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Bhatia H, Singla V, Soni S, Kakkar N, Joshi B. Fetal Ascites: Expecting the Unexpected! J Obstet Gynaecol India 2024; 74:278-280. [PMID: 38974748 PMCID: PMC11224058 DOI: 10.1007/s13224-023-01898-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 10/24/2023] [Indexed: 07/09/2024] Open
Affiliation(s)
- Harsimran Bhatia
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Veenu Singla
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Saumya Soni
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Nandita Kakkar
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Bharti Joshi
- Department of Obstetrics and Gynaecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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2
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Medicine and the Law. S Afr Med J 2022; 112:791-794. [PMID: 36472335 DOI: 10.7196/samj.2022.v112i10.16471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Indexed: 01/04/2023] Open
Abstract
Congenital high airway obstruction syndrome (CHAOS) is a rare condition that can be diagnosed antenatally by ultrasound. It is usually lethal without immediate intervention at delivery. A 24-year-old woman was diagnosed with fetal CHAOS at 27 weeks' gestation. The couple declined termination of pregnancy. A multidisciplinary team including obstetricians, geneticists, paediatric surgeons, neonatologists and anaesthetists was constituted to plan an ex utero intrapartum treatment (EXIT) procedure. After several simulations, a caesarean section was performed at 38 weeks' gestation under deep inhalational anaesthesia. The fetus was fully delivered with placenta remaining in utero to maintain perfusion. A surgical airway was established via tracheostomy in approximately 5 minutes. The operation was then completed with no maternal complications. The child remains well at 3 years of age. To our knowledge, this is the first EXIT procedure performed for CHAOS in the public sector. This procedure can be lifesaving and is possible with proper planning.
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3
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Hasina Z, Wang CC. Prenatal and Postnatal Therapies for Down's Syndrome and Associated Developmental Anomalies and Degenerative Deficits: A Systematic Review of Guidelines and Trials. Front Med (Lausanne) 2022; 9:910424. [PMID: 35865169 PMCID: PMC9294288 DOI: 10.3389/fmed.2022.910424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/03/2022] [Indexed: 12/04/2022] Open
Abstract
Down's syndrome (DS) is the most common genetic disorder at birth. Multiple developmental abnormalities before birth and early onset of degenerative deficits after birth are features of DS. Early treatment for the manifestations associated with DS in either prenatal or postnatal period may improve clinical outcomes. However, information available from professional bodies and to communities is very limited. We carried out a systematic review and attempted meta-analysis of clinical trials for developmental abnormalities and degenerative deficits in DS. Only 15 randomized controlled trials (RCTs) in 995 (24 days to 65 years old) individuals with DS showed some improvement in cognitive disorders, development and growth, and musculoskeletal problem. However, each trial used different parameters and methods to measure various outcomes. RCTs of prenatal interventions in fetus with DS are lacking. The efficacy and safety of specific interventions in DS are still largely unknown. Proper counseling of the potential treatment for pregnant mothers who wish to continue their pregnancy carrying fetus with DS, and to health care professionals who take care of them are not adequate nowadays.
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Affiliation(s)
- Zinnat Hasina
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Chi Chiu Wang
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- School of Biomedical Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- Chinese University of Hong Kong-Sichuan University Joint Laboratory in Reproductive Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- *Correspondence: Chi Chiu Wang
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4
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Chaturvedi A, Klionsky N, Biyyam D, Chess MA, Sultan N. Acutely presenting congenital chest lesions: a primer for the radiologist. Emerg Radiol 2022; 29:557-570. [PMID: 35253079 DOI: 10.1007/s10140-022-02035-3] [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: 02/09/2022] [Accepted: 02/20/2022] [Indexed: 11/26/2022]
Abstract
Congenital chest lesions encompass several important entities. Without prompt intervention, many of these can culminate in serious complications. Timely and accurate radiologic interpretation of these entities is integral to patient management. Imaging can help characterize and prognosticate several of these entities, and may both suggest the need for and guide therapy. We overview the clinical presentation, associated complications, imaging characteristics, and prognostic indicators-both postnatal and antenatal-of the spectrum of emergently presenting congenital chest lesions. We also outline current and evolving management strategies, whether fetal, peripartum, or postnatal. The ultimate goal is to help radiologists formulate timely and effective diagnoses of these entities and boost the relevance of their input towards clinical decision-making.
