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Huntley ES, Hernandez-Andrade E, Papanna R, Bergh E, Espinoza J, Soto E, Lopez SM, Harting MT, Johnson A. Abnormal Shape and Size of the Cardiac Ventricles Are Associated with a Higher Risk of Neonatal Death in Fetuses with Isolated Left Congenital Diaphragmatic Hernia. Fetal Diagn Ther 2024; 51:191-202. [PMID: 38194948 DOI: 10.1159/000536171] [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: 05/16/2023] [Accepted: 01/03/2024] [Indexed: 01/11/2024]
Abstract
INTRODUCTION The objective of this study was to evaluate the association between fetal cardiac deformation analysis (CDA) and cardiac function with severe adverse perinatal outcomes in fetuses with isolated left congenital diaphragmatic hernia (CDH). METHODS CDA in each ventricle (contractility, size, and shape), evaluated by speckle tracking and novel FetalHQ software, and markers of cardiac function (E/A ratios, pulmonary and aortic peak systolic velocities, and sigmoid annular valve diameters), were evaluated in fetuses with isolated left CDH. Two evaluations were performed: at referral (CDA and function) and within 3 weeks of delivery (CDA). Severe adverse neonatal outcomes were considered neonatal death (ND) or survival with CDH-associated pulmonary hypertension (CDH-PH). Differences and associations between CDA, cardiac function, and severe adverse outcomes were estimated. RESULTS Fifty fetuses were included, and seventeen (34%) had severe adverse neonatal outcomes (11 ND and 6 survivors with CDH-PH). At first evaluation, the prevalence of a small left ventricle was 34% (17/50) with a higher prevalence among neonates presenting severe adverse outcomes (58.8 [10/17] vs. 21.2% [7/33]; p = 0.01; OR, 5.03 [1.4-19.1; p = 0.01]) and among those presenting with neonatal mortality (8/11 [72.7] vs. 9/39 [23.0%]; p = 0.03; OR, 8.9 [1.9-40.7; p = 0.005]). No differences in cardiac function or strain were noted between fetuses with or without severe adverse outcomes. Within 3 weeks of delivery, the prevalence of small left ventricle was higher (19/34; 55.8%) with a more globular shape (reduced transverse/longitudinal ratio). A globular right ventricle was significantly associated with ND or survival with CDH-PH (OR, 14.2 [1.5-138.3]; p = 0.02). CONCLUSION Fetuses with isolated CDH at risk of perinatal death or survival with CDH-PH had a higher prevalence of a small left ventricle and abnormal shape of the right ventricle.
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Affiliation(s)
- Erin S Huntley
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Edgar Hernandez-Andrade
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Ramesha Papanna
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Eric Bergh
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Eleazar Soto
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Maternal Fetal Medicine, McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Suzanne M Lopez
- Department of Pediatrics, McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
| | - Anthony Johnson
- Department of Obstetrics and Gynecology and Reproductive Sciences, Divisions of McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
- Fetal Intervention and McGovern Medical School at The University of Texas, Health Science Center at Houston, Houston, Texas, USA
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Stanek J. Placental fetal vascular malperfusion in congenital diaphragmatic hernia. Virchows Arch 2024; 484:83-91. [PMID: 37439836 DOI: 10.1007/s00428-023-03600-y] [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: 05/11/2023] [Revised: 06/19/2023] [Accepted: 07/07/2023] [Indexed: 07/14/2023]
Abstract
The success of in-utero or intrapartum treatment for congenital diaphragmatic hernia (CDH) can be impacted by poor placental function; however, this relationship has not yet been studied. To analyze placental histomorphology in CDH, the frequencies of 24 independent clinical and 48 placental phenotypes were compared. Slides from 103 CDH placentas (group 1) and 133 clinical umbilical cord (UC) compromise/anatomical UC abnormality placentas without CDH (group 2) were subjected to hematoxylin/eosin staining and CD34 immunostaining and then examined. CD34 immunostaining was performed to identify clustered distal villi with endothelial fragmentation of recent fetal vascular malperfusion (FVM). Cesarean delivery and ex utero intrapartum treatment were more common in group 1, but group 2 showed a higher frequency of statistically significant increases in other clinical phenotypes. The frequencies of large vessels and distal villous FVMs (clustered endothelial fragmentation by CD34 immunostaining, stromal vascular karyorrhexis, avascular, or mineralized villi) did not differ between the groups, but low-grade distal villous FVMs were statistically significantly more common in group 1 than in group 2, while high-grade distal villous FVMs were significantly more common in group 2 than group 1. Large vessel and distal villous FVMs were manyfold more common in both the CDH and UC compromise groups than in the general population. However, CDH placentas were more likely to show low-grade distal villous FVMs and less likely to show high-grade distal villous FVMs in UC compromise placentas. FVM of CDH may therefore be caused by a similar pathomechanism as that of UC compromise, resulting in impaired placental fetal blood outflow.
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Affiliation(s)
- Jerzy Stanek
- Division of Pathology, Cincinnati Children's Hospital Medical Center, and Department of Pathology, University of Cincinnati Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
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Masahata K, Yamoto M, Umeda S, Nagata K, Terui K, Fujii M, Shiraishi M, Hayakawa M, Amari S, Masumoto K, Okazaki T, Inamura N, Toyoshima K, Koike Y, Furukawa T, Yazaki Y, Yokoi A, Endo M, Tazuke Y, Okuyama H, Usui N. Prenatal predictors of mortality in fetuses with congenital diaphragmatic hernia: a systematic review and meta-analysis. Pediatr Surg Int 2022; 38:1745-1757. [PMID: 36102982 DOI: 10.1007/s00383-022-05232-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE This study aimed to evaluate prenatal predictors of mortality in fetuses with congenital diaphragmatic hernia (CDH). METHODS A systematic literature search was performed to identify relevant observational studies that evaluated the ability of lung-to-head ratio (LHR), observed-to-expected LHR (o/e-LHR), observed-to-expected total fetal lung volume (o/e-TFLV), lung-to-thorax transverse area ratio (L/T ratio), intrathoracic herniation of the liver and the stomach, and side of diaphragmatic hernia, using a threshold for the prediction of mortality in fetuses with CDH. Study quality was assessed using the QUADAS-2 tool. Hierarchical summary receiver operating characteristic curves were constructed. RESULTS A total of 50 articles were included in this meta-analysis. The QUADAS-2 tool identified a high risk of bias in more than one domain scored in all parameters. Among those parameters, the diagnostic odds ratio of mortality with o/e-LHR < 25%, o/e-TFLV < 25%, and L/T ratio < 0.08 were 11.98 [95% confidence interval (CI) 4.65-30.89], 11.14 (95% CI 5.19-23.89), and 10.28 (95% CI 3.38-31.31), respectively. The predictive values for mortality were similar between the presence of liver herniation and retrocardiac fetal stomach position. CONCLUSIONS This systematic review suggests that o/e-LHR, o/e-TFLV, and L/T ratio are equally good predictors of neonatal mortality in fetuses with isolated CDH.
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Affiliation(s)
- Kazunori Masahata
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan.
| | - Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Satoshi Umeda
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Kouji Nagata
- Department of Pediatric Surgery, Kyushu University, Fukuoka, Japan
| | - Keita Terui
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Makoto Fujii
- Department of Health Science, Graduate School of Medicine, Osaka University, Suita, Japan
| | | | - Masahiro Hayakawa
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Shoichiro Amari
- Division of Neonatology, National Center for Child Health and Development, Tokyo, Japan
| | - Kouji Masumoto
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tadaharu Okazaki
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Noboru Inamura
- Department of Pediatrics, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Katsuaki Toyoshima
- Departments of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Yuki Koike
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Taizo Furukawa
- Department of Pediatric Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuta Yazaki
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Akiko Yokoi
- Departments of Pediatric Surgery, Kobe Children's Medical Center, Kobe, Japan
| | - Masayuki Endo
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuko Tazuke
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
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MRI in Pregnancy and Precision Medicine: A Review from Literature. J Pers Med 2021; 12:jpm12010009. [PMID: 35055324 PMCID: PMC8778056 DOI: 10.3390/jpm12010009] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/11/2021] [Accepted: 12/15/2021] [Indexed: 12/29/2022] Open
Abstract
Magnetic resonance imaging (MRI) offers excellent spatial and contrast resolution for evaluating a wide variety of pathologies, without exposing patients to ionizing radiations. Additionally, MRI offers reproducible diagnostic imaging results that are not operator-dependent, a major advantage over ultrasound. MRI is commonly used in pregnant women to evaluate, most frequently, acute abdominal and pelvic pain or placental abnormalities, as well as neurological or fetal abnormalities, infections, or neoplasms. However, to date, our knowledge about MRI safety during pregnancy, especially about the administration of gadolinium-based contrast agents, which are able to cross the placental barrier, is still limited, raising concerns about possible negative effects on both the mother and the health of the fetus. Contrast agents that are unable to cross the placenta in a way that is safe for the fetus are desirable. In recent years, some preclinical studies, carried out in rodent models, have evaluated the role of long circulating liposomal nanoparticle-based blood-pool gadolinium contrast agents that do not penetrate the placental barrier due to their size and therefore do not expose the fetus to the contrast agent during pregnancy, preserving it from any hypothetical risks. Hence, we performed a literature review focusing on contrast and non-contrast MRI use during pregnancy.
