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Kontopoulos E, Bulman M, Gordienko I, Rodriguez MJ, Gallardo M, Copado Y, Acevedo S, Quintero L, Quintero RA. Clinical assessment of the fetal right Quantitative Lung Index. J Matern Fetal Neonatal Med 2023; 36:2242555. [PMID: 37580087 DOI: 10.1080/14767058.2023.2242555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/25/2023] [Indexed: 08/16/2023]
Abstract
OBJECTIVES We have previously described gestational-age-independent sonographic indices to assess fetal lung size in the right and left lungs: The Quantitative Lung Index for the right lung (QLI-R) and for the left lung (QLI-L), respectively. The purpose of this study was to evaluate the clinical cutoff point of the QLI-R to predict pulmonary hypoplasia and neonatal death. MATERIALS AND METHODS Retrospective assessment of the QLI-R in patients with left-sided congenital diaphragmatic hernia (CDH-L) and other fetal conditions at risk for fetal pulmonary hypoplasia. Cross-section and longitudinal assessment of the behavior of the QLI-R in untreated and treated patients. ROC curve analysis to determine the optimal cutoff point of the QLI-R in predicting neonatal death. RESULTS One hundred eighteen patients with CDH-L and other fetal conditions at risk for pulmonary hypoplasia had QLI-R measurements done. Seventeen patients were excluded for various reasons. Eleven patients with conditions other than CDH-L but at risk for pulmonary hypoplasia were used for intraclass coefficient measurements of the QLI-R. Ninety patients had CDH-L, of which 78 did not undergo antenatal intervention and in which the cutoff point for pulmonary hypoplasia and neonatal demise was assessed. Stent tracheal occlusion was performed in the remaining 12 patients with CDH-L, in which the behavior of the QLI after surgery was assessed. Analysis of the ICC showed an overall intra-rater reliability of 0.985 (Cronbach's Alpha-based). There was no correlation between gestational age and QLI-R (-0.73, Pearson correlation, p = .72). Twenty-six of the 78 patients (33%) with CDH-L managed expectantly had a neonatal demise. A QLI-R equal to or less than 0.45 was significantly predictive of neonatal demise (area under the curve 0.64, p = .046, sensitivity 77%). Nine of the 12 patients (75%) that underwent tracheal occlusion had neonatal survival. Of these, 10 had serial assessments of the QLI-R after surgery. An increase in the QLI-R of 0.11 was associated with a tendency for neonatal survival (p = .056). CONCLUSION Our study confirms that the QLI-R is a gestational-age-independent measurement of fetal lung size, with a high degree of reproducibility. In a population of expectantly managed CDH-L patients, a cutoff value of the QLI-R of 0.45 or lower is predictive of neonatal death from pulmonary hypoplasia. The QLI-R can be used to monitor fetal lung growth after tracheal occlusion, and an increase in the QLI-R is suggestive of neonatal survival. Further prospective studies are needed to confirm these findings and to explore the use of the QLI in other populations at risk for pulmonary hypoplasia and consequent neonatal demise.
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Affiliation(s)
- Eftichia Kontopoulos
- The USFetus Research Consortium, Miami, FL, USA
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Florida International University, Miami, FL, USA
- The Fetal Institute Miami, Miami, FL, USA
| | | | - Irina Gordienko
- Institute of Paediatrics, Obstetrics and Gynecology, Department of Maternal-Fetal Medicine, Kiev, Ukraine
| | - Maria Jose Rodriguez
- Instituto Nacional de Perinatología, División de Medicina Materno-Fetal, Ciudad de México, México
| | - Manuel Gallardo
- Instituto Nacional de Perinatología, División de Medicina Materno-Fetal, Ciudad de México, México
| | - Yazmin Copado
- Instituto Nacional de Perinatología, División de Medicina Materno-Fetal, Ciudad de México, México
| | - Sandra Acevedo
- Instituto Nacional de Perinatología, División de Medicina Materno-Fetal, Ciudad de México, México
| | | | - Ruben A Quintero
- The USFetus Research Consortium, Miami, FL, USA
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Florida International University, Miami, FL, USA
- The Fetal Institute Miami, Miami, FL, USA
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2
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Rana A, Sharma KA, Kumar V, Chaudhary P, Thukral A, Agarwala S, Dadhwal V. Perinatal Outcome in Congenital Diaphragmatic Hernia (CDH): A Single-Center Experience. J Obstet Gynaecol India 2023; 73:37-42. [PMID: 37916008 PMCID: PMC10616035 DOI: 10.1007/s13224-023-01796-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/12/2023] [Indexed: 11/03/2023] Open
Abstract
Objective To study the perinatal outcome in fetuses diagnosed with congenital diaphragmatic hernia (CDH). Methods Thirty-two pregnant women with antenatal diagnosis of CDH in fetus, who delivered between 2018 and 2021, were included in the study. Postnatally eventration of diaphragm was diagnosed in 3 neonates and were excluded. Results The median gestational age at diagnosis was 23 weeks (IQR: 216-261 weeks). The mean O/E LHR was 34.88 ± 9.03%, and the O/E LHR was significantly lower in fetuses who did not survive (40.81 ± 4.25 vs 31.26 ± 9.33; p = 0.0037). On ROC analysis, at a cutoff of ≤ 32.93, O/E LHR had a specificity of 100% with a sensitivity of 72.22% in predicting mortality. Cases with liver herniation were not significantly different between survivors versus non-survivors. The overall survival rate was 37.93%, and the leading cause of death was severe persistent pulmonary hypertension. Conclusion O/E LHR can predict mortality in neonates with antenatal diagnosis of CDH. The presence of pulmonary hypertension was the leading cause of death in these neonates.
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Affiliation(s)
- Anubhuti Rana
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - K. Aparna Sharma
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Vivek Kumar
- Division of Neonatology, Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Priyanka Chaudhary
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Anu Thukral
- Division of Neonatology, Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Agarwala
- Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Vatsla Dadhwal
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
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3
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Schwab ME, Lee H, Tsao K. In Utero Therapy for Congenital Diaphragmatic Hernia. Clin Perinatol 2022; 49:863-872. [PMID: 36328604 DOI: 10.1016/j.clp.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Congenital diaphragmatic hernia is an anomaly that is often prenatally diagnosed and spans a wide spectrum of disease, with high morbidity and mortality associated with fetuses with severe defects. Congenital diaphragmatic hernia is thus an ideal target for fetal intervention. We review the literature on prenatal diagnosis, describe the history of fetal intervention for congenital diaphragmatic hernia, and discuss fetal endoscopic tracheal occlusion and the Tracheal Occlusion To Accelerate Lung growth trial results. Finally, we present preclinical studies for potential future directions.
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Affiliation(s)
- Marisa E Schwab
- Division of Pediatric Surgery, University of California San Francisco, 550 16th Street, San Francisco, San Francisco, CA 94158, USA; Department of Surgery, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Hanmin Lee
- Division of Pediatric Surgery, University of California San Francisco, 550 16th Street, San Francisco, San Francisco, CA 94158, USA
| | - KuoJen Tsao
- Department of Pediatric Surgery and Obstetrics, Gynecology & Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, 6410 Fannin Street, Suite 950, Houston, TX 77030, USA.
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4
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Perrone EE, Karmakar M, Lally PA, Chung S, Kipfmueller F, Morini F, Phillips R, Van Meurs KP, Harting MT, Mychaliska GB, Lally KP. Image-based prenatal predictors correlate with postnatal survival, extracorporeal life support use, and defect size in left congenital diaphragmatic hernia. J Perinatol 2022; 42:1195-1201. [PMID: 35228684 DOI: 10.1038/s41372-022-01357-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/25/2022] [Accepted: 02/15/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the association between prenatal imaging predictors of patients with left-sided congenital diaphragmatic hernia (LCDH) and postnatal outcomes. STUDY DESIGN CDH study group data were reviewed for LCDH infants born 2015-2019. Prenatal ultrasound (US) and magnetic resonance imaging (MRI) data were collected and correlated with postnatal information including CDHSG defect size (A through D or non-repair (NR)). RESULTS In total, 929 LCDH patients were included. Both US and MRI imaging predictors correlated with postnatal survival (72.2%) and ECLS use (29.6%). Logistic regression models confirmed increased survival and decreased ECLS use with larger values for all predictors. Importantly, all prenatal values evaluated showed no significant difference between defect size D and NR patients. CONCLUSIONS This is the largest cohort of LCDH patients and demonstrates that prenatal imaging factors correlate with postnatal outcomes and confirms that patients in the non-repair group are prenatally similar to type D defects.
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Affiliation(s)
- Erin E Perrone
- Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Ann Arbor, MI, USA.
| | - Monita Karmakar
- Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Ann Arbor, MI, USA
| | - Pamela A Lally
- Department of Pediatric Surgery, McGovern Medical School at UTHealth and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Sukyung Chung
- Department of Primary Care and Population Health, Stanford University, Palo Alto, CA, USA
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care Children's Hospital, University of Bonn, Bonn, Germany
| | - Francesco Morini
- Neonatal Surgical Unit, Ospedale Pediatrico Bambino Gesu, IRCCS, Medical and Surgical Department of the Fetus, Newborn, and Infant, Rome, Italy
| | - Ryan Phillips
- Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at UTHealth and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - George B Mychaliska
- Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Ann Arbor, MI, USA
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at UTHealth and Children's Memorial Hermann Hospital, Houston, TX, USA
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5
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Fetal liver and lung volume index of neonatal survival with congenital diaphragmatic hernia. Pediatr Radiol 2021; 51:1637-1644. [PMID: 33779798 DOI: 10.1007/s00247-021-05049-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 01/28/2021] [Accepted: 03/09/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) assesses pulmonary hypoplasia in fetal congenital diaphragmatic hernia (CDH). Neonatal mortality may occur with CDH. OBJECTIVE To quantify MRI parameters associated with neonatal survival in fetuses with isolated CDH. MATERIALS AND METHODS Fetal MRI for assessing CDH included region of interest (ROI) measurements for total lung volume (TLV), herniated liver volume, herniated other organ volume and predicted lung volume. Ratios of observed lung volume and liver up volume to predicted lung volume (observed to predicted TLV, percentage of the thorax occupied by liver) were calculated and compared to neonatal outcomes. Analyses included Wilcoxon rank sum test, multivariate logistic regression and receiver operating characteristic (ROC) curves. RESULTS Of 61 studies, the median observed to predicted TLV was 0.25 in survivors and 0.16 in non-survivors (P=0.001) with CDH. The median percentage of the thorax occupied by liver was 0.02 in survivors and 0.22 in non-survivors (P<0.001). The association of observed to predicted TLV and percentage of the thorax occupied by liver with survival for gestational age (GA) >28 weeks was greater compared to GA ≤28 weeks. The ROC analysis demonstrated an area under the curve of 0.96 (95% confidence interval 0.91-1.00) for the combined observed to predicted TLV, percentage of the thorax occupied by liver and GA. CONCLUSION The percentage of the thorax occupied by liver and observed to predicted TLV was predictive of neonatal survival in fetuses with CDH.
