses that require immediate surgical treatment. They may affect the foregut, pulmonary airway, and vasculature. Hybrid conditions are commonly seen, with interrelated chest malformations having various radiologic and pathologic features. An understanding of the in utero complications associated with fetal chest masses is essential for appropriate monitoring during pregnancy, treatment recommendations, and delivery management. Technologic advances have greatly improved the diagnosis of fetal anomalies. Congenital chest malformations are usually evaluated in the prenatal period with fetal sonography, but fetal magnetic resonance (MR) imaging is a well-established modality that is used as an adjunct technique in difficult diagnostic situations. MR imaging can provide excellent tissue contrast with more accurate analysis of the fetal anatomy and superior differentiation between the abnormalitites and adjacent structures, thereby allowing early planning of prenatal management.
Collapse
Affiliation(s)
- Pedro Daltro
- Clinica de DiagnOstico por Imagem, Av das Amé ricas 4666, Sala 325, Rio de Janeiro, RJ 22631004, Brazil
| | | | | | | | | | | | | |
Collapse
|
49
|
Courtier J, Poder L, Wang ZJ, Westphalen AC, Yeh BM, Coakley FV. Fetal tracheolaryngeal airway obstruction: prenatal evaluation by sonography and MRI. Pediatr Radiol 2010; 40:1800-5. [PMID: 20737145 PMCID: PMC2950274 DOI: 10.1007/s00247-010-1800-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Revised: 07/14/2010] [Accepted: 07/27/2010] [Indexed: 11/12/2022]
Abstract
We reviewed the sonographic and MRI findings of tracheolaryngeal obstruction in the fetus. Conditions that can cause tracheolaryngeal obstruction include extrinsic causes such as lymphatic malformation, cervical teratoma and vascular rings and intrinsic causes such as congenital high airway obstruction syndrome (CHAOS). Accurate distinction of these conditions by sonography or MRI can help facilitate parental counseling and management, including the decision to utilize the ex utero intrapartum treatment (EXIT) procedure.
Collapse
Affiliation(s)
- Jesse Courtier
- Department of Radiology, University of California San Francisco, Box 0628, M-372, 505 Parnassus Ave., San Francisco, CA 94143-0628 USA
| | - Liina Poder
- Department of Radiology, University of California San Francisco, Box 0628, M-372, 505 Parnassus Ave., San Francisco, CA 94143-0628 USA
| | - Zhen J. Wang
- Department of Radiology, University of California San Francisco, Box 0628, M-372, 505 Parnassus Ave., San Francisco, CA 94143-0628 USA
| | - Antonio C. Westphalen
- Department of Radiology, University of California San Francisco, Box 0628, M-372, 505 Parnassus Ave., San Francisco, CA 94143-0628 USA
| | - Benjamin M. Yeh
- Department of Radiology, University of California San Francisco, Box 0628, M-372, 505 Parnassus Ave., San Francisco, CA 94143-0628 USA
| | - Fergus V. Coakley
- Department of Radiology, University of California San Francisco, Box 0628, M-372, 505 Parnassus Ave., San Francisco, CA 94143-0628 USA
| |
Collapse
|