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Jeong J, Lee BS, Cha T, Jung E, Kim EAR, Kim KS, Kim DY, Namgoong JM, Kim SC, Lee MY, Won HS. Prenatal prognostic factors for isolated right congenital diaphragmatic hernia: a single center's experience. BMC Pediatr 2021; 21:460. [PMID: 34666738 PMCID: PMC8526355 DOI: 10.1186/s12887-021-02931-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Right-sided congenital diaphragmatic hernia (RCDH) is relatively rare compared with left-sided congenital diaphragmatic hernia (LCDH). Clinical data of RCDH, especially with respect to antenatal prediction of neonatal outcome, are lacking. The aim of this study was to report the treatment outcomes of patients with antenatally diagnosed RCDH and to evaluate the predictability of observed-to-expected lung area-to-head circumference ratio (O/E LHR) for perinatal outcomes, focused on mortality or extracorporeal membrane oxygenation (ECMO) requirement. METHODS We retrospectively reviewed the medical records of newborn infants with isolated RCDH. We analyzed and compared the clinical and prenatal characteristics including the fetal lung volume, which was measured as the O/E LHR, between the survivors and the non-survivors. RESULTS A total of 26 (66.7%) of 39 patients with isolated RCDH survived to discharge. The O/E LHR was significantly greater in survivors (64.7 ± 21.2) than in non-survivors (40.5 ± 23.4) (P =.027). It was greater in survivors without ECMO requirement (68.3 ± 15.1) than non-survivors or those with ECMO requirement (46.3 ± 19.4; P = .010). The best O/E LHR cut-off value for predicting mortality in isolated RCDH was 50. CONCLUSIONS The findings in this study suggest that O/E LHR, a well-characterized prognostic indicator in LCDH, could be applied to a fetus with antenatally diagnosed RCDH. A large cohort study is required to verify the association between O/E LHR values and the graded severity of RCDH.
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Affiliation(s)
- Jiyoon Jeong
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Byong Sop Lee
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Teahyen Cha
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Euiseok Jung
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ellen Ai-Rhan Kim
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ki-Soo Kim
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Dae Yeon Kim
- Department of Pediatric Surgery, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Jung-Man Namgoong
- Department of Pediatric Surgery, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Seong Chul Kim
- Department of Pediatric Surgery, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Mi-Young Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Hye-Sung Won
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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Tanacan A, Orgul G, Aydin E, Kayki G, Celik HT, Yalcin S, Soyer T, Yigit S, Yurdakok M, Beksac MS. Antenatal management and outcomes of pregnancies with congenital diaphragmatic hernia. J Neonatal Perinatal Med 2021; 13:323-330. [PMID: 31796690 DOI: 10.3233/npm-190266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The objective of this study is to evaluate the obstetric outcomes of pregnancies with congenital diaphragmatic hernia (CDH). METHODS Fifty one pregnancies prenatally diagnosed with CDH at our institution between January 1, 2002 and August 31, 2018 were retrospectively evaluated. The pregnancies were divided into two groups according to neonatal survival. Demographic features, clinical characteristics and prognostic factors were compared between the neonatal survival (n = 16) and non-survival (n = 28) groups. Cut-off values of fetal lung area to head circumference ratio (LHR), observed/expected LHR (o/e LHR) and observed/expected total fetal lung volume (o/e TFLV) for neonatal survival were calculated. RESULTS Thirty six (70.6%) and fifteen (29.4%) fetuses had left and right sided CDH respectively. Seven patients chose termination of their pregnancies (13.7%). Statistically significant differences were found between survival and non-survival groups in terms of parity, median gestational week at diagnosis, polyhydroamniosis rate, CDH type, stomach position, liver position, median LHR, o/e LHR, o/e TFLV, median 5th minute Apgar score and neonatal operation rate values (p values were 0.03,<0.001, 0.02, 0.006,<0.001, 0.006,<0.001,<0.001,<0.001, 0.04 and <0.001 respectively). According to ROC curve analysis, 1.05 (82% sensitivity, 74% specificity) for LHR, 22.5 (78.6% sensitivity, 73.9% specifity) for o/e LHR and 23.5 (85.7% sensitivity,74.2% specificity) for o/e TFLV were determined to be cut-offs for neonatal survival, respectively, with highest sensitivity and specificity. CONCLUSION Earlier gestational week at diagnosis, right sided CDH, presence of liver herniation, supradiaphragmatic stomach position, lower LHR, o/e LHR and o/e TFLV were associated with decreased rates of neonatal survival.
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Affiliation(s)
- Atakan Tanacan
- Department of Obstetric and Gynecology, Division of Perinatology, Hacettepe University Hospital, Ankara, Turkey
| | - Gokcen Orgul
- Department of Obstetric and Gynecology, Division of Perinatology, Hacettepe University Hospital, Ankara, Turkey
| | - Emine Aydin
- Department of Obstetric and Gynecology, Division of Perinatology, Hacettepe University Hospital, Ankara, Turkey
| | - Gozdem Kayki
- Department of Pediatrics, Division of Neonatology, Hacettepe University Hospital, Ankara, Turkey
| | - Hasan Tolga Celik
- Department of Pediatrics, Division of Neonatology, Hacettepe University Hospital, Ankara, Turkey
| | - Sule Yalcin
- Department of Pediatric Surgery, Hacettepe University Hospital, Ankara, Turkey
| | - Tutku Soyer
- Department of Pediatric Surgery, Hacettepe University Hospital, Ankara, Turkey
| | - Sule Yigit
- Department of Pediatrics, Division of Neonatology, Hacettepe University Hospital, Ankara, Turkey
| | - Murat Yurdakok
- Department of Pediatrics, Division of Neonatology, Hacettepe University Hospital, Ankara, Turkey
| | - Mehmet Sinan Beksac
- Department of Obstetric and Gynecology, Division of Perinatology, Hacettepe University Hospital, Ankara, Turkey
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Bergholz R, Fromm F, Meinzer A, Muehlfeld C, Boettcher M, Wenke K, Tiemann B, Reinshagen K, Krebs T. Stereological Lung Parameters After Fetoscopic Abdominal Decompression of Congenital Diaphragmatic Hernia in an Ovine Model: A Pilot Study. J Laparoendosc Adv Surg Tech A 2021; 31:712-718. [PMID: 33913757 DOI: 10.1089/lap.2020.0954] [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] [Indexed: 11/12/2022] Open
Abstract
Background: Fetoscopic endoluminal tracheal occlusion (FETO) improves lung maturation in severe cases of congenital diaphragmatic hernia (CDH) but it does not ameliorate lung compression by herniated abdominal organs. Surgically opening the fetal abdomen (abdominal decompression [AD]) reduces the intrathoracic pressure by diverting the abdominal organs into the amniotic cavity-a probable causal therapy for lung hypoplasia and pulmonary hypertension in CDH. Open surgical abdominal decompression has been reported: we describe a minimally invasive approach in an ovine model of CDH as a probable fetoscopic intervention. Materials and Methods: Eight fetuses were included, 2 were kept as HEALTHY controls. A CDH (left side, liver down) was created by open fetal surgery at midgestation in 6 fetuses, 2 were taken as CDH controls. Fetoscopic abdominal decompression (fAD) was performed 21 days later in 4 animals. The fetuses were retrieved at the end of gestation and evaluated by lung stereology. Results: fAD led to a near total evacuation of the thoracic cavity in 2 of the 4 animals. Fetuses with CDH had a lower total volume and fraction of alveolar air space, a lower volume fraction of the parenchyma, and an increase of the volume fraction of the alveolar septa and atelectasis, as well as an increased mean thickness of alveolar septa compared with HEALTHY fetuses. Fetuses treated with abdominal decompression showed an improvement of stereological parameters. Conclusions: In spite of relevant limitations (pilot study, small groups, spontaneous closure of the abdominal incision) we were able to demonstrate that abdominal decompression for CDH can be performed by fetoscopy. Our results support the hypothesis of causally improving lung development by abdominal decompression, thus implying increased survival in extreme cases of CDH. A refinement of the fetoscopic techniques and direct comparison to FETO appears warranted.
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Affiliation(s)
- Robert Bergholz
- Department of General, Visceral, Thoracic, Transplant, and Pediatric Surgery, UKSH University Hospital of Schleswig-Holstein Kiel Campus, Kiel, Germany
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Felipe Fromm
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Andreas Meinzer
- Department of General, Visceral, Thoracic, Transplant, and Pediatric Surgery, UKSH University Hospital of Schleswig-Holstein Kiel Campus, Kiel, Germany
| | - Christian Muehlfeld
- Institute of Functional and Applied Anatomy, Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Michael Boettcher
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Katharina Wenke
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Bastian Tiemann
- Department of Experimental Animal Research, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Konrad Reinshagen
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Thomas Krebs
- Department of Pediatric Surgery, Ostschweizer Children's Hospital, St.Gallen, Switzerland
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Kang X, Carlin A, Cannie MM, Sanchez TC, Jani JC. Fetal postmortem imaging: an overview of current techniques and future perspectives. Am J Obstet Gynecol 2020; 223:493-515. [PMID: 32376319 DOI: 10.1016/j.ajog.2020.04.034] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 04/19/2020] [Accepted: 04/28/2020] [Indexed: 12/19/2022]
Abstract
Fetal death because of miscarriage, unexpected intrauterine fetal demise, or termination of pregnancy is a traumatic event for any family. Despite advances in prenatal imaging and genetic diagnosis, conventional autopsy remains the gold standard because it can provide additional information not available during fetal life in up to 40% of cases and this by itself may change the recurrence risk and hence future counseling for parents. However, conventional autopsy is negatively affected by procedures involving long reporting times because the fetal brain is prone to the effect of autolysis, which may result in suboptimal examinations, particularly of the central nervous system. More importantly, fewer than 50%-60% of parents consent to invasive autopsy, mainly owing to the concerns about body disfigurement. Consequently, this has led to the development of noninvasive perinatal virtual autopsy using imaging techniques. Because a significant component of conventional autopsy involves the anatomic examination of organs, imaging techniques such as magnetic resonance imaging, ultrasound, and computed tomography are possible alternatives. With a parental acceptance rate of nearly 100%, imaging techniques as part of postmortem examination have become widely used in recent years in some countries. Postmortem magnetic resonance imaging using 1.5-Tesla magnets is the most studied technique and offers an overall diagnostic accuracy of 77%-94%. It is probably the best choice as a virtual autopsy technique for fetuses >20 weeks' gestation. However, for fetuses <20 weeks' gestation, its performance is poor. The use of higher magnetic resonance imaging magnetic fields such as 3-Tesla may slightly improve performance. Of note, in cases of fetal maceration, magnetic resonance imaging may offer diagnoses in a proportion of brain lesions wherein conventional autopsy fails. Postmortem ultrasound examination using a high-frequency probe offers overall sensitivity and specificity of 67%-77% and 74%-90%, respectively, with the advantage of easy access and affordability. The main difference between postmortem ultrasound and magnetic resonance imaging relates to their respective abilities to obtain images of sufficient quality for a confident diagnosis. The nondiagnostic rate using postmortem ultrasound ranges from 17% to 30%, depending on the organ examined, whereas the nondiagnostic rate using postmortem magnetic resonance imaging in most situations is far less than 10%. For fetuses ≤20 weeks' gestation, microfocus computed tomography achieves close to 100% agreement with autopsy and is likely to be the technique of the future in this subgroup. The lack of histology has always been listed as 1 limitation of all postmortem imaging techniques. Image-guided needle tissue biopsy coupled with any postmortem imaging can overcome this limitation. In addition to describing the diagnostic accuracy and limitations of each imaging technology, we propose a novel, stepwise diagnostic approach and describe the possible application of these techniques in clinical practice as an alternative or an adjunct or for triage to select cases that would specifically benefit from invasive examination, with the aim of reducing parental distress and pathologist workload. The widespread use of postmortem fetal imaging is inevitable, meaning that hurdles such as specialized training and dedicated financing must be overcome to improve access to these newer, well-validated techniques.