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Shetty S, Arattu Thodika FMS, Greenough A. Managing respiratory complications in infants and newborns with congenital diaphragmatic hernia. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1865915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
| | | | - Anne Greenough
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London, UK
- Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, UK
- Asthma UK Centre in Allergic Mechanisms of Asthma, King’s College London, London, UK
- NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, UK
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7
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Abstract
Because congenital diaphragmatic hernia (CDH) is characterized by a spectrum of severity, risk stratification is an essential component of care. In both the prenatal and postnatal periods, accurate prediction of outcomes may inform clinical decision-making, care planning, and resource allocation. This review examines the history and utility of the most well-established risk prediction tools currently available, and provides recommendations for their optimal use in the management of CDH patients.
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Affiliation(s)
- Tim Jancelewicz
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, 49 North Dunlap St., Second Floor, Memphis, TN, 38112, USA.
| | - Mary E Brindle
- Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
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8
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Peluso AM, Othman HF, Elsamny EM, Sammour I, Yeaney NK, Aly H. Survival trends and outcomes among preterm infants with congenital diaphragmatic hernia. J Perinatol 2020; 40:263-268. [PMID: 31624324 DOI: 10.1038/s41372-019-0523-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/24/2019] [Accepted: 09/27/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The objective of this study was to use current national data to evaluate the characteristics and survival trends of preterm infants born with CDH from 2004 to 2014. STUDY DESIGN Data was queried from the National Inpatient Sample (NIS) and KID database from 2004 to 2014. Infants were included if diagnosed with CDH by ICD-9 coding and gestational age <37 weeks. Descriptive statistics, chi-square, and trend analysis were completed. RESULTS We identified 2356 infants born prematurely with CDH. The overall survival rate was 49%. The survival range is 21.2-62.3% for gestational age <26 weeks to 35-36 weeks, respectively. Total mortality was 1183; of them, 1052 (89%) were not repaired and 363 (30.7%) did not receive mechanical ventilation. Surgical repair occurred in 55.1% of infants. CONCLUSIONS Preterm infants have lower survival compared with term infants. Survival rates decrease with lower gestational age and have improved over time.
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Affiliation(s)
- Allison M Peluso
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA.
| | - Hasan F Othman
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Esraa M Elsamny
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Ibrahim Sammour
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Natalie K Yeaney
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
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9
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Abstract
Congenital diaphragmatic hernia (CDH) is a condition that results from incomplete diaphragm formation during embryogenesis. The diaphragmatic defect allows for herniation of abdominal viscera into the chest, and the resulting pulmonary hypoplasia and pulmonary hypertension can lead to cardiorespiratory failure in the neonatal period. There is a wide spectrum of disease severity in CDH, and while advances in neonatal care and the introduction of extracorporeal membrane oxygenation have improved outcomes in many cases, the most severe defects are still associated with high morbidity and mortality. Improvements in prenatal diagnostic and prognostic capabilities have created an opportunity to select high risk patients for fetal intervention. Three decades of refinements in the fetal surgical therapy for CDH have led to the current technique of Fetoscopic Endoluminal Tracheal Occlusion (FETO). Herein, we review the current considerations for selecting patients for fetal intervention, and the contemporary fetal surgical operation for CDH, FETO, with a focus on early outcomes and ongoing studies.
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Affiliation(s)
- Mark L Kovler
- Johns Hopkins Hospital, Division of General Pediatric Surgery, Baltimore, MD, United States
| | - Eric B Jelin
- Johns Hopkins Hospital, Division of General Pediatric Surgery, Baltimore, MD, United States.
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10
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Vieira R, Pearse R, Rankin J. Mortality factors in infants with congenital diaphragmatic hernia: A systematic review. Birth Defects Res 2018; 110:1241-1249. [PMID: 30198646 DOI: 10.1002/bdr2.1376] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/13/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is a malformation of the diaphragm accounting for 8% of all major congenital anomalies. Although many clinical factors of survival in children with CDH have been established, limited research exists on the role of sociodemographic and other factors. We aimed to systematically identify and summarize all available international literature, published from January 2000 to July 2017, evaluating specific mortality factors for children with prenatally diagnosed, isolated, left-sided CDH. METHODS MEDLINE, PROSPERO, EMBASE, Scopus, The Cochrane Library databases, and the table of contents for the past 5 years for relevant journals were searched systematically. The risk factors of interest were as follows: birth weight, gestational age (GA) at diagnosis, GA at birth, infant sex, maternal age, ethnicity, socioeconomic status (SES), and plurality. The primary outcome measure was survival. Data were extracted on study design, study quality, participant data, and survival-related effect estimates. RESULTS Seven studies fulfilled the inclusion criteria. In total, 347 children were included in the review. Birth weight, GA at diagnosis, and GA at birth were evaluated in five studies each, infant sex in two, and maternal age in one. None of these factors were significantly associated with survival. No studies evaluated the influence of plurality, ethnicity or SES. CONCLUSION Although the factors of interest showed no significant association with survival, more evidence is required to confirm these findings. Understanding whether sociodemographic factors are associated with survival may help inform the development of public health interventions to improve survival rates for children with CDH.
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Affiliation(s)
- Rute Vieira
- Institute of Health and Society, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK
| | - Rachel Pearse
- Institute of Health and Society, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK
| | - Judith Rankin
- Institute of Health and Society, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK
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11
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Bruns AS, Lau PE, Dhillon GS, Hagan J, Kailin JA, Mallory GB, Lohmann P, Olutoye OO, Ruano R, Fernandes CJ. Predictive value of oxygenation index for outcomes in left-sided congenital diaphragmatic hernia. J Pediatr Surg 2018; 53:1675-1680. [PMID: 29428594 DOI: 10.1016/j.jpedsurg.2017.12.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 12/01/2017] [Accepted: 12/20/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND & OBJECTIVES Congenital Diaphragmatic Hernia (CDH) is associated with significant morbidity and mortality. This study compares the efficacy of the highest oxygenation index in the first 48 h (HiOI) versus current prenatal indices to predict survival and morbidity. METHODS Medical records of 50 prenatally diagnosed, isolated, left-sided CDH patients treated from January 2011 to April 2016 were reviewed. Data abstracted included HiOI, lung to head ratio (LHR), observed to expected total fetal lung volume (O/E TFLV), percent liver herniation (%LH), 6 month survival, respiratory support at discharge, ventilator days and length of stay. Data were analyzed using parametric and nonparametric tests and regression analyses as appropriate. RESULTS HiOI was associated with significantly increased LOS (p<0.001), respiratory support at discharge (p<0.001), greater ventilator days (p=0.001) and higher odds of death (p=0.004) with risk of death increasing by 5% for every one-unit increase in OI. HiOI was statistically a better predictor of LOS than O/E TFLV (p=0.007) and %LH (p=0.02). CONCLUSIONS In isolated, left-sided CDH patients, HiOI is associated with higher mortality, greater length of stay, more ventilator days and increased respiratory support at discharge. HiOI is a better predictor of length of stay than O/E TFLV and %LH. TYPE OF STUDY Retrospective Study LEVEL OF EVIDENCE: II.
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Affiliation(s)
- Ashley S Bruns
- Section of Neonatology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA.
| | - Patricio E Lau
- Department of Pediatric Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Gurpreet S Dhillon
- Section of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Joseph Hagan
- Center for Research & Evidence Based Practice, Texas Children's Hospital, Houston, TX, USA
| | - Joshua A Kailin
- Section of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - George B Mallory
- Department of Pediatric Pulmonary Medicine, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Pablo Lohmann
- Section of Neonatology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Oluyinka O Olutoye
- Department of Pediatric Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Caraciolo J Fernandes
- Section of Neonatology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
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12
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Sperling JD, Sparks TN, Berger VK, Farrell JA, Gosnell K, Keller RL, Norton ME, Gonzalez JM. Prenatal Diagnosis of Congenital Diaphragmatic Hernia: Does Laterality Predict Perinatal Outcomes? Am J Perinatol 2018; 35:919-924. [PMID: 29304545 PMCID: PMC6033692 DOI: 10.1055/s-0037-1617754] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objective of this study was to examine laterality as a predictor of outcomes among fetuses with prenatally diagnosed congenital diaphragmatic hernia (CDH). METHODS This is a retrospective cohort study of pregnancies with CDH evaluated at our center from 2008 to 2016 compared cases with right-sided CDH (RCDH) versus left-sided CDH (LCDH). The primary outcome was survival to discharge. Secondary outcomes included ultrasound predictors of poor prognosis (liver herniation, stomach herniation, lung area-to-head circumference ratio [LHR]), concurrent anomalies, hydrops, stillbirth, preterm birth, mode of delivery, small for gestational age, use of extracorporeal membrane oxygenation, and length of stay. Terminations and stillbirths were excluded from analyses of neonatal outcomes. RESULTS In this study, 157 (83%) LCDH and 32 (17%) RCDH cases were identified. Survival to discharge was similar (64 vs. 66.4%, p = 0.49) with regard to laterality. RCDH had higher rates of liver herniation (90.6 vs. 72%, p = 0.03), hydrops fetalis (15.6 vs. 1.3%, p < 0.01), and lower LHR (0.87 vs. 0.99, p = 0.04). LCDH had higher rates of stomach herniation (69.4 vs. 12.5%, p < 0.01). Rates of other outcomes were similar in univariate analyses. Adjusting for microarray abnormalities, the odds for survival to discharge for RCDH compared with LCDH was 0.93 (0.38-2.30, p = 0.88). CONCLUSION Compared with LCDH, fetuses with RCDH had higher rates of adverse ultrasound predictors, but equivalent survival.