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Affiliation(s)
- Apeksha Chaturvedi
- Department of Imaging Sciences, Division of Pediatric Radiology, University of Rochester Medical Center, Rochester, NY, 14642, USA.
| | - Nina Klionsky
- Department of Imaging Sciences, Division of Pediatric Radiology, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | | | - Mitchell A Chess
- Department of Imaging Sciences, Division of Pediatric Radiology, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Nadia Sultan
- Department of Imaging Sciences, Division of Pediatric Radiology, University of Rochester Medical Center, Rochester, NY, 14642, USA
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5
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Prenatal Diagnosis and Outcome of Tracheal Agenesis as Part of Congenital High Airway Obstruction Syndrome. Case Presentation and Literature Review. Medicina (B Aires) 2021; 57:medicina57111253. [PMID: 34833471 PMCID: PMC8619531 DOI: 10.3390/medicina57111253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/24/2021] [Accepted: 11/09/2021] [Indexed: 11/17/2022] Open
Abstract
Tracheal atresia is an extremely rare condition whereby a partial or total obstruction of the trachea is seen. It is almost always lethal, with just a handful of cases that ended with a good outcome. In this study we report on a 15-week male fetus, diagnosed with hyperechogenic lungs, midline heart position and inverted diaphragm. Sonographic findings suggest congenital High Airway Obstruction Syndrome (CHAOS) An ultrasound scan and fetal MRI were not able to point out the exact obstruction level. In spite of extensive counselling, the parents opted to carry on with the pregnancy. Fetal demise was noted on a scan at 19 weeks gestation. After the elective termination of pregnancy, a post-mortem examination showed partial tracheal atresia with no other anomalies. Despite technological progress in CHAOS syndrome, a precise diagnosis and accurate prognosis remain elusive.
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6
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Ex utero intrapartum technique (EXIT): Indications, procedure methods and materno-fetal complications - A literature review. J Gynecol Obstet Hum Reprod 2021; 51:102252. [PMID: 34638008 DOI: 10.1016/j.jogoh.2021.102252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/24/2021] [Accepted: 10/06/2021] [Indexed: 12/23/2022]
Abstract
A congenital malformation of the head, neck or thorax can lead to upper airway compression with a risk of asphyxia or neonatal death. To secure and protect the upper airway, the Ex Utero Intrapartum Therapy (EXIT) procedure has been developed. The procedure allows delivery of the fetus via a hysterotomy while relying on the placenta as the organ of respiration for the fetus prior to clamping of the umbilical cord. A high level of expertise is necessary for successful completion of the EXIT procedure, which is not void of maternal and fetal risks. In this literature review, we present the indications, procedure methods and materno-fetal complications associated with the EXIT procedure.
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7
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Barrette LX, Morales CZ, Oliver ER, Gebb JS, Feygin T, Lioy J, Howell LJ, Hedrick HL, Jackson OA, Adzick NS, Javia LR. Risk factor analysis and outcomes of airway management in antenatally diagnosed cervical masses. Int J Pediatr Otorhinolaryngol 2021; 149:110851. [PMID: 34311168 DOI: 10.1016/j.ijporl.2021.110851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/01/2021] [Accepted: 07/20/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE To investigate antenatally-determined imaging characteristics associated with invasive airway management at birth in patients with cervical masses, as well as to describe postnatal management and outcomes. STUDY DESIGN A retrospective analysis of 52 patients with antenatally diagnosed neck masses was performed using single-center data from January 2008 to January 2019. Antenatal imaging, method of delivery, management, and outcomes data were abstracted from the medical record and analyzed. RESULTS Antenatal diagnosis of neck masses in this cohort consisted of 41 lymphatic malformations (78.8%), 6 teratomas (11.5%), 3 hemangiomas (5.8%), 1 hemangioendothelioma (1.9%), and 1 giant foregut duplication cyst (1.9%). Mean gestational age at time of diagnostic imaging was 29 weeks 3 days (range: 19w4d - 37w). Overall, 22 patients (42.3%) required invasive airway management at birth, specifically 18 patients (34.6%) required endotracheal intubation and 4 (7.7%) required tracheostomy. 15 patients (28.8%) underwent ex-utero intrapartum treatment (EXIT) for the purposes of securing an airway. Polyhydramnios, tracheal deviation and compression, and anterior mass location on antenatal imaging were significantly associated with incidence of invasive airway intervention at birth, EXIT procedure, and tracheostomy during the neonatal hospitalization (p < 0.025; Fisher's exact test). Logistic regression analysis demonstrated statistically significant association between increasing antenatally-estimated mass volume and incidence of invasive airway management at birth (p = 0.02). Post-natal cervical mass management involved surgical excision (32.7%), sclerotherapy (50%), and adjuvant therapy with rapamycin (17.3%). Demise in the neonatal period occurred in 4 (7.7%) patients. CONCLUSION This series documents the largest single-center experience of airway management in antenatally diagnosed cervical masses. Fetal imaging characteristics may help inform the appropriate method of delivery, airway management strategy at birth, and prenatal counseling.