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Affiliation(s)
- Xin Kang
- Departments of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Andrew Carlin
- Departments of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Mieke M Cannie
- Radiology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium; Department of Radiology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Teresa Cos Sanchez
- Departments of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques C Jani
- Departments of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium.
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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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Leopold DK, Phillips RC, Shahi N, Gien J, Marwan AI, Kinsella JP, Mulligan J, Liechty KW, Moulton SL. Low postnatal CRI values are associated with the need for ECMO in newborns with CDH. J Pediatr Surg 2020; 55:39-44. [PMID: 31679772 DOI: 10.1016/j.jpedsurg.2019.09.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 09/29/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Accurate, real-time technology is needed to predict which newborns with congenital diaphragmatic hernia (CDH) will require ECMO. The Compensatory Reserve Index (CRI) is a noninvasive monitoring technology that continuously trends an individual's capacity to compensate from normovolemia (CRI = 1) to decompensation (CRI = 0). We hypothesized that postnatal CRI values would be lower in CDH newborns that required ECMO than those who did not require ECMO. METHODS Newborns with a CDH were prospectively monitored with a CipherOx® CRI M1 device. We compared CRI values from delivery to ECMO (ECMO group) versus delivery to clinical stabilization (non-ECMO group). RESULTS Postnatal CRI values were available from 26 newborns. Eight underwent ECMO within 33 h of delivery, and median CRI prior to ECMO was 0.068 (IQR: 0.057, 0.078). Eighteen did not require ECMO. Median CRI from birth to 48 h was 0.112 (IQR: 0.082, 0.15). CRI values were significantly lower in newborns that required ECMO versus those who did not (p = 0.0035). Postnatal CRI had the highest AUC (0.85) compared to other prenatal prognostic measures. CONCLUSION Humans from newborns to adults share elemental features of the pulsatile waveform that are associated with progression to decompensation. CRI may be helpful when deciding when to initiate ECMO. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Diagnostic test.
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Affiliation(s)
- David K Leopold
- Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO.
| | - Ryan C Phillips
- Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Niti Shahi
- Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Jason Gien
- Department of Pediatrics, Division of Neonatology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Ahmed I Marwan
- Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - John P Kinsella
- Department of Pediatrics, Division of Neonatology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | | | - Kenneth W Liechty
- Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Steven L Moulton
- Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO; Flashback Technologies Inc., Louisville, CO
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Karmazyn B, Shold AJ, Delaney LR, Brown BP, Marine MB, Jennings SG, Gray BW. Ultrasound evaluation of right diaphragmatic eventration and hernia. Pediatr Radiol 2019; 49:1010-1017. [PMID: 31139880 DOI: 10.1007/s00247-019-04417-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/11/2019] [Accepted: 04/22/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND A hernia is due to a defect in the diaphragm. An eventration is due to a thinned diaphragm with no central muscle. Distinguishing right diaphragmatic hernia from eventration on chest radiographs can be challenging if no bowel loops are herniated above the diaphragm. Experience is limited with postnatal ultrasound (US) evaluation of diaphragmatic hernia or eventration. OBJECTIVE To evaluate for specific US signs in the diagnosis of right diaphragmatic hernia and eventration. MATERIALS AND METHODS We identified all patients (January 2007-December 2017) with right diaphragm US and surgery for eventration or hernia. We reviewed medical charts, and US images/reports for clinical presentation and diaphragm abnormalities. Surgical diagnosis was considered the reference standard. RESULTS Seventeen children (mean age: 5 months) had US examination before surgery for hernia (n=9) or eventration (n=8). The most common presentation was respiratory distress. In the US reports, hernia was correctly diagnosed in all patients and three patients with eventration were misdiagnosed as hernia, yielding 100% sensitivity and 62.5% specificity. In a retrospective evaluation of the US studies, a combination of folding of a free muscle edge with a narrow angle waist had 100% specificity for hernia and was seen in 7/9 children with hernia. Combination of a broad angle waist and hypoechoic strip of diaphragmatic muscle covering the waist had 100% specificity for eventration and was demonstrated in 4/8 children with eventration. Five of 17 patients (31.6%) had no specific sign that differentiated hernia from eventration. CONCLUSION On US, folding of the free edge of the diaphragm and a narrow angle waist are specific for hernia; a broad angle waist with muscle covering the elevated area is specific for eventration. Definitive differentiation between eventration and hernia may not be possible in about a third of patients.
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Affiliation(s)
- Boaz Karmazyn
- Department of Radiology and Imaging Sciences, Riley Hospital for Children, Indiana University, 705 Riley Hospital Dr., Rm. 1053, Indianapolis, IN, 46202, USA.
| | - Andrew J Shold
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lisa R Delaney
- Department of Radiology and Imaging Sciences, Riley Hospital for Children, Indiana University, 705 Riley Hospital Dr., Rm. 1053, Indianapolis, IN, 46202, USA
| | - Brandon P Brown
- Department of Radiology and Imaging Sciences, Riley Hospital for Children, Indiana University, 705 Riley Hospital Dr., Rm. 1053, Indianapolis, IN, 46202, USA
| | - Megan B Marine
- Department of Radiology and Imaging Sciences, Riley Hospital for Children, Indiana University, 705 Riley Hospital Dr., Rm. 1053, Indianapolis, IN, 46202, USA
| | - S Gregory Jennings
- Department of Radiology and Imaging Sciences, Indiana University, Indianapolis, IN, USA
| | - Brian W Gray
- Department of Pediatric Surgery, Riley Hospital for Children, Indiana University, Indianapolis, IN, USA
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Basurto D, Russo FM, Van der Veeken L, Van der Merwe J, Hooper S, Benachi A, De Bie F, Gomez O, Deprest J. Prenatal diagnosis and management of congenital diaphragmatic hernia. Best Pract Res Clin Obstet Gynaecol 2019; 58:93-106. [PMID: 30772144 DOI: 10.1016/j.bpobgyn.2018.12.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 12/31/2018] [Indexed: 12/13/2022]
Abstract
Congenital diaphragmatic hernia is characterized by failed closure of the diaphragm, thereby allowing abdominal viscera to herniate into the thoracic cavity and subsequently interfering with normal lung development. At birth, pulmonary hypoplasia leads to respiratory insufficiency and persistent pulmonary hypertension (PHT), that is lethal in up to 32% of patients. In isolated cases, the outcome may be predicted prenatally by medical imaging and advanced genetic testing. In those fetuses with a predicted poor outcome, fetoscopic endoluminal tracheal occlusion may be offered. This procedure is currently being evaluated in a global randomized clinical trial (www.TOTALtrial.eu). We are currently investigating alternative strategies including transplacental sildenafil administration to reduce the occurrence of persistent PHT.
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Affiliation(s)
- David Basurto
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium
| | - Francesca Maria Russo
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium; Clinical Department of Obstetrics & Gynaecology, KU Leuven, Leuven, Belgium
| | - Lennart Van der Veeken
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium; Clinical Department of Obstetrics & Gynaecology, KU Leuven, Leuven, Belgium
| | - Johannes Van der Merwe
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium; Clinical Department of Obstetrics & Gynaecology, KU Leuven, Leuven, Belgium
| | - Stuart Hooper
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Alexandra Benachi
- Obstetrics and Gynaecology Department, Centre de Référence Maladie Rare: Hernie de Coupole Diaphragmatique, Hôpital Antoine Béclère, Université Paris Sud, AP-HP, Clamart, France; European Reference Network on Rare and Inherited Congenital Anomalies "ERNICA"
| | - Felix De Bie
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium
| | - Olga Gomez
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Fetal I+D Fetal Medicine Research Center, Institut Clinic de Ginecologia, Obstetricia I Neonatologia, IDIBAPS, CIBER-ER, University of Barcelona, Spain
| | - Jan Deprest
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium; Clinical Department of Obstetrics & Gynaecology, KU Leuven, Leuven, Belgium; Institute for Women's Health, University College London, London, UK; European Reference Network on Rare and Inherited Congenital Anomalies "ERNICA".