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Affiliation(s)
- Jeffrey D. Sperling
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California,Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Teresa N. Sparks
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California,Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Victoria K. Berger
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California,Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Jody A. Farrell
- Division of Pediatric Surgery, Department of Surgery, Fetal Treatment Center, University of California, San Francisco, San Francisco, California
| | - Kristen Gosnell
- Division of Pediatric Surgery, Department of Surgery, Fetal Treatment Center, University of California, San Francisco, San Francisco, California
| | - Roberta L. Keller
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Mary E. Norton
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California,Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Juan M. Gonzalez
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California,Department of Pediatrics, University of California, San Francisco, San Francisco, California
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13
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Abstract
In congenital diaphragmatic hernia (CDH), herniation of the abdominal organs into the fetal chest causes pulmonary hypoplasia and pulmonary hypertension, the main causes of neonatal mortality. As antenatal ultrasound screening improves, the risk of postnatal death can now be better predicted, allowing for the identification of fetuses that might most benefit from a prenatal intervention. Fetoscopic tracheal occlusion is being evaluated in a large international randomized controlled trial. We present the antenatal imaging approaches that can help identify fetuses that might benefit from antenatal therapy, and review the evolution of fetal surgery for CDH to date.
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Affiliation(s)
- Titilayo Oluyomi-Obi
- Section of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, University of Calgary, 1403 29 Street NW, Calgary, Alberta.
| | - Tim Van Mieghem
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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14
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Morgan TA, Shum DJ, Basta AM, Filly RA. Prognosis in Congenital Diaphragmatic Hernia Diagnosed During Fetal Life. JOURNAL OF FETAL MEDICINE 2017. [DOI: 10.1007/s40556-017-0124-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Basta AM, Lusk LA, Keller RL, Filly RA. Spleen Behind the Heart Complicates Lung-to-Head Ratio Measurement in Left-Sided Congenital Diaphragmatic Hernia. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:2717-2721. [PMID: 27872422 DOI: 10.7863/ultra.15.11063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 12/23/2015] [Accepted: 02/26/2015] [Indexed: 06/06/2023]
Abstract
In fetuses with left-sided congenital diaphragmatic hernia, intrathoracic herniation of the spleen is a common occurrence. The herniated spleen can reside posterior to the left atrium of the heart in the right hemithorax and is increasingly differentiated from the lung with the use of newer sonographic equipment. Estimation of the neonatal prognosis relies on accurate measurement of fetal lung size, particularly with commonly used measurements such as the lung-to-head ratio. Here we describe how herniation of the spleen behind the heart can complicate measurement of the lung-to-head ratio on sonography and lead to overestimation, with implications for perinatal prognostication and management.
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Affiliation(s)
- Amaya M Basta
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, Medical Center, San Francisco, California USA
| | - Leslie A Lusk
- Department of Pediatrics, Division of Neonatology, University of California, San Francisco, Benioff Children's Hospital, San Francisco, California USA
| | - Roberta L Keller
- Department of Pediatrics, Division of Neonatology, University of California, San Francisco, Benioff Children's Hospital, San Francisco, California USA
- University of California, San Francisco, Fetal Treatment Center, San Francisco, California USA
| | - Roy A Filly
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, Medical Center, San Francisco, California USA
- University of California, San Francisco, Fetal Treatment Center, San Francisco, California USA
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Byrne FA, Keller RL, Meadows J, Miniati D, Brook MM, Silverman NH, Moon-Grady AJ. Severe left diaphragmatic hernia limits size of fetal left heart more than does right diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:688-694. [PMID: 25597867 DOI: 10.1002/uog.14790] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Revised: 12/05/2014] [Accepted: 01/12/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To assess whether severity of congenital diaphragmatic hernia (CDH) correlates with the degree of left heart hypoplasia and left ventricle (LV) output, and to determine if factors leading to abnormal fetal hemodynamics, such as compression and reduced LV preload, contribute to left heart hypoplasia. METHODS This was a retrospective cross-sectional study of fetuses at 16-37 weeks' gestation that were diagnosed with CDH between 2000 and 2010. Lung-to-head ratio (LHR), liver position and side of the hernia were determined from stored ultrasound images. CDH severity was dichotomized based on LHR and liver position. The dimensions of mitral (MV) and aortic (AV) valves and LV were measured, and right and left ventricular outputs were recorded. RESULTS In total, 188 fetuses with CDH were included in the study, 171 with left CDH and 17 with right CDH. Fetuses with severe left CDH had a smaller MV (Z = -2.24 ± 1.3 vs -1.33 ± 1.08), AV (Z = -1.39 ± 1.21 vs -0.51 ± 1.05) and LV volume (Z = -4.23 ± -2.71 vs -2.08 ± 3.15) and had lower LV output (26 ± 10% vs 32 ± 10%) than those with mild CDH. MV and AV in fetuses with right CDH (MV, Z = -0.83 ± 1.19 and AV, Z = -0.71 ± 1.07) were larger than those in fetuses with left CDH, but LV outputs were similarly diminished, regardless of hernia side. Severe dextroposition and abnormal liver position were associated independently with smaller left heart, while LHR was not. CONCLUSION The severity of left heart hypoplasia correlates with the severity of CDH. Altered fetal hemodynamics, leading to decreased LV output, occurs in both right- and left-sided CDH, but the additional compressive effect on the left heart is seen only when the hernia is left-sided. Improved knowledge of the physiology of this disease may lead to advances in therapy and better risk assessment for use in counseling affected families.
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Affiliation(s)
- F A Byrne
- Department of Pediatrics, Divisions of Cardiology, University of California, Benioff Children's Hospital, San Francisco, CA, USA
| | - R L Keller
- Department of Pediatrics, Division of Neonatology, University of California, Benioff Children's Hospital, San Francisco, CA, USA
| | - J Meadows
- Department of Pediatrics, Divisions of Cardiology, University of California, Benioff Children's Hospital, San Francisco, CA, USA
| | - D Miniati
- Department of Surgery, Division of Pediatric Surgery, University of California, San Francisco, CA, USA
- Fetal Treatment Center, University of California, San Francisco, CA, USA
| | - M M Brook
- Department of Pediatrics, Divisions of Cardiology, University of California, Benioff Children's Hospital, San Francisco, CA, USA
| | - N H Silverman
- Department of Pediatrics, Divisions of Cardiology, University of California, Benioff Children's Hospital, San Francisco, CA, USA
| | - A J Moon-Grady
- Department of Pediatrics, Divisions of Cardiology, University of California, Benioff Children's Hospital, San Francisco, CA, USA
- Fetal Treatment Center, University of California, San Francisco, CA, USA
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Basta AM, Lusk LA, Keller RL, Filly RA. Fetal Stomach Position Predicts Neonatal Outcomes in Isolated Left-Sided Congenital Diaphragmatic Hernia. Fetal Diagn Ther 2015; 39:248-55. [PMID: 26562540 DOI: 10.1159/000440649] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 08/25/2015] [Indexed: 12/30/2022]
Abstract
INTRODUCTION We sought to determine the relationship between the degree of stomach herniation by antenatal sonography and neonatal outcomes in fetuses with isolated left-sided congenital diaphragmatic hernia (CDH). MATERIALS AND METHODS We retrospectively reviewed neonatal medical records and antenatal sonography of fetuses with isolated left CDH cared for at a single institution (2000-2012). Fetal stomach position was classified on sonography as follows: intra-abdominal, anterior left chest, mid-to-posterior left chest, or retrocardiac (right chest). RESULTS Ninety fetuses were included with 70% surviving to neonatal discharge. Stomach position was intra-abdominal in 14% (n = 13), anterior left chest in 19% (n = 17), mid-to-posterior left chest in 41% (n = 37), and retrocardiac in 26% (n = 23). Increasingly abnormal stomach position was linearly associated with an increased odds of death (OR 4.8, 95% CI 2.1-10.9), extracorporeal membrane oxygenation (ECMO; OR 5.6, 95% CI 1.9-16.7), nonprimary diaphragmatic repair (OR 2.7, 95% CI 1.4-5.5), prolonged mechanical ventilation (OR 5.9, 95% CI 2.3-15.6), and prolonged respiratory support (OR 4.0, 95% CI 1.6-9.9). All fetuses with intra-abdominal stomach position survived without substantial respiratory morbidity or need for ECMO. DISCUSSION Fetal stomach position is strongly associated with neonatal outcomes in isolated left CDH. This objective tool may allow for accurate prognostication in a variety of clinical settings.