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Affiliation(s)
- Louis-Xavier Barrette
- Division of Otolaryngology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Carrie Z Morales
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Leonard and Madlyn Abramson Pediatric Research Center, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Edward R Oliver
- Department of Radiology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Juliana S Gebb
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Tamara Feygin
- Department of Radiology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Janet Lioy
- Division of Neonatology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Lori J Howell
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Holly L Hedrick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Oksana A Jackson
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Leonard and Madlyn Abramson Pediatric Research Center, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - N Scott Adzick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Luv R Javia
- Division of Otolaryngology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
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Lago Leal V, Cortés LM, Seco Del Cacho C. Prenatal diagnosis of congenital high airway obstruction syndrome. Indian J Radiol Imaging 2021; 28:366-368. [PMID: 30319217 PMCID: PMC6176680 DOI: 10.4103/ijri.ijri_396_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Congenital high airway obstruction syndrome (CHAOS) is a rare sequence due to a complete obstruction of the fetal airway that blocks the larynx or trachea, either intrinsic atresia or extrinsic compression (e.g., congenital neck mass). Despite the true incidence of CHAOS is unknown, an incidence of 1 per 50,000 newborns is described. If any obstruction occurs in the tracheobronchial airway, this secretion cannot be extricated. Because of this situation, a knock-on effect starts: the enlargement of the lungs squeezes the heart and great veins, what results in a replacement of the heart to the center of the chest becoming small and dysfunctional. Decreased venous return and the failure of cardiovascular system end in ascites and hydrops. The diaphragm planes or inverts according to the severity of the process. In case of unrecognized syndrome during the prenatal period, it usually results in stillbirth or death shortly after delivery. The overall prognosis remains fatal, and long-term medical and surgical challenges for survivors remain considerable even after overcoming fetal intervention.
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Affiliation(s)
- Víctor Lago Leal
- Department of Obstetrics and Gynecology, University Hospital of Getafe, Getafe, Madrid, Spain
| | - Luis Martínez Cortés
- Department of Obstetrics and Gynecology, University Hospital of Getafe, Getafe, Madrid, Spain
| | - Carlos Seco Del Cacho
- Department of Obstetrics and Gynecology, University Hospital of Getafe, Getafe, Madrid, Spain
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9
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Varela MF, Pinzon-Guzman C, Riddle S, Parikh R, McKinney D, Rutter M, Lim FY, Peiro JL. EXIT-to-airway: Fundamentals, prenatal work-up, and technical aspects. Semin Pediatr Surg 2021; 30:151066. [PMID: 34172204 DOI: 10.1016/j.sempedsurg.2021.151066] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Ex-utero intrapartum treatment (EXIT) is a delivery strategy developed to manage a variety of prenatally diagnosed conditions in the transition to newborn life. This procedure allows control and provides time for intervention in otherwise life-threatening malformations, such as congenital upper airway obstructions. EXIT-to-airway has changed the outcome of fetuses with these anomalies. The main purpose of this intervention is to improve the safety of establishing a reliable airway at birth. Maximal but controlled uterine relaxation to maintain feto-maternal perfusion and thus gas exchange, while keeping the fetal and maternal well-being are the paradigms of any type of EXIT. The most important aspect of fetal airway management is to consolidate a highly trained, well-coordinated, multidisciplinary team that is prepared for every contingency. A comprehensive prenatal assessment, including ultrasound, fetal echocardiogram, fetal MRI, and genetic testing is imperative for patient selection. Extensive preoperative planning, ad-hoc team meetings, and surgical simulations for challenging cases are critical strategies to achieve the best outcomes. This article outlines the prenatal work-up, decision making, technical aspects, and principles for a successful EXIT-to-airway procedure.