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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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Pre- and neonatal imaging of gastrointestinal complications in congenital diaphragmatic hernia. Abdom Radiol (NY) 2018; 43:574-582. [PMID: 28695234 DOI: 10.1007/s00261-017-1246-9] [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: 10/19/2022]
Abstract
The initial outcome in infants with congenital diaphragmatic hernia is mainly related to the associated lung hypoplasia. However, these patients frequently present with additional gastrointestinal pathology that also influences their quality of life and final prognosis. Congenital gastrointestinal anomalies are often observed and the displacement of the liver, the stomach and/or the intestines into the thorax may cause distortion of the vascular axis of these organs, increasing the risk of congestion and/or ischemia. Some of these gastrointestinal complications are already visible at imaging studies performed in utero and/or in newborns.This pictorial essay describes the imaging findings of the most frequently detected gastrointestinal complications in fetuses and infants with congenital diaphragmatic hernia, focusing on prenatal exams.
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Risk stratification for congenital diaphragmatic hernia by factors within 24 h after birth. J Perinatol 2017; 37:805-808. [PMID: 28230834 DOI: 10.1038/jp.2017.11] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 01/15/2017] [Accepted: 01/19/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To establish a simple risk stratification system for patients with congenital diaphragmatic hernia (CDH) based on postnatal information within 24 h after birth. STUDY DESIGN A multi-institutional retrospective cohort study was conducted including 348 neonates who had isolated CDH born between 2006 and 2010. Based on the two most powerful variables for 90-day survival selected by multivariate analyses, a risk stratification system was established. RESULTS Multiple logistic regression analysis identified two adverse prognostic factors: an Apgar score at 1 min (Ap1) of 0-4 (odds ratio (OR) 3.3, P=0.004), and a best oxygenation index (OI) ⩾8.0 (OR 11.4, P<0.001). Based on a combinations of these two factors, patients were classified into three risk categories. The 90-day survival rates in categories 1-3 were 100, 88 and 52%, respectively (P<0.001). CONCLUSION Our simple risk stratification system based on Ap1 and best OI was capable of predicting mortality well.
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16
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Morgan TA, Basta A, Filly RA. Fetal stomach and gallbladder in contact with the bladder wall is a common ultrasound sign of stomach-down left congenital diaphragmatic hernia. JOURNAL OF CLINICAL ULTRASOUND : JCU 2017; 45:8-13. [PMID: 27663268 DOI: 10.1002/jcu.22400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/21/2016] [Indexed: 06/06/2023]
Abstract
PURPOSE The aim of this study was to identify sonographic (US) findings that can assist in prenatal diagnosis of stomach-down left congenital diaphragmatic hernia (CDH), specifically related to positioning of the abdominal contents including the stomach, bladder, and gallbladder. METHODS All US examinations with a postnatally confirmed diagnosis of stomach-down left CDH over a 13-year period were retrospectively reviewed for abnormal position of the abdominal contents, including whether the fetal stomach was in contact with the urinary bladder. Normal fetuses that underwent comprehensive US surveys were similarly evaluated for comparison in a 2:1 ratio. RESULTS Twenty-two fetuses with stomach-down left CDH were identified in a cohort of 278 fetuses with left CDH. In 15/22 (68.2%) cases of stomach-down left CDH, the bladder and stomach walls were in contact. Contact of the fetal gallbladder with the fetal bladder wall was also observed and was present even more commonly (17/22 cases [77.3%]). There was no case of either the stomach or gallbladder in contact with the bladder wall in the normal fetal cohort (n = 44). CONCLUSIONS Recognition of the fetal stomach and/or gallbladder in contact with the bladder wall can help in the detection of stomach-down left CDH. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:8-13, 2017.
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Affiliation(s)
- Tara A Morgan
- Department of Radiology and Biomedical Imaging, University of California San Francisco, L374, 505 Parnassus Avenue, San Francisco, CA, 94143-0628
| | - Amaya Basta
- Department of Diagnostic Radiology, Oregon Health & Science University, Portland, OR
| | - Roy A Filly
- Department of Radiology and Biomedical Imaging, University of California San Francisco, L374, 505 Parnassus Avenue, San Francisco, CA, 94143-0628
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Arias D, Narváez C. Atención al recién nacido con hipertensión pulmonar persistente. REPERTORIO DE MEDICINA Y CIRUGÍA 2016. [DOI: 10.1016/j.reper.2016.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Werner NL, Coughlin M, Kunisaki SM, Hirschl R, Ladino-Torres M, Berman D, Kreutzman J, Mychaliska GB. Prenatal and postnatal markers of severity in congenital diaphragmatic hernia have similar prognostic ability. Prenat Diagn 2016; 36:107-11. [PMID: 26537560 DOI: 10.1002/pd.4721] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 10/29/2015] [Accepted: 10/30/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The purpose of this study was to compare prenatal versus postnatal markers of congenital diaphragmatic hernia (CDH) severity at a single fetal-care center. METHODS A retrospective study was performed of patients having a complete prenatal evaluation and surgical repair (n = 55). Observed-to-expected lung-to-head ratio (o/eLHR), observed-to-expected total lung volume (o/eTLV), liver position (LP), a predictive dependent variable from logistic regression of o/eLHR and liver position (o/eLHR + LP), and diaphragmatic defect size per the CDH Study Group A-D classification were plotted into receiver-operating characteristics (ROC) curves. Survival and need for extracorporeal membrane oxygenation (ECMO) were primary outcomes. RESULTS Survival was 69%, and ECMO utilization was 56%. Distribution was 80% left-sided defects. In the survival ROC curve, the area under the curve (AUC) for o/eLHR was 0.73, o/eTLV 0.74, LP 0.73, o/eLHR + LP 0.78, and defect size 0.84 (p = 0.23). The ROC curve for ECMO support showed o/eLHR had an AUC of 0.82, o/eTLV 0.89, LP 0.79, o/eLHR + LP 0.87, and defect size 0.90 (p = 0.19). The AUCs were similar when only left-sided CDH was analyzed. CONCLUSIONS These data suggest that prenatal evaluation was equivalent to the postnatal diaphragmatic defect classification for predicting survival and need for ECMO in CDH patients.
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Affiliation(s)
- N L Werner
- Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School and The C.S. Mott Children's Hospital and the Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan, USA
| | - M Coughlin
- Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School and The C.S. Mott Children's Hospital and the Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan, USA
| | - S M Kunisaki
- Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School and The C.S. Mott Children's Hospital and the Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan, USA
| | - R Hirschl
- Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School and The C.S. Mott Children's Hospital and the Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan, USA
| | - M Ladino-Torres
- Section of Pediatric Radiology, Department of Radiology, The University of Michigan Medical School and The C.S. Mott Children's Hospital and the Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan, USA
| | - D Berman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The University of Michigan Medical School and The C.S. Mott Children's Hospital and the Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan, USA
| | - J Kreutzman
- Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School and The C.S. Mott Children's Hospital and the Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan, USA
| | - G B Mychaliska
- Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School and The C.S. Mott Children's Hospital and the Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan, 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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Congenital diaphragmatic hernia: does gestational age at diagnosis matter when evaluating morbidity and mortality? Am J Obstet Gynecol 2015; 213:535.e1-7. [PMID: 26070705 DOI: 10.1016/j.ajog.2015.06.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 04/12/2015] [Accepted: 06/01/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective of the investigation was to study the relationship between gestational age at diagnosis and mortality and morbidity in fetuses with an isolated congenital diaphragmatic hernia. STUDY DESIGN Between January 2008 and November 2013, 377 live births with isolated congenital diaphragmatic hernia diagnosed antenatally at a known gestational age were recorded in the database of the French National Center for Rare Diseases. The primary outcome studied was mortality estimated at 28 days and at 6 months. The secondary outcome was morbidity evaluated by pulmonary arterial hypertension at 48 hours, oxygen therapy dependence at 28 days, oral disorders, enteral feeding, and prosthetic patch repair. Analyses were adjusted for the main factors of congenital diaphragmatic hernia severity (side of the hernia, thoracic herniation of the liver, gestational age at birth, lung-to-head ratio, and prenatal treatment by tracheal occlusion. RESULTS Mortality rates at 28 days decreased significantly (P < .001) when gestational age at diagnosis increased: 61.1%, 39.2%, and 10.4% for a diagnosis in the first, second, and third trimester, respectively. Adjusted odds ratios were 3.12 [95% confidence interval, 1.86-5.25] and 0.35 [95% confidence interval, 0.18-0.66] for a diagnosis in the first and third trimesters, respectively, compared with a diagnosis in the second trimester. Similarly, morbidity decreased significantly when gestational age at diagnosis increased, and the trend remained significant after adjustment for the main factors of congenital diaphragmatic hernia severity (P < .001). CONCLUSION Gestational age at diagnosis is an independent predictor of postnatal prognosis for children presenting an isolated congenital diaphragmatic hernia and should be taken into account when estimating postnatal morbidity and mortality.
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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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Pruetz JD, Votava-Smith J, Miller DA. Clinical relevance of fetal hemodynamic monitoring: Perinatal implications. Semin Fetal Neonatal Med 2015; 20:217-24. [PMID: 25823939 DOI: 10.1016/j.siny.2015.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Comprehensive assessment of fetal wellbeing involves monitoring of fetal growth, placental function, central venous pressure, and cardiac function. Ultrasound evaluation of the fetus using 2D, color Doppler, and pulse-wave Doppler techniques form the foundation of antenatal diagnosis of structural anomalies, rhythm abnormalities and altered fetal circulation. Accurate and timely prenatal identification of the fetus at risk is critical for appropriate parental counseling, antenatal diagnostic testing, consideration for fetal intervention, perinatal planning, and coordination of postnatal care delivery. Fetal hemodynamic monitoring and serial assessment are vital to ensuring fetal wellbeing, particularly in the setting of complex congenital anomalies. A complete hemodynamic evaluation of the fetus gives important information on the likelihood of a smooth postnatal transition and contributes to ensuring the best possible outcome for the neonate.