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Affiliation(s)
- Amaya M Basta
- Department of Diagnostic Radiology, Oregon Health and Science University, Portland, Oreg., USA
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18
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Cordier AG, Jani JC, Cannie MM, Rodó C, Fabietti I, Persico N, Saada J, Carreras E, Senat MV, Benachi A. Stomach position in prediction of survival in left-sided congenital diaphragmatic hernia with or without fetoscopic endoluminal tracheal occlusion. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:155-161. [PMID: 25487417 DOI: 10.1002/uog.14759] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 12/02/2014] [Accepted: 12/04/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To investigate the value of fetal stomach position in predicting postnatal outcome in left-sided congenital diaphragmatic hernia (CDH) with and without fetoscopic endoluminal tracheal occlusion (FETO). METHODS This was a retrospective review of CDH cases that were expectantly managed or treated with FETO, assessed from May 2008 to October 2013, in which we graded, on a scale of 1-4, stomach position on the four-chamber view of the heart with respect to thoracic structures. Logistic regression analysis was used to investigate the effect of management center (Paris, Brussels, Barcelona, Milan), stomach grading, observed-to-expected lung area-to-head circumference ratio (O/E-LHR), gestational age at delivery, birth weight in expectantly managed CDH, gestational ages at FETO and at removal and period of tracheal occlusion, on postnatal survival in CDH cases treated with FETO. RESULTS We identified 67 expectantly managed CDH cases and 47 CDH cases that were treated with FETO. In expectantly managed CDH, stomach position and O/E-LHR predicted postnatal survival independently. In CDH treated with FETO, stomach position and gestational age at delivery predicted postnatal survival independently. CONCLUSION In left-sided CDH with or without FETO, stomach position is predictive of postnatal survival.
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Affiliation(s)
- A-G Cordier
- Department of Obstetrics, Gynaecology and Reproductive Medicine and Centre Maladies Rares: Hernie de Coupole Diaphragmatique, Hospital Antoine Beclere, APHP, Paris Sud University, Clamart, Paris, France
| | - J C Jani
- Department of Obstetrics and Gynaecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - M M Cannie
- Department of Radiology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
- Department of Radiology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - C Rodó
- Department of Obstetrics, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - I Fabietti
- Department of Obstetrics and Gynecology 'L. Mangiagalli', Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - N Persico
- Department of Obstetrics and Gynecology 'L. Mangiagalli', Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - J Saada
- Department of Obstetrics, Gynaecology and Reproductive Medicine and Centre Maladies Rares: Hernie de Coupole Diaphragmatique, Hospital Antoine Beclere, APHP, Paris Sud University, Clamart, Paris, France
| | - E Carreras
- Department of Obstetrics, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - M-V Senat
- Department of Obstetrics and Gynaecology, Hospital Bicêtre, APHP, Paris Sud University, Kremlin Bicêtre, Paris, France
| | - A Benachi
- Department of Obstetrics, Gynaecology and Reproductive Medicine and Centre Maladies Rares: Hernie de Coupole Diaphragmatique, Hospital Antoine Beclere, APHP, Paris Sud University, Clamart, Paris, France
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Ruano R, Britto ISW, Sangi-Haghpeykar H, Bussamra LCS, Da Silva MM, Belfort MA, Deter RL, Lee W, Tannuri U, Zugaib M. Longitudinal assessment of lung area measurements by two-dimensional ultrasound in fetuses with isolated left-sided congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:566-571. [PMID: 24862641 DOI: 10.1002/uog.13420] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 05/10/2014] [Accepted: 05/16/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate lung growth in healthy fetuses and those with congenital diaphragmatic hernia (CDH) using two-dimensional (2D) ultrasound. METHODS Fetal right lung measurements obtained by 2D ultrasound between 19 and 37 weeks' gestation were evaluated longitudinally in 66 healthy fetuses and 52 fetuses with isolated left-sided CDH. Right lung areas were determined by the 'tracing' and 'longest-diameters' methods and, subsequently, lung area-to-head circumference ratios (LHRs) were calculated. Functions fitted to these size parameters with respect to gestational age were evaluated for three sets of group-wise comparisons: (1) healthy vs CDH fetuses; (2) different degrees of severity of CDH; and (3) CDH fetuses that survived vs those that died by 6 months postpartum. RESULTS There was a significantly slower increase in right lung areas and LHRs with advancing gestational age in CDH fetuses than in healthy individuals (P < 0.05). Compared to those with milder forms of CDH, lung areas and LHRs of fetuses with more severe forms displayed a smaller increase (P < 0.05) and LHRs of fetuses with severe CDH did not increase during pregnancy (P > 0.05). Individuals who died postpartum did not show any increase in LHR (P > 0.05) throughout gestation. CONCLUSIONS The right lung area and LHR, calculated using either the longest-diameters or tracing method, display reduced growth rates during gestation in cases of isolated left-sided CDH as compared with healthy fetuses. The growth curve characteristics of fetal lung areas and LHRs may be useful for predicting neonatal mortality.
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Affiliation(s)
- R Ruano
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, TX, USA; Department of Obstetrics and Gynecology, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
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Abstract
Over the past 20 years, prenatal detection of congenital diaphragmatic hernia (CDH) has improved worldwide, reaching up to 60% in Europe. Pulmonary hypoplasia and persistent pulmonary hypertension are the two main determinants of neonatal mortality and morbidity, so new tools have been focused on their evaluation. Fetal surgery for severe cases requires proper evaluation of the prognosis of fetuses with CDH. Observed-to-expected lung-to-head ratio, liver position, and total lung volume measured by magnetic resonance are the prognostic factors most often used, and have been shown to correlate not only with neonatal mortality but also with morbidity. In daily practice, pulmonary hypertension by itself, although most often associated with lung hypoplasia, is more difficult to predict.
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MRI-based ratio of fetal lung volume to fetal body volume as a new prognostic marker in congenital diaphragmatic hernia. AJR Am J Roentgenol 2014; 202:1330-6. [PMID: 24848832 DOI: 10.2214/ajr.13.11023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of our study was to evaluate the prognostic accuracy of the MRI-based ratio of fetal lung volume (FLV) to fetal body volume (FBV) for predicting survival and the need for extracorporeal membrane oxygenation (ECMO) therapy in fetuses with congenital diaphragmatic hernia (CDH). MATERIALS AND METHODS MRI was performed in 96 fetuses (34 females and 62 males; mean gestational age, 33 ± 5 [SD] weeks; range, 23-39 weeks) with CDH and 44 healthy control subjects. FLV and FBV were measured for each fetus by one of three investigators, and we calculated the FLV/FBV ratio. Additionally, a subgroup analysis of growth-restricted fetuses was performed. Logistic regression analysis was used to model the dependence of survival and ECMO requirement on the FLV/FBV ratio. Prognostic accuracy was evaluated by applying the area under the curve (AUC). RESULTS Seventy-eight of the 96 (81%) fetuses survived and 35 (36%) neonates needed ECMO therapy. The FLV/FBV ratio was significantly higher in fetuses who survived (p < 0.0001; AUC = 0.829). Neonates who received ECMO therapy showed a significantly lower prenatal FLV/FBV ratio (p = 0.0001; AUC = 0.811) than neonates who did not need ECMO therapy. A subgroup analysis (n = 13) showed a trend toward a higher FLV/FBV ratio of survivors in comparison with nonsurvivors (p = 0.065; AUC = 0.875). CONCLUSION In our study, the MRI-based FLV/FBV ratio was able to predict neonatal survival and ECMO requirement in children with CDH with high accuracy. Unlike other prognostic parameters, FLV/FBV ratio is independent of a reference to a control group and may enhance prognostic accuracy particularly in growth-restricted neonatal patients.
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22
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Cordier AG, Cannie MM, Guilbaud L, De Laveaucoupet J, Martinovic J, Nowakowska D, Milejska-Lewandowska M, Rodó C, Viaris de Lesegno B, Votino C, Senat MV, Jani JC, Benachi A. Stomach position versus liver-to-thoracic volume ratio in left-sided congenital diaphragmatic hernia. J Matern Fetal Neonatal Med 2014; 28:190-5. [DOI: 10.3109/14767058.2014.906576] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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23
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Alves da Rocha L, Byrne FA, Keller RL, Miniati D, Brook MM, Silverman NH, Moon-Grady AJ. Left Heart Structures in Human Neonates with Congenital Diaphragmatic Hernia and the Effect of Fetal Endoscopic Tracheal Occlusion. Fetal Diagn Ther 2013; 35:36-43. [DOI: 10.1159/000356437] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 10/13/2013] [Indexed: 11/19/2022]
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Another dimension to survival: predicting outcomes with fetal MRI versus prenatal ultrasound in patients with congenital diaphragmatic hernia. J Pediatr Surg 2013; 48:1190-7. [PMID: 23845606 PMCID: PMC7183370 DOI: 10.1016/j.jpedsurg.2013.03.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Accepted: 03/09/2013] [Indexed: 11/24/2022]
Abstract
PURPOSE A major determinant of survival in patients with congenital diaphragmatic hernia (CDH) is severity of pulmonary hypoplasia. This study addresses the comparative effectiveness of prenatal methods of lung assessment in predicting mortality, extracorporeal membrane oxygenation (ECMO), and ventilator dependency. METHODS We retrospectively reviewed all patients born with isolated CDH between 2004 and 2008. Lung-to-head ratio (LHR) and observed-to-expected LHR (OELHR) were obtained from prenatal ultrasounds. Percent-predicted lung volume (PPLV) was obtained from fetal MRI (fMRI). Postnatal data included in-hospital mortality, need for ECMO, and ventilator dependency at day-of-life 30. RESULTS Thirty-seven patients underwent 81 prenatal ultrasounds, while 26 of this sub-cohort underwent fMRI. Gestational age during imaging study was associated with LHR (p=0.02), but not OELHR (p=0.12) or PPLV (p=0.72). PPLV, min-LHR, and min-OELHR were each associated with mortality (p=0.03, p=0.02, p=0.01), ECMO (p<0.01, p<0.01, p=0.03), and ventilator dependency (p<0.01, p<0.01, p=0.02). For each outcome, PPLV was a more discriminative measure, based on Akaike's information criterion. Using longitudinal analysis techniques for patients with multiple ultrasounds, OELHR remained associated with mortality (p=0.04), ECMO (p=0.03), and ventilator dependency (p=0.02), while LHR was associated with ECMO (p=0.01) and ventilator dependency (p=0.02) but not mortality (p=0.06). CONCLUSION When assessing fetuses with CDH, OELHR and PPLV may be most helpful for counseling regarding postnatal outcomes.