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Affiliation(s)
- Maria Florencia Varela
- The Center for Fetal and Placental Research, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, USA
| | - Carolina Pinzon-Guzman
- The Center for Fetal and Placental Research, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, USA; Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA
| | - Stefanie Riddle
- Division of Neonatology, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA.; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rupi Parikh
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David McKinney
- Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael Rutter
- Division of Pediatric Otolaryngology, Head and Neck Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Foong-Yen Lim
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jose L Peiro
- The Center for Fetal and Placental Research, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, USA; Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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10
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Perinatal outcome of fetuses with congenital high airway obstruction syndrome: a single-center experience. Obstet Gynecol Sci 2020; 64:52-61. [PMID: 33285045 PMCID: PMC7834760 DOI: 10.5468/ogs.20266] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 10/21/2020] [Indexed: 11/17/2022] Open
Abstract
Objective To report our experience with management of fetuses with congenital high airway obstruction syndrome (CHAOS). Methods We retrospectively reviewed the cases of fetuses who were prenatally diagnosed and postnatally confirmed with CHAOS between 2010 and 2019 at Asan Medical Center, Seoul, Korea. Results Of 13 fetuses prenatally diagnosed with CHAOS, 7 were lost to follow-up and 6 were postnatally confirmed as having CHAOS. All fetuses, except one were delivered via cesarean section with an ex utero intrapartum treatment (EXIT) procedure. Two patients had coexisting congenital heart diseases requiring several cardiac surgeries following birth. Both of these patients demonstrated developmental delay; however, the remaining 4 had a normal development except for expressive language. Two infants died of respiratory complications, and the remaining 4 were alive at the end of the follow-up period. All 4 live patients underwent tracheostomy with planned reconstruction surgery. Three children are now able to phonate, and 1 can maintain a conservation. Conclusion The proper management of CHAOS using the EXIT procedure results in high survival and low hypoxemia-induced complication rates. Therefore, an accurate prenatal diagnosis is necessary for an appropriate perinatal management.
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11
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Puricelli MD, Rahbar R, Allen GC, Balakrishnan K, Brigger MT, Daniel SJ, Fayoux P, Goudy S, Hewitt R, Hsu WC, Ida JB, Johnson R, Leboulanger N, Rickert SM, Roy S, Russell J, Rutter M, Sidell D, Soma M, Thierry B, Trozzi M, Zalzal G, Zdanski CJ, Smith RJH. International Pediatric Otolaryngology Group (IPOG): Consensus recommendations on the prenatal and perinatal management of anticipated airway obstruction. Int J Pediatr Otorhinolaryngol 2020; 138:110281. [PMID: 32891939 DOI: 10.1016/j.ijporl.2020.110281] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 07/25/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To make recommendations on the identification, routine evaluation, and management of fetuses at risk for airway compromise at delivery. METHODS Recommendations are based on expert opinion by members of the International Pediatric Otolaryngology Group (IPOG). A two-iterative Delphi method questionnaire was distributed to all members of the IPOG and responses recorded. The respondents were given the opportunity to comment on the content and format of the survey, which was modified for the second round. "Consensus" was defined by >80% respondent affirmative responses, "agreement" by 51-80% affirmative responses, and "no agreement" by 50% or less affirmative responses. RESULTS Recommendations are provided regarding etiologies of perinatal airway obstruction, imaging evaluation, adjunct evaluation, multidisciplinary team and decision factors, micrognathia management, congenital high airway obstruction syndrome management, head and neck mass management, attended delivery procedure, and delivery on placental support procedure. CONCLUSIONS Thorough evaluation and thoughtful decision making are required to optimally balance fetal and maternal risks/benefits.