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Affiliation(s)
- Jay D Pruetz
- Division of Cardiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Jodie Votava-Smith
- Division of Cardiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - David A Miller
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Spaggiari E, Stirnemann JJ, Sonigo P, Khen-Dunlop N, De Saint Blanquat L, Ville Y. Prenatal prediction of pulmonary arterial hypertension in congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:572-577. [PMID: 24976012 DOI: 10.1002/uog.13450] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 06/12/2014] [Accepted: 06/19/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate the role of prenatal prognostic markers obtained routinely by ultrasound examination and magnetic resonance imaging (MRI) in the prediction of development of postnatal pulmonary arterial hypertension (PAH) in isolated congenital diaphragmatic hernia (CDH). METHODS One hundred and ten cases of isolated CDH were referred to our fetal medicine unit between January 2004 and April 2013. Mortality and morbidity rates were reviewed for those presenting with postnatal PAH. The following prenatal markers were evaluated as potential predictive factors of PAH: liver position, side of the CDH defect, lung area to head circumference ratio (LHR) and observed/expected LHR (o/e-LHR), which were measured by ultrasound, and observed/expected total fetal lung volume (o/e-TFLV), which was measured by MRI. Univariable logistic regression was used to assess associations. RESULTS PAH was significantly associated with perinatal mortality and morbidity (P < 0.001). The occurrence of PAH decreased significantly with an increasing LHR, o/e-LHR and o/e-TFLV and was significantly increased for cases with an intrathoracic liver, but not for those with right-sided defects. Univariable regression revealed that o/e-TFLV (odds ratio (OR), 0.9 (95% CI, 0.86-0.95); P < 0.05 for percentage unit change in o/e), LHR (OR, 0.19 (95% CI, 0.09-0.40); P < 0.05 for unit change), o/e-LHR (OR, 0.95 (95% CI, 0.93-0.98); P < 0.05 for percentage unit change in o/e) and liver position (OR, 2.82 (95% CI, 1.13-7.00); P < 0.05 for intrathoracic liver) were significant predictors of subsequent PAH. No differences were found after adjusting for gestational age at delivery. The areas under the receiver-operating characteristics curve were 0.80 and 0.75 for o/e-TFLV and o/e-LHR, respectively. CONCLUSION In cases of CDH, PAH is associated with high rates of mortality and morbidity. Routinely obtained prenatal markers, usually used for the assessment of pulmonary hypoplasia, are also relevant for the postnatal prediction of PAH.
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MESH Headings
- Female
- Gestational Age
- Head
- Hernias, Diaphragmatic, Congenital/diagnosis
- Hernias, Diaphragmatic, Congenital/embryology
- Hernias, Diaphragmatic, Congenital/pathology
- Humans
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/embryology
- Hypertension, Pulmonary/pathology
- Infant, Newborn
- Liver/embryology
- Liver/pathology
- Lung/embryology
- Lung/pathology
- Lung Volume Measurements/methods
- Predictive Value of Tests
- Pregnancy
- Prognosis
- Survival Rate
- Ultrasonography, Prenatal
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Affiliation(s)
- E Spaggiari
- Department of Obstetrics and Maternal-Fetal Medicine, Necker-Enfants Malades Hospital, AP-HP, Paris, France; University Paris Descartes, Sorbonne Paris-Cité, Paris, France
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25
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Abstract
Over the past 20 years, prenatal detection of congenital diaphragmatic hernia (CDH) has improved worldwide, reaching up to 60% in Europe. Pulmonary hypoplasia and persistent pulmonary hypertension are the two main determinants of neonatal mortality and morbidity, so new tools have been focused on their evaluation. Fetal surgery for severe cases requires proper evaluation of the prognosis of fetuses with CDH. Observed-to-expected lung-to-head ratio, liver position, and total lung volume measured by magnetic resonance are the prognostic factors most often used, and have been shown to correlate not only with neonatal mortality but also with morbidity. In daily practice, pulmonary hypertension by itself, although most often associated with lung hypoplasia, is more difficult to predict.
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Done E, Debeer A, Gucciardo L, Van Mieghem T, Lewi P, Devlieger R, De Catte L, Lewi L, Allegaert K, Deprest J. Prediction of Neonatal Respiratory Function and Pulmonary Hypertension in Fetuses with Isolated Congenital Diaphragmatic Hernia in the Fetal Endoscopic Tracleal Occlusion Era: A Single-Center Study. Fetal Diagn Ther 2014; 37:24-32. [DOI: 10.1159/000364805] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 05/22/2014] [Indexed: 11/19/2022]
Abstract
Objective: To correlate prenatal indicators of pulmonary hypoplasia with neonatal lung function and pulmonary hypertension (PHT) in isolated congenital diaphragmatic hernia (iCDH). Materials and Methods: Prospective single-center study on 40 fetuses with iCDH either expectantly managed (n = 13) or undergoing tracheal occlusion (n = 27). Prenatal predictors included observed/expected lung-head ratio (O/E LHR), observed/expected total fetal lung volume, fetal pulmonary reactivity to maternal O2 administration (Δpulsatility index, ΔPI) and liver-to-thorax ratio (LiTR) as measured in the second and third trimesters. Postnatal outcome measures included survival until discharge, best oxygenation index (OI) and alveolar-arterial oxygen gradient [D(A-a)O2] in the first 24 h of life and the occurrence of PHT in the first 28 days of life. Results: Median gestational age (GA) at evaluations was 27.2 and 34.3 weeks. GA at delivery was 36.0 weeks, and overall survival was 55%. In the second trimester, measurement of lung size, LiTR and pulmonary reactivity were significantly related to survival and the best OI and D(A-a)O2.The occurrence of PHT was better predicted by ΔPI and LiTR. Conclusions: O/E LHR, LiTR and vascular reactivity correlate with ventilatory parameters in the first 24 h of life. Occurrence of PHT at ≥28 days was best predicted by LiTR and ΔPI, but not by lung size.
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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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Periodic MRI lung volume assessment in fetuses with congenital diaphragmatic hernia: prediction of survival, need for ECMO, and development of chronic lung disease. AJR Am J Roentgenol 2013; 201:419-26. [PMID: 23883224 DOI: 10.2214/ajr.12.8655] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of the study was to investigate the ability to predict survival, need for extracorporeal membrane oxygenation (ECMO), and incidence of chronic lung disease in patients with congenital diaphragmatic hernia in the context of a classification into three different times of gestation (< 28, 28-32, and > 32 weeks) by assessing the ratio between observed and expected MRI fetal lung volume. MATERIALS AND METHODS The data analysis included 226 fetuses with congenital diaphragmatic hernia. MRI was performed at different times of gestation with a T2-weighted HASTE sequence. Receiver operating characteristic curve analysis was performed to investigate the prognostic value of assessment of the ratio between observed and expected MRI fetal lung volumes at different stages of fetal growth. RESULTS For all reviewed times of gestation, the ratio between observed and expected MRI fetal lung volumes had almost equivalent statistically significant differences for neonatal survival (p ≤ 0.0029), need for ECMO therapy (p ≤ 0.0195), and development of chronic lung disease (p ≤ 0.0064). Results with high prognostic accuracy for early and for medium and late times in gestation also were obtained. Receiver operating characteristic analysis showed the highest area under the curve (≥ 0.819) for neonatal survival. CONCLUSION In patients with congenital diaphragmatic hernia, the relation between observed and expected MRI fetal lung volume is a valuable prognostic parameter for predicting neonatal mortality, morbidity represented by the development of chronic lung disease, and the need for ECMO therapy in early gestation (< 28 weeks) as well as later gestation with no statistically significant differences.
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Doné E, Gratacos E, Nicolaides KH, Allegaert K, Valencia C, Castañon M, Martinez JM, Jani J, Van Mieghem T, Greenough A, Gomez O, Lewi P, Deprest J. Predictors of neonatal morbidity in fetuses with severe isolated congenital diaphragmatic hernia undergoing fetoscopic tracheal occlusion. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:77-83. [PMID: 23444265 DOI: 10.1002/uog.12445] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Revised: 01/26/2013] [Accepted: 02/01/2013] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To investigate neonatal morbidity in fetuses with severe congenital diaphragmatic hernia (CDH) treated with fetoscopic endoluminal tracheal occlusion (FETO) and compare it with historical controls with less severe forms of CDH that were managed expectantly. METHODS This was a prospective, multicenter study on neonatal outcomes and prenatal predictors in 90 FETO survivors (78 left-sided, 12 right) and 41 controls from the antenatal CDH registry with either severe or moderate hypoplasia who were managed expectantly. We also investigated early neonatal morbidity indicators, including the need for patch repair, duration of mechanical ventilation and supplemental oxygen, age at full enteral feeding and incidence of pulmonary hypertension. RESULTS Gestational age at delivery was predictive of duration of assisted ventilation (P = 0.046), days on supplemental oxygen (P = 0.019) and age at full enteral feeding (P = 0.020). When delivery took place after 34 weeks' gestation, neonatal morbidity of FETO cases was comparable with that of expectantly managed cases with moderate hypoplasia. CONCLUSIONS Fetal intervention for severe CDH is associated with neonatal morbidity that is comparable with that of an expectantly managed group with less severe disease.