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25
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Garcia AV, Fingeret AL, Thirumoorthi AS, Hahn E, Leskowitz MJ, Aspelund G, Krishnan US, Stolar CJH. Lung to head ratio in infants with congenital diaphragmatic hernia does not predict long term pulmonary hypertension. J Pediatr Surg 2013; 48:154-7. [PMID: 23331808 DOI: 10.1016/j.jpedsurg.2012.10.031] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 10/13/2012] [Indexed: 11/18/2022]
Abstract
PURPOSE Lung-to-head ratio (LHR) has been used for antenatal evaluation of infants with congenital diaphragmatic hernia (CDH). We hypothesized that LHR was predictive of acute and chronic pulmonary hypertension in infants with CDH. METHODS Echocardiograms on all inborn infants with CDH (December 2001-March 2011) were reviewed. Echocardiograms at 1 and 3 months post-repair and most recent follow-up were assessed for presence of pulmonary hypertension (PAH). LHR, gestational age, birth weight, extracorporeal membrane oxygenation (ECMO), and death rate were obtained. Bivariate and multivariate analyses were performed. RESULTS 106 infants with CDH had LHR obtained at median 28 weeks gestation (median LHR=1.25 [range 0.4-5.3]). Median follow-up was 26.6 months (range 4.6-97.5). The long-term incidence of pulmonary hypertension was 16%. LHR was significantly associated with pulmonary hypertension at one month (p=0.0001) but not at 3 months (p=0.22) or long-term (p=0.54). LHR was predictive of ECMO use (p=0.01) and death (p=0.001). CONCLUSIONS The overall incidence of PAH in infants with CDH decreases over time. Prenatal LHR predicts PAH at one month but not long-term in infants with CDH. The ability for LHR to predict PAH at one month but not long term may suggest remodeling of the pulmonary vasculature over time.
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MESH Headings
- Acute Disease
- Child
- Child, Preschool
- Chronic Disease
- Female
- Follow-Up Studies
- Head/diagnostic imaging
- Head/embryology
- Hernia, Diaphragmatic/complications
- Hernia, Diaphragmatic/diagnostic imaging
- Hernia, Diaphragmatic/mortality
- Hernia, Diaphragmatic/surgery
- Hernias, Diaphragmatic, Congenital
- Herniorrhaphy
- Humans
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/diagnostic imaging
- Hypertension, Pulmonary/epidemiology
- Hypertension, Pulmonary/etiology
- Incidence
- Infant
- Infant, Newborn
- Logistic Models
- Lung/diagnostic imaging
- Lung/embryology
- Multivariate Analysis
- Pregnancy
- Prognosis
- Retrospective Studies
- Ultrasonography, Prenatal
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Affiliation(s)
- Alejandro V Garcia
- Department of Surgery, Division of Pediatric Surgery, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY 10032, USA.
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Lava JR, Hettwer GA, Reginatto CJ, Galoro G, Gehlen CT, Subtil MC, Valenti VE, Deabreu LC, de Mello Monteiro CB, Petenusso M. Congenital diaphragmatic Bochdaleck hernia: case report. Int Arch Med 2012; 5:30. [PMID: 23110948 PMCID: PMC3549796 DOI: 10.1186/1755-7682-5-30] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 10/16/2012] [Indexed: 11/10/2022] Open
Abstract
Congenital diaphragmatic Bochdaleck hernia is an anatomical defect of the diaphragm, which allows protrusion of abdominal viscera into the chest, causing serious pulmonary and cardiac complications in the neonate. In this study we aimed to present a case of congenital Bochdaleck hernia. We investigated a 40 weeks old child, with a pregnancy carried out in a public hospital in Passo Fundo, Rio Grande do Sul, Brazil. We suggest that if diagnosis occurs in the prenatal period, the prognosis of this disease improves. As a consequence, it allows the parity of the fetus to occur in a higher complexity center, optimizing the chances of survival.
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Affiliation(s)
- Jamile Rizzardi Lava
- Departamento de Medicina, Universidade do Planalto Catarinense, Avenida Castelo Branco, Lages, SC, 88509-900, Brazil.
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27
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Britto ISW, Tedesco GD, Herbst SRS, Bussamra LCS, de Andrade FM, Araujo Júnior E, Nardozza LMM, Ruano R, Moron AF, Aoki T. New anatomical landmarks to study the relationship between fetal lung area and thoracic circumference by three-dimensional ultrasonography. J Matern Fetal Neonatal Med 2012; 25:1927-32. [PMID: 22372878 DOI: 10.3109/14767058.2012.667176] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the relation between total lung area (TLA) and thoracic circumference (TC) ratio by three-dimensional (3D) ultrasonography applying new anatomical landmarks as the fetal aorta and inferior angle of the scapula. METHODS A longitudinal prospective study was conducted with 56 uncomplicated pregnancies between 24 and 32 weeks of gestation. Polynomial regressions were used to evaluate the correlation between TC and gestational age (GA) as well as TC and estimated fetal weight (EFW). A simple linear regression was used to evaluate the correlation between TLA and Total thoracic area (TTA) and GA. The intraclass correlation coefficient (ICC) was used to assess the intra and interobserver variability. RESULTS 127 examinations were performed. TC values ranged from 150 to 174 mm (mean 166 mm) at 24 weeks and 215-248 mm (mean 231 mm) at 32 weeks. The TLA/TC ratio ranged from a mean of 0.64 at 24 weeks (range 0.56-0.70) to 0.90 at 32 weeks gestation (range 0.79-1.01). The intraobserver variability using the ICC was of 0.919 for TC; 0.916 for TTA; 0.860 for right lung area (RLA) and 0.910 for left lung area (LLA). Interobserver reproducibility was with an ICC of 0.970 for TC; 0.984 for RLA and 0.910 for LLA. CONCLUSIONS Measurement of fetal TC and the relationship between TLA and TC by 3D-ultrasonography applying new anatomical landmarks shows good reproducibility and allows a new assessment of thoracic and lung growth.
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Affiliation(s)
- Ingrid Schwach Werneck Britto
- Department of Obstetrics and Gynecology, Medical Science College of Santa Casa of São Paulo (FCMSCSP), São Paulo, SP, Brazil
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Kline-Fath BM. Current advances in prenatal imaging of congenital diaphragmatic [corrected] hernia. Pediatr Radiol 2012; 42 Suppl 1:S74-90. [PMID: 21739292 DOI: 10.1007/s00247-011-2183-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 03/22/2011] [Accepted: 03/31/2011] [Indexed: 11/29/2022]
Abstract
Congenital diaphragmatic hernia, despite advances in therapy, remains a complex condition with significant morbidity and mortality. The etiology of the disorder is still incompletely understood, though the pulmonary hypoplasia and pulmonary hypertension that develop secondarily must be overcome to improve survival. Prenatal US and fetal MRI have helped in the development of a greater understanding of this disease. Also with these modalities, measurement techniques have been developed in an attempt to provide prognosticators for the development of pulmonary hypoplasia and pulmonary hypertension. There is a broad range of approaches for performing these measurements, and variability among imaging centers is noted. Despite inconsistent approaches, these techniques have become the foundation for counseling and prenatal and postnatal therapy. It is hoped that with further research with prenatal US and fetal MRI and the development of innovative medical and surgical therapies that the morbidity and mortality of children with congenital diaphragmatic hernias can be significantly reduced.
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Affiliation(s)
- Beth M Kline-Fath
- Department of Radiology, Fetal Care Center of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
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Jani JC, Nicolaides KH. Fetal surgery for severe congenital diaphragmatic hernia? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 39:7-9. [PMID: 22213616 DOI: 10.1002/uog.11064] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- J C Jani
- Fetal Medicine Unit of the University Hospital Brugmann, Brussels, Belgium.
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Jani JC, Peralta CFA, Nicolaides KH. Lung-to-head ratio: a need to unify the technique. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 39:2-6. [PMID: 22213615 DOI: 10.1002/uog.11065] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Quintero RA, Quintero LF, Chmait R, Gómez Castro L, Korst LM, Fridman M, Kontopoulos EV. The quantitative lung index (QLI): a gestational age-independent sonographic predictor of fetal lung growth. Am J Obstet Gynecol 2011; 205:544.e1-8. [PMID: 21944224 DOI: 10.1016/j.ajog.2011.07.031] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 07/08/2011] [Accepted: 07/16/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE We sought to develop a gestational age-independent sonographic parameter to characterize lung growth. STUDY DESIGN Reported descriptors of lung growth, including lung-to-head circumference (HC) ratio (LHR) and observed/expected LHR, were examined. A new index, the quantitative lung index (QLI) was derived using published data on HC and the area of the base of the right lung. RESULTS Neither the LHR nor the observed/expected LHR proved to be gestational age independent. Right lung growth can be expressed using the following formula: QLI = lung area/(HC/10)^2. The 50th percentile of the QLI remained constant at approximately 1.0 for the gestational age between 16-32 weeks. A small lung (<1st percentile) was defined as a QLI <0.6. CONCLUSION Fetal right lung growth can be adequately described using the QLI, independent of gestational age. Further studies are needed to assess the clinical accuracy of the QLI in characterizing fetal right lung growth.