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Affiliation(s)
- Michael D Puricelli
- Department of Otolaryngology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
| | - Reza Rahbar
- Department of Otolaryngology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory C Allen
- Department of Otolaryngology - Head & Neck Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Karthik Balakrishnan
- Department of Otolaryngology, Head and Neck Surgery, Division of Pediatric Otolaryngology, Stanford University, Stanford, CA, USA
| | - Matthew T Brigger
- Division of Pediatric Otolaryngology, Rady Children's Hospital San Diego, University of California San Diego, San Diego, CA, USA
| | - Sam J Daniel
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Canada
| | - Pierre Fayoux
- Department of Pediatric Otolaryngology Head-Neck Surgery, University Hospital of Lille, Lille, France
| | - Steven Goudy
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Richard Hewitt
- Department of Ear, Nose and Throat Surgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Wei-Chung Hsu
- Department of Otolaryngology, College of Medicine, National Taiwan University and National Taiwan University Hospital, Taipei, Taiwan
| | - Jonathan B Ida
- Division of Pediatric Otolaryngology, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Romaine Johnson
- Otolaryngology-Head and Neck Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Nicolas Leboulanger
- Pediatric Otolaryngology - Head and Neck Surgery, Necker Enfants Malades Hospital, Paris University, Paris, France
| | - Scott M Rickert
- Department of Otolaryngology, NYU Langone, New York, NY, USA
| | - Soham Roy
- Department of Otorhinolaryngology, University of Texas - Houston, Houston, TX, USA
| | - John Russell
- Department of Paediatric Otolaryngology, Childrens Health Ireland, Crumlin, Ireland
| | - Michael Rutter
- FRACS, Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Douglas Sidell
- Department of Otolaryngology, Head and Neck Surgery, Division of Pediatric Otolaryngology, Stanford University, Stanford, CA, USA
| | - Marlene Soma
- Department of Otolaryngology, Sydney Children's Hospital, Randwick, Australia
| | - Briac Thierry
- Pediatric Otolaryngology - Head and Neck Surgery, Necker Enfants Malades Hospital, Paris University, Paris, France
| | - Marilena Trozzi
- Airway Surgery Unit, Pediatric Surgery Department, Bambino Gesù Children's Hospital, Rome (IT), Italy
| | - George Zalzal
- Department of Otolaryngology, Children's National Health System, Washington, DC, USA
| | - Carlton J Zdanski
- Division of Pediatric Otolaryngology/Head and Neck Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Richard J H Smith
- Department of Otolaryngology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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12
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Congenital High Airway Obstruction Syndrome (CHAOS): No Intervention, No Survival-A Case Report and Literature Review. Case Rep Radiol 2020; 2020:1036073. [PMID: 32685231 PMCID: PMC7336206 DOI: 10.1155/2020/1036073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 06/15/2020] [Indexed: 11/17/2022] Open
Abstract
Congenital high airway obstruction syndrome (CHAOS) is complete or partial obstruction of the fetal upper airway. CHAOS is a rare and fatal condition if no perinatal intervention is done. Antenatal sonographic imaging has typical findings that can help in an early diagnosis, which is important in deciding elective termination of the pregnancy or successful planning of appropriate perinatal management.
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13
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Propst EJ, Wolter NE, Morency AM, Amin R, Blaser S, Moore AM, Windrim R, Ryan G. Fetoscopic Balloon Dilation and Cricotracheal Resection for Laryngeal Atresia in CHAOS. Laryngoscope 2020; 131:660-662. [PMID: 32574407 DOI: 10.1002/lary.28775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/28/2020] [Accepted: 05/08/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Evan J Propst
- Department of Otolaryngology - Head & Neck Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Nikolaus E Wolter
- Department of Otolaryngology - Head & Neck Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Anne-Maude Morency
- University of Toronto, Toronto, Ontario, Canada.,Fetal Medicine Program, Mount Sinai Hospital, Toronto, Ontario, Canada.,Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Reshma Amin
- University of Toronto, Toronto, Ontario, Canada.,Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Susan Blaser
- University of Toronto, Toronto, Ontario, Canada.,Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Aideen M Moore
- University of Toronto, Toronto, Ontario, Canada.,Division of Neonatology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rory Windrim
- University of Toronto, Toronto, Ontario, Canada.,Fetal Medicine Program, Mount Sinai Hospital, Toronto, Ontario, Canada.,Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Greg Ryan
- University of Toronto, Toronto, Ontario, Canada.,Fetal Medicine Program, Mount Sinai Hospital, Toronto, Ontario, Canada.,Ontario Fetal Centre, Toronto, Ontario, Canada