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MESH Headings
- Analysis of Variance
- Balloon Occlusion/adverse effects
- Belgium/epidemiology
- England/epidemiology
- Female
- Fetoscopy/adverse effects
- Gestational Age
- Hernia, Diaphragmatic/embryology
- Hernia, Diaphragmatic/mortality
- Hernia, Diaphragmatic/physiopathology
- Hernia, Diaphragmatic/surgery
- Hernias, Diaphragmatic, Congenital
- Humans
- Predictive Value of Tests
- Pregnancy
- Prospective Studies
- Respiration, Artificial/methods
- Respiration, Artificial/statistics & numerical data
- Spain/epidemiology
- Trachea
- Treatment Outcome
- Ultrasonography, Doppler
- Ultrasonography, Prenatal
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Affiliation(s)
- E Doné
- Department of Obstetrics and Gynaecology, Division of Woman and Child, University Hospitals Leuven, Leuven, Belgium
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Park HW, Lee BS, Lim G, Choi YS, Kim EAR, Kim KS. A simplified formula using early blood gas analysis can predict survival outcomes and the requirements for extracorporeal membrane oxygenation in congenital diaphragmatic hernia. J Korean Med Sci 2013; 28:924-8. [PMID: 23772159 PMCID: PMC3678011 DOI: 10.3346/jkms.2013.28.6.924] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Accepted: 04/08/2013] [Indexed: 11/20/2022] Open
Abstract
The aims of this study were to investigate whether early arterial blood gas analysis (ABGA) could define the severity of disease in infants with congenital diaphragmatic hernia (CDH). We conducted a retrospective study over a 21-yr period of infants diagnosed with CDH. Outcomes were defined as death before discharge, and extracorporeal membrane oxygenation requirements (ECMO) or death. A total 114 infants were included in this study. We investigated whether simplified prediction formula [PO2-PCO2] values at 0, 4, 8, and 12 hr after birth were associated with mortality, and ECMO or death. The area under curve (AUC) of receiver operating characteristic curve was used to determine the optimum ABGA values for predicting outcomes. The value of [PO2-PCO2] at birth was the best predictor of mortality (AUC 0.803, P < 0.001) and at 4 hr after birth was the most reliable predictor of ECMO or death (AUC 0.777, P < 0.001). The value of [PO2-PCO2] from ABGA early period after birth can reliably predict outcomes in infants with CDH.
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Affiliation(s)
- Hye Won Park
- Department of Pediatrics, Division of Neonatology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Byong Sop Lee
- Department of Pediatrics, Division of Neonatology, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Gina Lim
- Department of Pediatrics, Division of Neonatology, Ulsan University Hospital, Ulsan, Korea
| | - Yong-Sung Choi
- Department of Pediatrics, Division of Neonatology, Kyung Hee University Medical Center, Seoul, Korea
| | - Ellen Ai-Rhan Kim
- Department of Pediatrics, Division of Neonatology, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Soo Kim
- Department of Pediatrics, Division of Neonatology, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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Al-Turkistani H. Epidemiology and outcome of congenital diaphragmatic hernia in a tertiary care university hospital: 10 Years′ Experience. SAUDI JOURNAL OF MEDICINE AND MEDICAL SCIENCES 2013. [DOI: 10.4103/1658-631x.123655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Spaggiari E, Stirnemann J, Ville Y. Outcome in fetuses with isolated congenital diaphragmatic hernia with increased nuchal translucency thickness in first trimester. Prenat Diagn 2012; 32:268-71. [PMID: 22430726 DOI: 10.1002/pd.3819] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To examine the possible association between increased nuchal translucency (NT) thickness in the first trimester and perinatal outcome in isolated congenital diaphragmatic hernia (CDH). METHODS We conducted a retrospective study between January 2004 and June 2010. The database was searched to identify all consecutive cases of CDH referred to the fetal medicine center of Necker Hospital in Paris. Enlarged NT was defined above the 95th centile. Only children born alive with an isolated CDH were selected for the analysis of prognostic factors. We also studied the correlation between NT thickness in the first trimester and lung-to-head ratio, observed to expected lung area-to-head ratio, lung volume estimated by magnetic resonance imaging, and other prenatal features of intrathoracic compression. RESULTS Seventy-one cases of isolated CDH were available. The fetal NT was above the 95th centile in 9 of the 71 cases. Neonatal death occurred in 7/9 (78%) cases with enlarged NT, compared with 24/62 (38%) with normal NT (P = 0.035). Enlarged NT was significantly associated with prenatal features of intrathoracic compression. CONCLUSION Enlarged NT thickness in CDH is associated with a poor outcome and is related to an early intrathoracic compression.
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Affiliation(s)
- E Spaggiari
- AP-HP, Department of Obstetrics and Gynecology, Necker Enfants-Malades Hospital, Paris, France
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33
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Sosa-Sosa C, Bermúdez C, Chmait RH, Kontopoulos E, Córdoba Y, Guevara-Zuloaga F, Steffensen T, Quintero RA. Intraluminal tracheal occlusion using a modified 8-mm Z-stent in a sheep model of left-sided congenital diaphragmatic hernia. J Matern Fetal Neonatal Med 2012; 25:2346-53. [PMID: 22631591 DOI: 10.3109/14767058.2012.695825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate pulmonary growth and development after fetoscopic intraluminal tracheal occlusion (FITO) using a modified 8-mm Z-stent in an ovine model of congenital left-sided diaphragmatic hernia (CDH). METHODS Thirty-three time-dated ewes were studied: Group I: healthy controls; Group II: CDH controls (untreated); Group III: CDH treated with FITO. CDH was created in Groups II and III at 70-80 days' gestation. FITO was performed at 100-110 days. Left lung histological, morphometric, immunohistochemical and biochemical studies were conducted after delivery and euthanasia at 138 days. RESULTS Fifteen (45%) animals (Group I: 3; Group II: 5; Group III: 7) were available for analysis. The left lung parenchymal volume to fetal weight ratios were similar between Groups I and III (p = 0.24), and higher than Group II (p < 0.05III (79 versus 75%, p = 0.26), compared to 41% in Group II (p < 0.05). Pulmonary hypoplasia occurred in 1/7 (16%) in the FITO group, compared to 100% in Group II and 0% in Group I (p = .003). DNA and protein were significantly increased in Group III (p < 0.001). The concentration of type II pneumocytes was similar between healthy controls and the FITO group, and was paradoxically increased in untreated hernia fetuses. There was no histological evidence of tracheal injury. CONCLUSION FITO with a modified 8-mm Z-stent is associated with lung growth and maturation similar to controls without obvious deleterious effects. A phase I clinical trial of FITO with the modified 8-mm Z-stent in severe CDH patients seems warranted.
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Affiliation(s)
- Christian Sosa-Sosa
- Instituto Venezolano de Investigaciones Científicas (IVIC), Altos de Pipe, Estado Miranda, Venezuela
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Magoulas PL, El-Hattab AW. Chromosome 15q24 microdeletion syndrome. Orphanet J Rare Dis 2012; 7:2. [PMID: 22216833 PMCID: PMC3275445 DOI: 10.1186/1750-1172-7-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 01/04/2012] [Indexed: 01/24/2023] Open
Abstract
Chromosome 15q24 microdeletion syndrome is a recently described rare microdeletion syndrome that has been reported in 19 individuals. It is characterized by growth retardation, intellectual disability, and distinct facial features including long face with high anterior hairline, hypertelorism, epicanthal folds, downslanting palpebral fissures, sparse and broad medial eyebrows, broad and/or depressed nasal bridge, small mouth, long smooth philtrum, and full lower lip. Other common findings include skeletal and digital abnormalities, genital abnormalities in males, hypotonia, behavior problems, recurrent infections, and eye problems. Other less frequent findings include hearing loss, growth hormone deficiency, hernias, and obesity. Congenital malformations, while rare, can be severe and include structural brain anomalies, cardiovascular malformations, congenital diaphragmatic hernia, intestinal atresia, imperforate anus, and myelomeningocele. Karyotypes are typically normal, and the deletions were detected in these individuals by array comparative genomic hybridization (aCGH). The deletions range in size from 1.7-6.1 Mb and usually result from nonallelic homologous recombination (NAHR) between paralogous low-copy repeats (LCRs). The majority of 15q24 deletions have breakpoints that localize to one of five LCR clusters labeled LCR15q24A, -B, -C, -D, and -E. The smallest region of overlap (SRO) spans a 1.2 Mb region between LCR15q24B to LCR15q24C. There are several candidate genes within the SRO, including CYP11A1, SEMA7A, CPLX3, ARID3B, STRA6, SIN3A and CSK, that may predispose to many of the clinical features observed in individuals with 15q24 deletion syndrome. The deletion occurred as a de novo event in all of the individuals when parents were available for testing. Parental aCGH and/or FISH studies are recommended to provide accurate genetic counseling and guidance regarding prognosis, recurrence risk, and reproductive options. Management involves a multi-disciplinary approach to care with the primary care physician and clinical geneticist playing a crucial role in providing appropriate screening, surveillance, and care for individuals with this syndrome. At the time of diagnosis, individuals should receive baseline echocardiograms, audiologic, ophthalmologic, and developmental assessments. Growth and feeding should be closely monitored. Other specialists that may be involved in the care of individuals with 15q24 deletion syndrome include immunology, endocrine, orthopedics, neurology, and urology. Chromosome 15q24 microdeletion syndrome should be differentiated from other genetic syndromes, particularly velo-cardio-facial syndrome (22q11.2 deletion syndrome), Prader-Willi syndrome, and Noonan syndrome. These conditions share some phenotypic similarity to 15q24 deletion syndrome yet have characteristic features specific to each of them that allows the clinician to distinguish between them. Molecular genetic testing and/or aCGH will be able to diagnose these conditions in the majority of individuals.
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Affiliation(s)
- Pilar L Magoulas
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
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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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36
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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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38
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Usui N, Kitano Y, Okuyama H, Saito M, Masumoto K, Morikawa N, Takayasu H, Nakamura T, Hayashi S, Kawataki M, Ishikawa H, Nose K, Inamura N, Sago H. Prenatal risk stratification for isolated congenital diaphragmatic hernia: results of a Japanese multicenter study. J Pediatr Surg 2011; 46:1873-80. [PMID: 22008320 DOI: 10.1016/j.jpedsurg.2011.06.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 05/09/2011] [Accepted: 06/06/2011] [Indexed: 11/15/2022]
Abstract
BACKGROUND/PURPOSE The aim of this study was to establish a prenatal prognostic classification system for risk-stratified management in fetuses with isolated congenital diaphragmatic hernia (CDH). METHODS A multi-institutional retrospective cohort study of isolated CDH, diagnosed prenatally in fetuses delivered during the 2002 to 2007 period at 5 participating institutions in Japan, was conducted. The risk stratification system was formulated based on the odds ratios of prenatal parameters for mortality at 90 days. The clinical severity in CDH infants were compared among the stratified risk groups. RESULTS Patients were classified into the 3 risk groups: group A (n = 48) consisted of infants showing liver-down with contralateral lung-to-thorax transverse area ratio (L/T) ratio ≥0.08; group B of infants showing liver-down with L/T ratio <0.08 or liver-up with L/T ratio ≥0.08 (n = 35), and group C of infants showing liver-up with L/T ratio <0.08 (n = 20). The mortality at 90 days in groups A, B, and C were 0.0%, 20.0%, and 65.0%, respectively. The intact discharge rates were 95.8%, 60.0%, and 5.0%, respectively. This system also accurately reflected the clinical severity in CDH infants. CONCLUSIONS Our prenatal risk stratification system, which demonstrated a significant difference in postnatal status and final outcome, would allow for accurate estimation of the severity of disease in fetuses with isolated CDH, although it needs prospective validation in a different population.