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Aspelund G, Fisher JC, Simpson LL, Stolar CJH. Prenatal lung-head ratio: threshold to predict outcome for congenital diaphragmatic hernia. J Matern Fetal Neonatal Med 2011; 25:1011-6. [PMID: 21815746 DOI: 10.3109/14767058.2011.608442] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The literature suggests that lung-head ratio (LHR) and liver position may inconsistently predict outcome for congenital diaphragmatic hernia (CDH). We reviewed our inborn neonates with isolated left-sided CDH to determine whether these variables predicted survival and to estimate the optimal LHR threshold. METHODS Prenatal LHR and liver position were obtained from 2002 to 2009. The primary endpoint was survival. RESULTS LHR was greater in survivors after adjusting for gestational age (median 1.40 versus 0.81; p < 0.001). LHR demonstrated excellent diagnostic discrimination, with area under receiver operating characteristic (ROC) curve 0.93 (95% CI 0.86-0.99). LHR threshold of 1.0 was 83% sensitive and 91% specific in predicting survival. An optimal LHR threshold of 0.85 predicted survival with 95% sensitivity and 64% specificity, reducing false negatives (survivors with low LHR). LHR > 0.85 predicted survival after adjustment for gestational age (OR = 33.6, 95% CI = 5.4-209.5). Liver position did not predict survival. CONCLUSIONS Prenatal LHR >0.85 predicts survival for infants with isolated left-sided CDH without compromising discrimination of survivors from non-survivors. The diagnostic utility of LHR may be confounded by gestational age at measurement. Stringent LHR threshold may minimize false-negative attribution and improve utility of this measurement as predictor of survival.
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Affiliation(s)
- Gudrun Aspelund
- Division of Pediatric Surgery, Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia University Medical Center, New York, NY 10032, USA.
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Brindle ME, Brar M, Skarsgard ED. Patch repair is an independent predictor of morbidity and mortality in congenital diaphragmatic hernia. Pediatr Surg Int 2011; 27:969-74. [PMID: 21590477 DOI: 10.1007/s00383-011-2925-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Infants with congenital diaphragmatic hernia (CDH) have variable outcomes. There is a considerable potential benefit in being able to predict perinatally, which infants have severe hypoplasia and are thus more likely to die or survive with significant morbidity. We examine the relationship between a need for patch repair of CDH (PR) and outcome, using a national database. METHODS Baseline characteristics of patients undergoing PR or non-patch repair (NPR) were compared. Multivariate analysis was performed to determine the association of PR with mortality and morbidity independent of other known predictors. RESULTS Baseline characteristics of PR and NPR infants were similar although those infants with PR had higher SNAP-II scores. PR was an independent predictor of mortality with an odds ratio of 17.1 (95%CI 2.0-149.2) and was independently associated with secondary outcome measures of morbidity, including the need for oxygen at discharge and the duration of ventilation. CONCLUSIONS Infants requiring PR have significantly higher mortality and suffer greater morbidity than those undergoing NPR. This association is independent of other known predictors of mortality. Identifying prenatal features associated with this high risk group would be of great clinical value.
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Alfaraj MA, Shah PS, Bohn D, Pantazi S, O'Brien K, Chiu PP, Gaiteiro R, Ryan G. Congenital diaphragmatic hernia: lung-to-head ratio and lung volume for prediction of outcome. Am J Obstet Gynecol 2011; 205:43.e1-8. [PMID: 21529758 DOI: 10.1016/j.ajog.2011.02.050] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Revised: 12/02/2010] [Accepted: 02/14/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate observed/expected (O/E) lung-to-head ratio (LHR) by ultrasound (US) and total fetal lung volume (TFLV) by magnetic resonance imaging as neonatal outcome predictors in isolated fetal congenital diaphragmatic hernia (CDH). STUDY DESIGN We conducted a retrospective study of 72 fetuses with isolated CDH, in whom O/E LHR and TFLV were evaluated as survival predictors. RESULTS O/E LHR on US and O/E TFLV by magnetic resonance imaging were significantly lower in newborn infants with isolated CDH who died compared with survivors (30.3 ± 8.3 vs 44.2 ± 14.2; P < .0001 for O/E LHR; 21.9 ± 6.3 vs 41.5 ± 17.6; P = .001 for O/E TFLV). Area under receiver-operator characteristics curve for survival for O/E LHR was 0.80 (95% confidence interval, 0.70-0.90). On multivariate analysis, O/E LHR predicted survival, whereas hernia side and first neonatal pH did not. For each unit increase in O/E LHR, mortality odds decreased by 11% (95% confidence interval, 4-17%). CONCLUSION In fetuses with isolated CDH, O/E LHR (US) independently predicts survival and may predict severity, allowing management to be optimized.
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Lee TC, Lim FY, Keswani SG, Frischer JS, Haberman B, Kingma PS, Habli M, Jaekle RK, Sharp G, Kline-Fath B, Rubio EI, Calvo M, Guimaraes C, Crombleholme TM. Late gestation fetal magnetic resonance imaging-derived total lung volume predicts postnatal survival and need for extracorporeal membrane oxygenation support in isolated congenital diaphragmatic hernia. J Pediatr Surg 2011; 46:1165-71. [PMID: 21683216 PMCID: PMC3870885 DOI: 10.1016/j.jpedsurg.2011.03.046] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2011] [Accepted: 03/26/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Magnetic resonance imaging (MRI) has been used as an imaging modality to assess pulmonary hypoplasia in congenital diaphragmatic hernias (CDHs). The objective of this study was to determine if there is a correlation between late gestational fetal MRI-derived total lung volumes (TLVs) and CDH outcomes. METHODS From 2006 to 2009, 44 patients met criteria of an isolated CDH with a late gestational MRI evaluation. The prenatal TLV (in milliliters) was obtained between 32 and 34 weeks gestation. The measured study outcomes included survival, need for extracorporeal membrane oxygenation (ECMO), and length of stay. RESULTS There were 39 left and 5 right CDH patients. The average TLV was significantly lower for nonsurvivors (P = .01), and there was a significant association between lower TLV and the need for ECMO (P = .0001). When stratified by TLV, patients with a TLV of greater than 40 mL had a 90% survival vs 35% survival for a TLV of less than 20 mL. Furthermore, patients with a TLV greater than 40 mL had a lower rate of ECMO use (10%) than patients with a TLV of less than 20 mL (86%). Shorter length of stay was found to correlate with increasing TLV (P = .022). CONCLUSION Late gestation fetal MRI-derived TLV significantly correlates with postnatal survival and need for ECMO. Fetal MRI may be useful for the evaluation of patients who present late in gestation with a CDH.
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Affiliation(s)
- Timothy C. Lee
- The CDH Team, Division of Pediatric General, Thoracic and Fetal Surgery, Cincinnati Children's Hospital, Cincinnati, OH 45229-3039, USA
| | - Foong Y. Lim
- The CDH Team, Division of Pediatric General, Thoracic and Fetal Surgery, Cincinnati Children's Hospital, Cincinnati, OH 45229-3039, USA
| | - Sundeep G. Keswani
- The CDH Team, Division of Pediatric General, Thoracic and Fetal Surgery, Cincinnati Children's Hospital, Cincinnati, OH 45229-3039, USA
| | - Jason S. Frischer
- The CDH Team, Division of Pediatric General, Thoracic and Fetal Surgery, Cincinnati Children's Hospital, Cincinnati, OH 45229-3039, USA
| | - Beth Haberman
- Division of Neonatology, Cincinnati Children's Hospital, Cincinnati, OH 45229-3039, USA
| | - Paul S. Kingma
- Division of Neonatology, Cincinnati Children's Hospital, Cincinnati, OH 45229-3039, USA
| | - Mounira Habli
- Divisions of Maternal-Fetal Medicine, Good Samaritan Hospital and University Hospital, Cincinnati, OH 45229-3039, USA
| | - Ronald K. Jaekle
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, OH 45229-3039, USA
| | - Gina Sharp
- The CDH Team, Division of Pediatric General, Thoracic and Fetal Surgery, Cincinnati Children's Hospital, Cincinnati, OH 45229-3039, USA
| | - Beth Kline-Fath
- Division of Radiology, Cincinnati Children's Hospital, Cincinnati, OH 45229-3039, USA
| | - Eva I. Rubio
- Division of Radiology, Cincinnati Children's Hospital, Cincinnati, OH 45229-3039, USA
| | - Maria Calvo
- Division of Radiology, Cincinnati Children's Hospital, Cincinnati, OH 45229-3039, USA
| | - Carolina Guimaraes
- Division of Radiology, Cincinnati Children's Hospital, Cincinnati, OH 45229-3039, USA
| | - Timothy M. Crombleholme
- The CDH Team, Division of Pediatric General, Thoracic and Fetal Surgery, Cincinnati Children's Hospital, Cincinnati, OH 45229-3039, USA,Corresponding author. The Fetal Care Center of Cincinnati, Division of Pediatric General, Thoracic, and Fetal Surgery, Cincinnati Children’s Hospital, Cincinnati, OH 45229-3039, USA. Tel.: +1 513 636 6259; fax: +1 513 636 5959. (T.M. Crombleholme)
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Lazar DA, Cass DL, Rodriguez MA, Hassan SF, Cassady CI, Johnson YR, Johnson KE, Johnson A, Moise KJ, Belleza-Bascon B, Olutoye OO. Impact of prenatal evaluation and protocol-based perinatal management on congenital diaphragmatic hernia outcomes. J Pediatr Surg 2011; 46:808-13. [PMID: 21616231 DOI: 10.1016/j.jpedsurg.2011.02.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 02/11/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND/PURPOSE Although intuitive, the benefit of prenatal evaluation and multidisciplinary perinatal management for fetuses with congenital diaphragmatic hernia (CDH) is unproven. We compared the outcome of prenatally diagnosed patients with CDH whose perinatal management was by a predefined protocol with those who were diagnosed postnatally and managed by the same team. We hypothesized that patients with CDH undergoing prenatal evaluation with perinatal planning would demonstrate improved outcome. METHODS Retrospective chart review of all patients with Bochdalek-type CDH at a single institution between 2004 and 2009 was performed. Patients were stratified by history of perinatal management, and data were analyzed by Fisher's Exact test and Student's t test. RESULTS Of 116 patients, 71 fetuses presented in the prenatal period and delivered at our facility (PRE), whereas 45 infants were either outborn or postnatally diagnosed (POST). There were more high-risk patients in the PRE group compared with the POST group as indicated by higher rates of liver herniation (63% vs 36%, P = .03), need for patch repair (57% vs 27%, P = .004), and extracorporeal membrane oxygenation use (35% vs 18%, P = .05). Despite differences in risk, there was no difference in 6-month survival between groups (73% vs 73%). CONCLUSIONS Patients with CDH diagnosed prenatally are a higher risk group. Prenatal evaluation and multidisciplinary perinatal management allows for improved outcome in these patients.