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Peiro JL, Nolan HR, Alhajjat A, Diaz R, Gil-Guevara E, Tabbah SM, Lim FY. A Technical Look at Fetoscopic Laser Ablation for Fetal Laryngeal Surgical Recanalization in Congenital High Airway Obstruction Syndrome. J Laparoendosc Adv Surg Tech A 2020; 30:695-700. [PMID: 32352856 DOI: 10.1089/lap.2019.0808] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background: Congenital high airway obstruction syndrome (CHAOS) is a rare condition characterized by complete obstruction of the upper fetal airways. Left untreated, it is uniformly fatal. Ex utero intrapartum treatment (EXIT) has been used to establish a surgical airway in affected fetuses during delivery. While this procedure benefits those fetuses that survive to delivery, high mortality in the prenatal period necessitates earlier innovative strategies. Herein, we report a novel technique for in utero intervention. Methods: A fetoscopic intervention was performed at 28 weeks on a 35-year-old G1P0 woman with fetal CHAOS from a laryngeal obstruction measuring 11 mm in length on prenatal imaging. Under ultrasound guidance, a 3.3-mm curved fetoscope was used to access the uterine cavity through a single subcentimeter maternal skin incision. The scope was driven through the fetal oral cavity and manipulated to attain a view of the vocal cords. A subglottic obstruction was observed. A 600-micron laser fiber was passed through the working channel of the scope and used to ablate the obstructed airway. Using the laser fiber and a guidewire, the ablated opening was traversed with the fetoscope to the level of the carina. Results: Postoperatively, the lungs became less hyperinflated. There was improvement in ascites and diaphragmatic eversion. At 31 1/7 weeks' gestation, the mother experienced preterm premature rupture of membranes with active labor and the fetus was delivered through EXIT to tracheostomy. The infant was managed on mechanical ventilation and is currently thriving at home with a tracheostomy at 2 years of age. Conclusion: Fetoscopy with laser ablation of the airway obstruction is an effective prenatal management strategy that offers the potential to alter the devastating natural course of CHAOS.
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Affiliation(s)
- Jose L Peiro
- Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
| | - Heather R Nolan
- Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
| | - Amir Alhajjat
- Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
| | - Ramiro Diaz
- Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
| | - Enrique Gil-Guevara
- Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
| | - Sammy M Tabbah
- Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
| | - Foong Y Lim
- Cincinnati Fetal Center, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, Ohio, USA
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Causes of death shortly after delivery and medical malpractice claims in congenital high airway obstruction syndrome: Review of the literature. Leg Med (Tokyo) 2019; 40:61-65. [PMID: 31442942 DOI: 10.1016/j.legalmed.2019.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 06/07/2019] [Accepted: 07/29/2019] [Indexed: 11/23/2022]
Abstract
Congenital High Airway Obstruction Syndrome is a rare pathology that may conduct the baby to death shortly after delivery. This outcome may cause emotional distress in the parents but it may also generate expensive medical malpractice claims about the reasons why the syndrome was not identified and/or correctly treated. The authors conducted a review of the cases in which Congenital High Airway Obstruction Syndrome caused death of the baby shortly after delivery. Then, they pointed out these ultrasonographic and anatomical reasons why the syndrome may be not identified and/or correctly treated: negative prenatal ultrasonography, recurrence of non-specific findings at prenatal ultrasonography, connection of respiratory and gastrointestinal tracts, tracheal agenesis or atresia, parent's refuse of post-partum therapeutic procedures, multiple malformations of the fetus/child. In conclusion, the authors highlighted that death shortly after delivery is usually caused by specific conditions that are not influenced by healthcare team's practice.
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Abstract
Ex Utero Intrapartum Treatment (EXIT) is a technique developed to safely and efficiently establish cardiopulmonary support at delivery while maintaining placental bypass. Indications for the EXIT approach are expanding and currently include EXIT-to-airway, EXIT-to-resection, EXIT-to-extracorporeal membrane oxygenation (ECMO), and EXIT-to-separation of conjoined twins. The EXIT technique involves planned partial delivery of the fetus via hysterotomy while maintaining uterine relaxation and placental support, allowing for the establishment of neonatal cardiopulmonary stability in a controlled manner. Fetal interventions performed during EXIT can include endotracheal intubation, tracheostomy, mass excision, removal of a temporary tracheal occlusive device, ECMO cannulation, and others. The most important aspect of an EXIT procedure is the formation of a multi-disciplinary team with broad expertise in fetal intervention to collaborate throughout the pre, intra, and post-partum periods. This chapter reviews the prenatal workup, decision making, surgical indications, and operative considerations associated with EXIT procedures.
