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Chimenea A, Domínguez-Moreno M, Barrera-Talavera M, García-Díaz L, Antiñolo G. Maternal and Neonatal Outcomes After Ex-Utero Intrapartum Treatment for Congenital Diaphragmatic Hernia: A Case Series. Eur J Pediatr Surg 2024; 34:319-324. [PMID: 37473779 DOI: 10.1055/a-2133-8380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
INTRODUCTION Despite advances in neonatal intensive care, fetuses with congenital diaphragmatic hernia (CDH) remain to have a poor prognosis. Exclusive postnatal treatment is inadequate in patients with moderate CDH (observed than expected lung-to-head ratio [O/E LHR] 26-45%) and can lead to respiratory failure at birth, requiring extracorporeal membrane oxygenation in 75% of cases. An ex-utero intrapartum treatment (EXIT) procedure may be beneficial in these cases, improving the fetal-neonatal transition. MATERIAL AND METHODS We review all pregnancies with fetal isolated left CDH with moderate O/E LHR delivered by EXIT in our center from January 2007 to December 2022. Maternal and neonatal variables were analyzed. As primary outcomes, we included neonatal survival and mortality rates, surgical and infectious complications, uterine scar dehiscence, and blood loss during EXIT. As secondary outcomes, we studied recurrences of the diaphragmatic defect, long-term evolution, subsequent pregnancies, and mode of delivery. RESULTS A total of 14 patients were delivered by the EXIT procedure, with a neonatal survival rate of 85.7%. All these children had optimal physical and neurocognitive development and no pulmonary morbidity. We found no major complications and 7.1% of minor maternal complications. There were no cases of surgical wound infection or endometritis. The median decrease in hemoglobin during the EXIT procedure was 1.9 mg/dL, and only one case required postoperative transfusion. Two out of the 14 women became pregnant again, and both pregnancies were uneventful. CONCLUSIONS In our series, the EXIT procedure allows for adequate airway management associated with a high neonatal survival rate in patients with moderate O/E LHR CDH, with a low rate of neonatal and maternal complications.
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Affiliation(s)
- Angel Chimenea
- Department of Materno-Fetal Medicine, Genetics, and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
- Fetal, IVF, and Reproduction Simulation Training Centre (FIRST), Seville, Spain
| | - Marta Domínguez-Moreno
- Department of Materno-Fetal Medicine, Genetics, and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
| | - María Barrera-Talavera
- Department of Materno-Fetal Medicine, Genetics, and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
| | - Lutgardo García-Díaz
- Department of Materno-Fetal Medicine, Genetics, and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
- Department of Surgery, University of Seville, Seville, Spain
| | - Guillermo Antiñolo
- Department of Materno-Fetal Medicine, Genetics, and Reproduction, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocio/CSIC/University of Seville, Seville, Spain
- Fetal, IVF, and Reproduction Simulation Training Centre (FIRST), Seville, Spain
- Department of Surgery, University of Seville, Seville, Spain
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), Seville, Spain
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Mohamed SHM, Reissland N, Anand KJS. An Evidence-Based Discussion of Fetal Pain and Stress. Neonatology 2024:1-7. [PMID: 38781940 DOI: 10.1159/000538848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/10/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND The concept of fetal pain results from procedures conducted without anesthesia in preterm newborns and fetuses, which indicate that it is possible to examine fetal pain based on stress hormone, metabolic, and behavioral changes. Anatomical and physiological data suggest that fetuses become capable of processing nociceptive stimuli around midgestation, although the associated changes in fetal brain development remain unclear. What constitutes fetal pain remains controversial in the light of the definition of pain adopted by the International Association for the Study of Pain (IASP), which posits pain as an "unpleasant sensory and emotional experience." SUMMARY Here, we examine the notion that human fetuses cannot "experience" pain and potential implications of this claim. We highlight the key scientific evidence related to fetal pain, including clinical studies on pain in fetuses and preterm newborns. We argue that consistent patterns of stress hormones, metabolic changes, body movements, hemodynamic changes, and pain-related facial expressions in fetuses exposed to invasive procedures overcome the need for subjective proof of pain as articulated in the IASP definition. No study to date has conclusively proven the absence of fetal pain beyond the age of viability. KEY MESSAGES Based on the current evidence, we propose that all fetuses receive anesthesia regardless of the invasive procedures being performed to guarantee the least possible pain and physiological, behavioral, or hormonal responses without exposing the mother or her baby to unnecessary complications.