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MESH Headings
- Clinical Protocols
- Comorbidity
- Counseling
- Delivery, Obstetric/statistics & numerical data
- Disease Management
- Extracorporeal Membrane Oxygenation/statistics & numerical data
- Hernia, Diaphragmatic/complications
- Hernia, Diaphragmatic/diagnosis
- Hernia, Diaphragmatic/embryology
- Hernia, Diaphragmatic/mortality
- Hernia, Diaphragmatic/surgery
- Hernias, Diaphragmatic, Congenital
- Hospitals, Pediatric/statistics & numerical data
- Humans
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/therapy
- Infant, Newborn
- Patient Care Team
- Patient Transfer/statistics & numerical data
- Perinatal Care/standards
- Prenatal Diagnosis/statistics & numerical data
- Referral and Consultation
- Retrospective Studies
- Risk
- Survival Rate
- Texas/epidemiology
- Treatment Outcome
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Affiliation(s)
- David A Lazar
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX, USA
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Hutcheon JA, Butler B, Lisonkova S, Marquette GP, Mayer C, Skoll A, Joseph KS. Timing of delivery for pregnancies with congenital diaphragmatic hernia. BJOG 2011; 117:1658-62. [PMID: 21125710 DOI: 10.1111/j.1471-0528.2010.02738.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A recent report has suggested that delivery at early term ages may be associated with lower mortality among infants with congenital diaphragmatic hernia. We sought to confirm this finding by examining gestational age-specific mortality in the USA in term infants with isolated congenital diaphragmatic hernia, delivered following the spontaneous onset of labour. In the final population of 928 infants, neonatal and infant mortality decreased with advancing gestation, from 25 and 36% at 37 weeks of gestation, respectively, to 17 and 20% at 40 weeks of gestation, respectively. Log-binomial regression models showed that neonatal and infant mortality at 37 weeks of gestation were significantly higher than at 40 weeks. Further evidence, ideally from a randomised trial, is needed before recommendations for clinical practice on timing of delivery should be made.
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Affiliation(s)
- J A Hutcheon
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada.
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Prendergast M, Rafferty GF, Davenport M, Persico N, Jani J, Nicolaides K, Greenough A. Three-dimensional ultrasound fetal lung volumes and infant respiratory outcome: a prospective observational study. BJOG 2011; 118:608-14. [PMID: 21291507 DOI: 10.1111/j.1471-0528.2010.02841.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine if fetal lung volumes (FLVs), determined by three-dimensional rotational ultrasound and virtual organ computer-aided analysis software (vocal), correlated with neonatal respiratory outcomes in surviving infants who had a high risk [fetuses with congenital diaphragmatic hernia (CDH)], lower risk [fetuses with anterior wall defects (AWDs)] and no risk (controls) of abnormal antenatal lung growth. DESIGN Prospective observational study. SETTING Tertiary fetal medicine and neonatal intensive care units. POPULATION Sixty fetuses (25 with CDH, 25 with AWDs and ten controls). METHODS FLVs were measured and expressed as the percentage of the observed compared with the expected for gestational age. MAIN OUTCOME MEASURES Neonatal respiratory outcome was determined by the duration of supplemental oxygen, mechanical ventilation and dependencies, and assessment of lung volume using a gas dilution technique to measure functional residual capacity (FRC). RESULTS The infants with CDH had lower FLV results than both the infants with AWDs (P=0.05) and the controls (P<0.05). The infants with CDH had longer durations of mechanical ventilation (P<0.001) and supplementary oxygen (P<0.001) dependence, compared with infants with AWDs. The infants with CDH had a lower median FRC than both the infants with AWDs (P<0.001) and the controls (P<0.001). FLV results correlated significantly with the durations of dependency on ventilation (r= -0.744, P<0.01) and oxygen (r= -0.788, P<0.001), and with FRC results (r=0.429, P=0.001). CONCLUSIONS These results suggest that FLVs obtained using three-dimensional rotational ultrasound might be useful in predicting neonatal respiratory outcome in surviving infants who had varying risks of abnormal lung growth. Larger and more comprehensive studies are needed to clarify the role that lung volume measurements have in assessing lung function and growth.
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Affiliation(s)
- M Prendergast
- Division of Asthma, Allergy and Lung Biology, MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
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Odibo AO, Najaf T, Vachharajani A, Warner B, Mathur A, Warner BW. Predictors of the need for extracorporeal membrane oxygenation and survival in congenital diaphragmatic hernia: a center's 10-year experience. Prenat Diagn 2010; 30:518-21. [PMID: 20509150 DOI: 10.1002/pd.2508] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the prenatal factors associated with the need for extracorporeal membrane oxygenation (ECMO) and neonatal survival in congenital diaphragmatic hernia (CDH). STUDY DESIGN A retrospective cohort study of all cases of CDH seen in our center between 1998 and 2008. Prenatal ultrasound and neonatal records were reviewed. Both univariable and logistic regression analyses were performed to determine the significant factors associated with the use of ECMO and survival. RESULTS Among 107 cases of CDH seen during the study period, 62 were evaluated prenatally in our center and 49 had information on all variables evaluated. The overall rate of ECMO use was 27/107 (25%) and survival rate was 53/107 (49.5%). The lung area to head circumference ratio (LHR) and gestational age (GA) at delivery were the only significant factors associated with ECMO use, and the LHR and absence of liver herniation were significantly associated with survival. LHR values under 1.0 were associated with 57% need for ECMO and 100% neonatal death. Although, overall, the observed:expected LHR (O:E LHR) was not significantly associated with ECMO use or survival, levels below 65% were associated with 58% need for ECMO (p = 0.004) and 100% neonatal death (p = 0.002). CONCLUSION The study confirms the LHR, GA at delivery and liver herniation as significant prenatal predictors of the need for ECMO or survival in cases with CDH. This information is helpful for counseling women with fetuses complicated by CDH.
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Affiliation(s)
- Anthony O Odibo
- Fetal Care Center, Division of Maternal Fetal Medicine and Ultrasound, Washington University Medical Center, St Louis, MO 63110, USA.
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Cruz-Martinez R, Figueras F, Moreno-Alvarez O, Martinez JM, Gomez O, Hernandez-Andrade E, Gratacos E. Learning curve for lung area to head circumference ratio measurement in fetuses with congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2010; 36:32-36. [PMID: 20131334 DOI: 10.1002/uog.7577] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To assess the learning curve for the fetal lung area to head circumference ratio (LHR) calculation in fetuses with congenital diaphragmatic hernia (CDH). METHODS Three trainees with the theoretical knowledge, but without prior experience in the LHR measurement, were selected. Each trainee and one experienced examiner measured the observed to expected (O/E)-LHR in the lung contralateral to the side of the hernia by two methods-manual tracing of lung borders and multiplication of the longest diameters-in a cohort of 95 consecutive CDH fetuses. The average difference between the three trainees and the expert in the O/E-LHR measurement was calculated. A difference below 10% was considered to indicate an accurate measurement. The average learning curve was delineated using cumulative sum analysis (CUSUM). RESULTS The CUSUM plots demonstrate that the learning curve was achieved by 77 and 72 tests performed for the area obtained by the manual-tracing and multiplication-of-the-longest-diameter methods, respectively. CONCLUSION The minimum number of scans required for an inexperienced trainee to become competent in examining the LHR is on average 70.
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Affiliation(s)
- R Cruz-Martinez
- Fetal and Perinatal Medicine Research Group, Department of Maternal-Fetal Medicine, Hospital Clinic-IDIBAPS, University of Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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Yamamoto M, Ville Y. Fetal lung assessment in congenital diaphragmatic hernia: evidence for growth. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2010; 35:522-524. [PMID: 20443196 DOI: 10.1002/uog.7653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- M Yamamoto
- Unidad de Medicina Materno Fetal, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
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Jancelewicz T, Vu LT, Keller RL, Bratton B, Lee H, Farmer D, Harrison M, Miniati D, Mackenzie T, Hirose S, Nobuhara K. Long-term surgical outcomes in congenital diaphragmatic hernia: observations from a single institution. J Pediatr Surg 2010; 45:155-60; discussion 160. [PMID: 20105597 DOI: 10.1016/j.jpedsurg.2009.10.028] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2009] [Accepted: 10/06/2009] [Indexed: 01/18/2023]
Abstract
BACKGROUND/PURPOSE Surgical complications are common in survivors of congenital diaphragmatic hernia (CDH), but little is known about long-term incidence patterns and associated predictors. METHODS A cohort of 99 CDH survivors was prospectively followed at a single-institution multidisciplinary clinic. Data were gathered regarding the adverse surgical outcomes of hernia recurrence, chest and spinal deformity, and operative small bowel obstruction (SBO), and then were retrospectively analyzed in relation to perinatal and perioperative markers of disease severity to determine significant predictors. Statistical methods used included univariate and multivariate regression analysis, hazard modeling, and Kaplan-Meier analysis. RESULTS At a median cohort age of 4.7 (range, 0.2-10.6) years, 46% of patients with patch repairs and 10% of those with primary repairs had a hernia recurrence at a median time of 0.9 (range, 0.1-7.3) years after repair. Chest deformity was detected in 47%. Small bowel obstruction and scoliosis occurred in 13%. Recurrence and chest deformity were significantly more common with patch repair, liver herniation, age at neonatal extubation greater than 16 days, oxygen requirement at discharge, and prematurity. The strongest predictor of SBO was patch repair. Multivariate analysis showed that patch repair was independently predictive of recurrence and early chest deformity (odds ratios of 5.0 and 4.8, confidence intervals of 1-24 and 1-21, P < .05). Use of an absorbable patch was associated with the highest risk of surgical complications. CONCLUSIONS For long-term survivors of CDH, specific perinatal and operative variables, particularly patch repair, are associated with subsequent adverse surgical outcomes.