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Affiliation(s)
- Noriaki Usui
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
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Mayer S, Klaritsch P, Petersen S, Done E, Sandaite I, Till H, Claus F, Deprest JA. The correlation between lung volume and liver herniation measurements by fetal MRI in isolated congenital diaphragmatic hernia: a systematic review and meta-analysis of observational studies. Prenat Diagn 2011; 31:1086-96. [DOI: 10.1002/pd.2839] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 06/28/2011] [Accepted: 06/29/2011] [Indexed: 11/06/2022]
Affiliation(s)
| | - Philipp Klaritsch
- Centre for Surgical Technologies, Faculty of Medicine; Katholieke Universiteit Leuven; B-3000; Leuven; Belgium
| | - Scott Petersen
- Centre for Surgical Technologies, Faculty of Medicine; Katholieke Universiteit Leuven; B-3000; Leuven; Belgium
| | | | | | - Holger Till
- Department of Paediatric Surgery; University Hospital Leipzig; D-40103; Leipzig; Germany
| | - Filip Claus
- Department of Radiology, Division of Medical Imaging; Katholieke Universiteit Leuven; B-3000; Leuven; Belgium
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40
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Roussel A, Hascoet JM, Desandes R, Claris O, Vieux R. [Does the regional health care organization impact the outcome of infants born with congenital diaphragmatic hernia?]. Arch Pediatr 2011; 18:1062-8. [PMID: 21873038 DOI: 10.1016/j.arcped.2011.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 04/06/2011] [Accepted: 07/22/2011] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Congenital diaphragmatic hernia (CDH) is a serious pathology that requires optimal management in very specialized health centers. French medical care organization is regionally based. Hence, evaluating local practices may help deliver clear information to parents before delivery. The aim of this study was to analyze the neonatal characteristics and the postnatal outcome of infants affected with CDH, treated within two different French perinatal health care networks. PATIENTS AND METHODS Retrospective cohort study of infants with CDH, cared for in the Lorraine perinatal health care network (Réseau Périnatal Lorrain [RPL]) or at Édouard-Herriot Hospital (HEH) in Lyon, between 1997 and 2007. RESULTS One hundred and twenty-seven newborns were included, 44 in the RPL and 83 in Lyon. Prenatal diagnosis of CDH was similar in RPL and at HEH; 47.7% of infants with CDH died in RPL vs 36.1% in HEH (P=0.2). Surgery delayed for more than 24h was more frequent in RPL (68.6% vs 31.7%; P<0.001), with a postoperative mortality rate of 31.4% vs 15.9%; P=0.08. In RPL, specialized medical follow-up was rare (33.3% vs 100%; P<0.001), while psychomotor retardation was more frequent (33.3% vs 5.7%; P=0.002). CONCLUSION This study brings to light the diversity of care and outcome for infants affected with CDH in two French perinatal health care networks. These results may help improve both centers' practices. In Lorraine for instance, the follow-up of these vulnerable children can be improved.
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MESH Headings
- Algorithms
- Cohort Studies
- France/epidemiology
- Health Services
- Hernia, Diaphragmatic/complications
- Hernia, Diaphragmatic/diagnosis
- Hernia, Diaphragmatic/mortality
- Hernia, Diaphragmatic/surgery
- Hernias, Diaphragmatic, Congenital
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/surgery
- Intensive Care, Neonatal
- Perinatal Care
- Postoperative Period
- Psychomotor Disorders/epidemiology
- Psychomotor Disorders/etiology
- Retrospective Studies
- Survival Rate
- Treatment Outcome
- Ultrasonography, Prenatal
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Affiliation(s)
- A Roussel
- Service de néonatalogie, soins intensifs et réanimation néonatale, maternité régionale universitaire de Nancy, 10, rue du Docteur-Heydenreich, 54042 Nancy cedex, France
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41
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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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Schaible T, Büsing KA, Felix JF, Hop WCJ, Zahn K, Wessel L, Siemer J, Neff KW, Tibboel D, Reiss I, van den Hout L. Prediction of chronic lung disease, survival and need for ECMO therapy in infants with congenital diaphragmatic hernia: additional value of fetal MRI measurements? Eur J Radiol 2011; 81:1076-82. [PMID: 21458944 DOI: 10.1016/j.ejrad.2011.02.060] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2010] [Revised: 02/15/2011] [Accepted: 02/23/2011] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The lung-to-head ratio (LHR), measured by ultrasound, and the fetal lung volume (FLV), measured by MRI, are both used to predict survival and need for extra corporeal membrane oxygenation (ECMO) in infants with congenital diaphragmatic hernia (CDH). The aim of this study is to determine whether MRI measurements of the FLV, in addition to standard ultrasound measurements of the LHR, give better prediction of chronic lung disease, mortality by day 28 and need for ECMO. MATERIALS AND METHODS Patients with unilateral isolated CDH born between January 2002 and December 2008 were eligible for inclusion. LHR and FLV were expressed as observed-to-expected values (O/E LHR and O/E FLV). Univariate and multivariate analyses were performed. Receiver operating characteristic curves were constructed and areas under the curve (AUC) were calculated to determine predictive values. RESULTS 90 patients were included in the analysis. Combined measurement of the O/E LHR and O/E FLV gave a slightly better prediction of chronic lung disease (AUC=0.83 and AUC=0.87) and need for ECMO therapy (AUC=0.77 and AUC=0.81) than standard ultrasound measurements of the O/E LHR alone. Combined measurement of the O/E LHR and O/E FLV did not improve prediction of early mortality (AUC=0.90) compared to measurement of the O/E LHR alone (AUC=0.89). An intrathoracal position of the liver was independently associated with a higher risk of early mortality (p<0.001), chronic lung disease (p=0.007) and need for ECMO therapy (p=0.001). DISCUSSION Chronic lung disease and need for ECMO therapy are slightly better predicted by combined measurement of the O/E LHR and the O/E FLV. Early mortality is very well predicted by measurement of the O/E LHR alone. CONCLUSION Clinical relevance of additional MRI measurements may be debated.
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Affiliation(s)
- T Schaible
- Universitätsmedizin Mannheim, Department of Paediatric Intensive Care Medicine, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
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43
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Done E, Allegaert K, Lewi P, Jani J, Gucciardo L, Van Mieghem T, Gratacos E, Devlieger R, Van Schoubroeck D, Deprest J. Maternal hyperoxygenation test in fetuses undergoing FETO for severe isolated congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 37:264-271. [PMID: 20652932 DOI: 10.1002/uog.7753] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVES To predict neonatal survival and pulmonary hypertension by measurement of fetal pulmonary artery reactivity to maternal hyperoxygenation in fetuses with severe congenital diaphragmatic hernia treated by fetoscopic endoluminal tracheal occlusion (FETO). METHODS Thirty-eight fetuses underwent FETO at around 28 weeks' gestation and the balloon was removed at 34 weeks in most cases. We performed a hyperoxygenation test and measured the lung-to-head ratio of each fetus before and after each procedure. Outcome measures were neonatal survival, occurrence of pulmonary hypertension and its response to inhaled nitric oxide (iNO). RESULTS Fetuses that survived had a larger increase in lung size and decrease of resistance in the first branch of the main pulmonary artery than did those that died. Both measures were also predictive of pulmonary hypertension unresponsive to iNO. The hyperoxygenation test and lung-to-head ratio were both best predictive for neonatal survival when measured following removal of the balloon (P < 0.002). Discriminant analysis confirmed that these two parameters are independent predictors of outcome. CONCLUSIONS In fetuses undergoing FETO, pulmonary vascular reactivity in relation to oxygen and lung size are independent predictors of neonatal survival and pulmonary hypertension. The hyperoxygenation test merits further study in expectantly managed cases.
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Affiliation(s)
- E Done
- Department of Obstetrics and Gynaecology, Division of Woman and Child, University Hospitals Leuven, Leuven, Belgium
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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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Deprest J, Nicolaides K, Done' E, Lewi P, Barki G, Largen E, DeKoninck P, Sandaite I, Ville Y, Benachi A, Jani J, Amat-Roldan I, Gratacos E. Technical aspects of fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia. J Pediatr Surg 2011; 46:22-32. [PMID: 21238635 DOI: 10.1016/j.jpedsurg.2010.10.008] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 10/14/2010] [Indexed: 10/18/2022]
Abstract
In isolated congenital diaphragmatic hernia, prenatal prediction is made based on measurements of lung size and the presence of liver herniation into the thorax. A subset of fetuses likely to die in the postnatal period is eligible for fetal intervention that can promote lung growth. Rather than anatomical repair, this is now attempted by temporary fetal endoscopic tracheal occlusion (FETO). Herein we describe purpose-designed instruments that were developed thanks to a grant from the European Commission. The feasibility and safety of FETO have now been demonstrated in several active fetal surgery programs. The most frequent complication of the procedure is preterm premature rupture of the membranes, which is probably iatrogenic in nature. It does have an impact on gestational age at delivery and complicates balloon removal. FETO is associated with an apparent increase in survival compared with same severity controls, although this needs to be evaluated in a formal trial. The time has come to do so.