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Affiliation(s)
- Samirah H M Mohamed
- Obstetric Clinic at the Clinics Hospital of the Medical School, The University of São Paulo, São Paulo, Brazil
- Research Department of the Hospital e Maternidade Vitória, São Paulo, Brazil
- Medical Tutor at the University Center of the Faculty of the Americas, São Paulo, Brazil
| | | | - Kanwaljeet J S Anand
- Departments of Pediatrics, Perioperative, and Pain Medicine, Stanford Child Wellness Lab, Maternal & Child Health Research Institute, Stanford University School of Medicine, Stanford, California, USA
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Montgomery A, Peiffer S, Mehl S, Lee TC, Keswani SG, King A. Management and Outcomes of Patients With High-Risk (Congenital Lung Malformation Volume Ratio≥ 1.6) Congenital Lung Malformations. J Surg Res 2024; 295:559-566. [PMID: 38086256 DOI: 10.1016/j.jss.2023.11.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/23/2023] [Accepted: 11/16/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Congenital lung malformations (CLMs) have a variable natural history. Larger lesions with CLM volume ratio (CVR) ≥ 1.6 are associated with hydrops and fetal mortality. The purpose of this study is to describe the management and outcomes of high-risk (CVR ≥ 1.6) CLM patients. METHODS A retrospective cohort study was performed for all fetuses evaluated between May 2015 and May 2022. Demographics, prenatal imaging factors, prenatal and postnatal treatment, and outcomes were collected. Descriptive statistics were used to compare the cohorts. RESULTS Of 149 fetal CLM patients referred to our fetal center, 21/149 (14%) had CVR ≥ 1.6. One CLM patient had intrauterine fetal demise, and 2 patients were lost to follow-up. Of the remaining 18 patients, 11/18 (67%) received maternal steroids. Seven out of 18 patients (39%) underwent resection at the time of delivery with 1/7 (14%) undergoing exutero intrapartum treatment (EXIT)-to-resection, 5/7 (71%) undergoing EXIT-to-exteriorization-to-resection, and 1/7 (14%) undergoing a coordinated delivery to resection; among those undergoing resection, there were 2 fatalities (28.5%). Seven out of 18 (39%) patients required urgent neonatal open lobectomies, and the remaining 4/18 (22%) patients underwent elective thoracoscopic lobectomies with no mortality. CONCLUSIONS The natural history and outcomes of severe CLM patients remain highly variable. The EXIT-to-exteriorization-to-resection procedure may be a safe and effective approach for a subset of CLM patients with persistent symptoms of mass effect and severe mediastinal shift due to the observed decreased operative time requiring placental support observed in our study.
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Affiliation(s)
- Ashley Montgomery
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sarah Peiffer
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Steven Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas.
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Jia Y, Liang X, Liu L, Ma H, Xu C, Zeng J, Xu R, Ye L, Xie L. Trends in research related to fetal therapy from 2012 to 2022: a bibliometric analysis. Front Pediatr 2024; 11:1288660. [PMID: 38293659 PMCID: PMC10826513 DOI: 10.3389/fped.2023.1288660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/13/2023] [Indexed: 02/01/2024] Open
Abstract
Background The development of prenatal diagnosis technology allows prompt detection of severe fetal diseases. To address adverse factors that threaten fetal survival, fetal therapy came into existence, which aims to preserve the function after birth to a higher degree and improve the quality of life. Objective To conduct a comprehensive bibliometric analysis of studies on fetal therapy in the past decade and explore the research trends and hotspots in this field. Methods We conducted a systematic search on the Web of Science Core Collection to retrieve studies related to fetal therapy published from 2012 to 2022. VOSviewer and CiteSpace were used to analyze the key features of studies, including annual output, countries/regions, institutions, authors, references, research hotspots, and frontiers. Results A total of 9,715 articles were included after eliminating duplicates. The annual distribution of the number of articles showed that the number of articles published in fetal therapy had increased in the past decade. Countries and institutions showed that fetal therapy is more mature in the United States. Author analysis showed the core investigators in the field. Keyword analysis showed the clustering and emergence frequency, which helped summarize the research results and frontier hotspots in this field. The cocited references were sorted out to determine the literature with a high ranking of fetal therapy in recent years, and the research trend in recent years was analyzed. Conclusions This study reveals that countries, institutions, and researchers should promote wider cooperation and establish multicenter research cooperation in fetal therapy research. Moreover, fetal therapy has been gradually explored from traditional surgical treatment to gene therapy and stem cell therapy. In recent years, fetoscopic laser surgery, guideline, and magnetic resonance imaging have become the research hotspots in the field.
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Affiliation(s)
- Yang Jia
- Department of Radiology, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaoling Liang
- Department of Ultrasound, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, Sichuan, China
| | - Lini Liu
- Department of Radiology, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Huixi Ma
- Department of Radiology, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chenhao Xu
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Jingyuan Zeng
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Rong Xu
- Department of Radiology, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lu Ye
- Department of Ultrasound, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Linjun Xie
- Department of Radiology, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
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