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Affiliation(s)
- Tim Jancelewicz
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, CA 94143, USA
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van den Hout L, Sluiter I, Gischler S, De Klein A, Rottier R, Ijsselstijn H, Reiss I, Tibboel D. Can we improve outcome of congenital diaphragmatic hernia? Pediatr Surg Int 2009; 25:733-43. [PMID: 19669650 PMCID: PMC2734260 DOI: 10.1007/s00383-009-2425-8] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
This review gives an overview of the disease spectrum of congenital diaphragmatic hernia (CDH). Etiological factors, prenatal predictors of survival, new treatment strategies and long-term morbidity are described. Early recognition of problems and improvement of treatment strategies in CDH patients may increase survival and prevent secondary morbidity. Multidisciplinary healthcare is necessary to improve healthcare for CDH patients. Absence of international therapy guidelines, lack of evidence of many therapeutic modalities and the relative low number of CDH patients calls for cooperation between centers with an expertise in the treatment of CDH patients. The international CDH Euro-Consortium is an example of such a collaborative network, which enhances exchange of knowledge, future research and development of treatment protocols.
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Affiliation(s)
- L. van den Hout
- Department of Paediatric Surgery, ErasmusMC-Sophia, Rotterdam, The Netherlands
| | - I. Sluiter
- Department of Paediatric Surgery, ErasmusMC-Sophia, Rotterdam, The Netherlands
| | - S. Gischler
- Department of Paediatric Surgery, ErasmusMC-Sophia, Rotterdam, The Netherlands
| | - A. De Klein
- Department of Genetics, ErasmusMC-Sophia, Rotterdam, The Netherlands
| | - R. Rottier
- Department of Paediatric Surgery, ErasmusMC-Sophia, Rotterdam, The Netherlands
| | - H. Ijsselstijn
- Department of Paediatric Surgery, ErasmusMC-Sophia, Rotterdam, The Netherlands
| | - I. Reiss
- Department of Paediatric Surgery, ErasmusMC-Sophia, Rotterdam, The Netherlands
| | - D. Tibboel
- Department of Paediatric Surgery, ErasmusMC-Sophia, Rotterdam, The Netherlands
- ErasmusMC-Sophia, Room SK-3284, P.O. Box 2060, 3000CB Rotterdam, The Netherlands
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Deprest JA, Gratacos E, Nicolaides K, Done E, Van Mieghem T, Gucciardo L, Claus F, Debeer A, Allegaert K, Reiss I, Tibboel D. Changing perspectives on the perinatal management of isolated congenital diaphragmatic hernia in Europe. Clin Perinatol 2009; 36:329-47, ix. [PMID: 19559323 DOI: 10.1016/j.clp.2009.03.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Congenital diaphragmatic hernia (CDH) should be diagnosed in the prenatal period and prompt referral to a tertiary referral center for imaging, genetic testing, and multidisciplinary counseling. Individual prediction of prognosis is based on the absence of additional anomalies, lung size, and liver herniation. In severe cases, a prenatal endotracheal balloon procedure is currently being offered at specialized centers. Fetal intervention is now also offered to milder cases within a trial, hypothesizing that this may reduce the occurrence of bronchopulmonary dysplasia in survivors. Postnatal management has been standardized by European high-volume centers for the purpose of this and other trials.
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Affiliation(s)
- Jan A Deprest
- Woman and Child Division, Fetal Medicine Unit, University Hospital Gasthuisberg, Leuven, Belgium.
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Sinha CK, Islam S, Patel S, Nicolaides K, Greenough A, Davenport M. Congenital diaphragmatic hernia: prognostic indices in the fetal endoluminal tracheal occlusion era. J Pediatr Surg 2009; 44:312-6. [PMID: 19231524 DOI: 10.1016/j.jpedsurg.2008.10.078] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 10/23/2008] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Management of congenital diaphragmatic hernia (CDH) in the UK now includes the possibility of fetal endoluminal tracheal occlusion (FETO) for poor prognosis fetuses. The objective of this study was to investigate the value of variables previously thought prognostic in the FETO era. METHODS A retrospective single-centre study was performed of all infants with CDH born between January 1994 and December 2007. Fetal endoluminal tracheal occlusion was available and had been used with parental consent for fetuses with lung-to-head ratio (LHR) of 1.0 or less and a liver-up position from 2002. Univariate analysis was used to predict survival (to leave hospital) using both prenatal (eg, polyhydramnios) and perinatal variables [eg, best oxygenation index on day 1, or BOI (d1)] and their dependence tested in a logistic regression model. Data were quoted as medians (range). P < .05 was regarded as significant. RESULTS Eighty-six infants with CDH (1994-2002, n = 35 and 2002-2007, n = 51 "FETO era") were studied. Successful FETO intervention was performed in 31 infants. Univariate analysis showed liver position, birth weight, LHR, and BOI (d1) were significant prognostic predictors (all P < .05); however, only BOI (d1) retained significance using logistic regression analysis (odds ratio, 21; 95% confidence interval, 6-74; P < .001). Best oxygenation index on day 1 was then used as a surrogate marker for outcome to test the relationship with LHR (available since 2002) and showed a significant inverse correlation (r(s) = -0.5; P < .001). There was no difference in median BOI (d1) between the FETO group and all those treated expectantly (40 [34-1046] vs 59 (23-581); P = .3]. CONCLUSION Best oxygenation index on day 1 is the best early postnatal predictor of survival. The more recently evaluated prenatal index, LHR, has an observable relationship with BOI (d1) when it is used as a surrogate marker of outcome.
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Deprest JA, Flemmer AW, Gratacos E, Nicolaides K. Antenatal prediction of lung volume and in-utero treatment by fetal endoscopic tracheal occlusion in severe isolated congenital diaphragmatic hernia. Semin Fetal Neonatal Med 2009; 14:8-13. [PMID: 18845492 DOI: 10.1016/j.siny.2008.08.010] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a severe malformation with an overall survival between 30% and 90%. Survival in the presence of associated malformations is very low. The condition should be detected in ultrasound screening programmes, but whether and how prenatal imaging can accurately predict outcome remains a matter of debate. Predictions based on the lung area:head circumference ratio and liver position are best studied. This information is highly relevant in counselling patients, leaving to severe cases the option of termination of pregnancy as experimental prenatal intervention aiming to reverse pulmonary hypoplasia. The purpose of this review is to update current knowledge regarding predictive value of prenatal assessment in terms of neonatal survival. We will also discuss experimental evidence and clinical data regarding fetal tracheal occlusion.
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Affiliation(s)
- Jan A Deprest
- Center for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, Minderbroedersstraat 17, B-3000 Leuven, Belgium
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Deprest JA, Hyett JA, Flake AW, Nicolaides K, Gratacos E. Current controversies in prenatal diagnosis 4: Should fetal surgery be done in all cases of severe diaphragmatic hernia? Prenat Diagn 2009; 29:15-9. [DOI: 10.1002/pd.2108] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Prédiction anténatale de l’hypoplasie pulmonaire et traitement in-utero par occlusion trachéale fœtale endoscopique (FETO) dans la hernie diaphragmatique congénitale isolée sévère. BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2008. [DOI: 10.1016/s0001-4079(19)32665-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Abstract
PURPOSE OF REVIEW To evaluate the impact of recent research on the management of congenital diaphragmatic hernia in the light of new theories on embryological development, earlier antenatal diagnosis, fetal and postnatal interventions together with advances in perinatal intensive care. RECENT FINDINGS The year 2007 provided in excess of 200 publications that address various aspects of congenital diaphragmatic hernia. The genetic basis and the causes of pulmonary hypoplasia at the molecular level are slowly being unravelled. Fetal MRI of lung volume, lung-head ratio, liver position and size of diaphragmatic defect have all been evaluated as early predictors of outcome and with a view to prenatal counselling. The impact of fetal interventions such as fetal endoluminal tracheal occlusion, the mode of delivery, the surgical techniques and agents for treating pulmonary hypertension were evaluated. The influence of associated anomalies and therapeutic interventions on the outcome and quality of life of survivors continue to be appraised. SUMMARY Deferred surgery after stabilization with gentle ventilation and reversal of pulmonary hypertension remain the cornerstones of management. Optimal presurgery and postsurgery ventilatory settings remain unproven. Continued improvement in neonatal intensive care raises the bar against which any intervention such as fetal endoluminal tracheal occlusion and extracorporeal membrane oxygenation will be judged.
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Abstract
PURPOSE OF REVIEW The following review should update any clinician treating infants with congenital diaphragmatic hernia regarding the latest developments affecting treatment and ultimate outcome in these patients. RECENT FINDINGS The search for the best prenatal predictors of postnatal outcome continues, and current findings are here summarized. In addition, recent work regarding the long-term follow-up and management of pediatric survivors treated for congenital diaphragmatic hernia is presented. SUMMARY These data should aid clinicians who encounter children with congenital diaphragmatic hernia on either a regular or infrequent basis to ensure the best care for all affected patients.
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Affiliation(s)
- Cynthia D Downard
- Division of Pediatric Surgery, University of Louisville, Louisville, Kentucky 40202, USA.
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