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Affiliation(s)
- Jan Deprest
- Division of Woman and Child, University Hospital Leuven, Leuven, Belgium.
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Deprest JA, Flake AW, Gratacos E, Ville Y, Hecher K, Nicolaides K, Johnson MP, Luks FI, Adzick NS, Harrison MR. The making of fetal surgery. Prenat Diagn 2010; 30:653-67. [PMID: 20572114 DOI: 10.1002/pd.2571] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Fetal diagnosis prompts the question for fetal therapy in highly selected cases. Some conditions are suitable for in utero surgical intervention. This paper reviews historically important steps in the development of fetal surgery. The first invasive fetal intervention in 1963 was an intra-uterine blood transfusion. It took another 20 years to understand the pathophysiology of other candidate fetal conditions and to develop safe anaesthetic and surgical techniques before the team at the University of California at San Francisco performed its first urinary diversion through hysterotomy. This procedure would be abandoned as renal and pulmonary function could be just as effectively salvaged by ultrasound-guided insertion of a bladder shunt. Fetoscopy is another method for direct access to the feto-placental unit. It was historically used for fetal visualisation to guide biopsies or for vascular access but was also abandoned following the introduction of high-resolution ultrasound. Miniaturisation revived fetoscopy in the 1990 s, since when it has been successfully used to operate on the placenta and umbilical cord. Today, it is also used in fetuses with congenital diaphragmatic hernia (CDH), in whom lung growth is triggered by percutaneous tracheal occlusion. It can also be used to diagnose and treat urinary obstruction. Many fetal interventions remain investigational but for a number of conditions randomised trials have established the role of in utero surgery, making fetal surgery a clinical reality in a number of fetal therapy programmes. The safety of fetal surgery is such that even non-lethal conditions, such as myelomeningocoele repair, are at this moment considered a potential indication. This, as well as fetal intervention for CDH, is currently being investigated in randomised trials.
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Affiliation(s)
- Jan A Deprest
- Division Woman and Child, University Hospitals KU Leuven, Leuven, Belgium.
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Moreno-Alvarez O, Cruz-Martinez R, Hernandez-Andrade E, Done E, Gómez O, Deprest J, Gratacos E. Lung tissue perfusion in congenital diaphragmatic hernia and association with the lung-to-head ratio and intrapulmonary artery pulsed Doppler. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2010; 35:578-582. [PMID: 20178113 DOI: 10.1002/uog.7592] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To evaluate lung tissue perfusion in fetuses with congenital diaphragmatic hernia (CDH) and to explore the association of lung tissue perfusion with the lung area to head circumference ratio (LHR) and intrapulmonary artery pulsed Doppler. METHODS Fetuses with isolated left CDH were evaluated and compared with a group of fetuses without CDH, which were sampled from our general population and matched by gestational age at inclusion. Lung tissue perfusion measured using fractional moving blood volume (FMBV), the observed to expected (O/E) LHR and pulsed Doppler of the proximal intrapulmonary artery were evaluated in the lung contralateral to the side of the hernia. Doppler waveform analysis included the pulsatility index (PI), the peak early diastolic reversed flow (PEDRF) and the peak systolic velocity (PSV). All Doppler parameters were converted into Z-scores for gestational age. The associations between FMBV and O/E-LHR and between FMBV and intrapulmonary arterial Doppler parameters were analyzed using multiple linear regression, adjusted by gestational age. RESULTS A total of 190 fetuses (95 with CDH and 95 controls) were evaluated. Fetuses with CDH showed significantly lower lung FMBV (26.8 (SD 8.4) vs. 37.9 (SD 8.1)%; P < 0.001) than controls. Lung tissue perfusion correlated positively with O/E-LHR (r = 0.37; P < 0.001) and negatively with intrapulmonary artery PI (r = - 0.31; P < 0.001), PEDRF (r = - 0.43; P < 0.001) and PSV (r = - 0.18; P = 0.03). CONCLUSIONS Fetuses with CDH have decreased lung tissue perfusion, which is associated with decreased lung growth and increased intrapulmonary artery impedance.
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Affiliation(s)
- O Moreno-Alvarez
- 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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Mullassery D, Ba'ath ME, Jesudason EC, Losty PD. Value of liver herniation in prediction of outcome in fetal congenital diaphragmatic hernia: a systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2010; 35:609-614. [PMID: 20178116 DOI: 10.1002/uog.7586] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVES Intrathoracic liver herniation (ILH) is being used to estimate prognosis and hence guide antenatal interventions in fetal congenital diaphragmatic hernia (CDH). However, the literature regarding its utility in this role is conflicting. This review systematically examines the currently available evidence of ILH use in fetal CDH. METHODS MEDLINE and EMBASE databases were searched for the terms ((congenital diaphragmatic hernia) OR CDH) AND liver. Inclusion criteria were human case series of fetuses diagnosed with CDH using either ultrasound or magnetic resonance imaging. Included studies were required to have reported the antenatal liver position and the outcome (survival or not). Case reports, reviews and eventration series were excluded. Studies reporting similar cases from the same center over an overlapping time period were considered duplicates; only the larger of the studies were therefore included. Absolute totals were extracted and sums calculated. Fisher's exact test (FET) was used to compare survival rates in different groups. RESULTS The original search retrieved 338 studies. Applying inclusion/exclusion criteria and removing duplicates left 21 case series in 20 studies. Retrieved studies differed in the definitions of liver herniation, survival and treatment modality. In total, there were 407 fetuses in the liver-up (herniated) and 303 in the liver-down (not herniated) groups. Survival rates were 45.4% and 73.9%, respectively. The difference was statistically significant (FET = 56.4, P < 0.005). Sensitivity analysis for cases that had only conventional postnatal treatment was still significant (FET = 52.8, P < 0.005). CONCLUSIONS Liver herniation is associated with poorer prognosis in fetal CDH. Grading liver herniation or using it as part of a panel of markers may enhance the value of liver herniation as a prognostic test in fetal CDH.
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Affiliation(s)
- D Mullassery
- Division of Child Health, University of Liverpool, Alder Hey Children's Hospital NHS Trust, Liverpool, UK.
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Fayoux P, Hosana G, Devisme L, Deprest J, Jani J, Vaast P, Storme L. Neonatal tracheal changes following in utero fetoscopic balloon tracheal occlusion in severe congenital diaphragmatic hernia. J Pediatr Surg 2010; 45:687-92. [PMID: 20385271 DOI: 10.1016/j.jpedsurg.2009.08.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2009] [Revised: 08/10/2009] [Accepted: 08/10/2009] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To report postnatal tracheal changes after in utero fetoscopic balloon tracheal occlusion in severe congenital diaphragmatic hernia (CDH). DESIGN Case series. SETTING Tertiary care center, CDH National Reference Center. PATIENTS Seven consecutive newborn infants with severe CDH who underwent fetoscopic balloon tracheal occlusion. INTERVENTIONS Flexible laryngotracheoscopy and histological aspect observed at necropsy in 2 nonsurvivors. RESULTS All infants displayed elongation and relaxation of the posterior tracheal wall, intermittently obstructing the lumen during tidal breathing. Whereas the cartilage displayed adequate rigidity, the pars membranacea appeared both flaccid and loose. Tracheal widening (tracheomegaly) was seen in all cases. Histology (n = 2) pointed to structural modifications throughout the pars membranacea, that is, loss of epithelial folding and of longitudinal elastic network and focal muscular disruption. The cartilage displayed no visible or histologic changes. The above tracheal changes were not symptomatic, except for a barking cough during increased respiratory efforts. CONCLUSIONS Tracheal widening and intermittent collapse of the posterior wall of the trachea during tidal breathing was found in 7 consecutive newborns who underwent fetoscopic balloon tracheal occlusion, causing mild clinical symptoms. Endoscopic tracheal assessment might provide useful information in children with CDH, in particular, when they underwent in utero fetoscopic balloon tracheal occlusion.
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Affiliation(s)
- Pierre Fayoux
- Department of Pediatric Otorhinolaryngology, Jeanne de Flandre Hospital, CHRU de Lille, France.
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Deprest JA, Devlieger R, Srisupundit K, Beck V, Sandaite I, Rusconi S, Claus F, Naulaers G, Van de Velde M, Brady P, Devriendt K, Vermeesch J, Toelen J, Carlon M, Debyser Z, De Catte L, Lewi L. Fetal surgery is a clinical reality. Semin Fetal Neonatal Med 2010; 15:58-67. [PMID: 19913467 DOI: 10.1016/j.siny.2009.10.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An increasing number of fetal anomalies are being diagnosed prior to birth, some of them amenable to fetal surgical intervention. We discuss the current clinical status and recent advances in endoscopic and open surgical interventions. In Europe, fetoscopic interventions are widely embraced, whereas the uptake of open fetal surgery is much less. The indications for each access modality are different, hence they cannot substitute each other. Although the stage of technical experimentation is over, most interventions remain investigational. Today there is level I evidence that fetoscopic laser surgery for twin-to-twin transfusion syndrome is the preferred therapy, but this operation actually takes place on the placenta. In terms of surgery on the fetus, an increasingly frequent indication is severe congenital diaphragmatic hernia as well as myelomeningocele. Overall maternal safety is high, but rupture of the membranes and preterm delivery remain a problem. The increasing application of fetal surgery and its mediagenicity has triggered the interest to embark on fetal surgical therapy, although the complexity as well as the overall rare indications are a limitation to sufficient experience on an individual basis. We plead for increased exchange between high volume units and collaborative studies; there may also be a case for self-regulation. Inclusion of patients into trials whenever possible should be encouraged rather than building up casuistic experience.
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Affiliation(s)
- Jan A Deprest
- Division Woman and Child, University Hospital Gasthuisberg, Leuven, Belgium.
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