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Affiliation(s)
- Christina M Bence
- Children's Hospital of Wisconsin, Medical College of Wisconsin, 999 N. 92nd Street, Suite 320, Milwaukee, WI 53226, USA
| | - Amy J Wagner
- Children's Hospital of Wisconsin, Medical College of Wisconsin, 999 N. 92nd Street, Suite 320, Milwaukee, WI 53226, USA.
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Nicolas CT, Lynch-Salamon D, Bendel-Stenzel E, Tibesar R, Luks F, Eyerly-Webb S, Lillegard JB. Fetoscopy-Assisted Percutaneous Decompression of the Distal Trachea and Lungs Reverses Hydrops Fetalis and Fetal Distress in a Fetus with Laryngeal Atresia. Fetal Diagn Ther 2019; 46:75-80. [PMID: 31238308 DOI: 10.1159/000500455] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 04/16/2019] [Indexed: 11/19/2022]
Abstract
We present a case of prenatal hydrops secondary to congenital high airway obstruction syndrome (CHAOS) that was treated with fetoscopy-assisted needle decompression. A 22-year-old G3P2 woman presented after a 21-week ultrasound demonstrated CHAOS. The fetus developed hydrops at 25 weeks, characterized by abdominal ascites, pericardial effusion, and scalp edema. Fetal MRI showed complete obstruction of the glottis and subglottic airway, suggestive of laryngeal atresia. At 27 weeks, due to the progression of the hydrops, operative fetoscopy was proposed and performed. Fetal laryngoscopy confirmed fusion of the vocal cords and laryngeal atresia. The atretic segment was a solid cartilaginous block, preventing intubation. Using the fetoscope to stabilize the fetal head and neck, we performed ultrasound-guided percutaneous needle drainage of the cervical trachea through the anterior fetal neck. We removed 17 mL of viscous fluid from the lower trachea, resulting in immediate lung decompression. Two weeks later, ultrasound confirmed hydrops resolution. The patient was delivered and tracheostomy performed at 30 weeks via an ex utero intrapartum treatment (EXIT) procedure after progression of preterm labor. At 27 days of life, the infant was stable on minimal ventilator support. To our knowledge, this is the first successful report of an ultrasound-guided percutaneous tracheal decompression through the anterior neck of a fetus with CHAOS secondary to laryngeal atresia.
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Affiliation(s)
- Clara T Nicolas
- Children's Hospital of Minnesota, Midwest Fetal Care Center, Minneapolis, Minnesota, USA.,Mayo Clinic, Division of Surgery Research, Rochester, Minnesota, USA
| | - David Lynch-Salamon
- Children's Hospital of Minnesota, Midwest Fetal Care Center, Minneapolis, Minnesota, USA
| | - Ellen Bendel-Stenzel
- Children's Hospital of Minnesota, Midwest Fetal Care Center, Minneapolis, Minnesota, USA.,Minnesota Neonatal Physicians, Minneapolis, Minnesota, USA
| | - Robert Tibesar
- Children's Hospital of Minnesota, Midwest Fetal Care Center, Minneapolis, Minnesota, USA
| | - Francois Luks
- Hasbro Children's Hospital and The Fetal Treatment Program of New England, Providence, Rhode Island, USA
| | - Stephanie Eyerly-Webb
- Children's Hospital of Minnesota, Midwest Fetal Care Center, Minneapolis, Minnesota, USA
| | - Joseph B Lillegard
- Children's Hospital of Minnesota, Midwest Fetal Care Center, Minneapolis, Minnesota, USA, .,Mayo Clinic, Division of Surgery Research, Rochester, Minnesota, USA, .,Pediatric Surgical Associates, Minneapolis, Minnesota, USA,
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18
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Congenital high airway obstruction syndrome (CHAOS): Natural history, prenatal management strategies, and outcomes at a single comprehensive fetal center. J Pediatr Surg 2019; 54:1153-1158. [PMID: 30890267 DOI: 10.1016/j.jpedsurg.2019.02.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 02/21/2019] [Indexed: 11/21/2022]
Abstract
PURPOSE Congenital high airway obstruction syndrome (CHAOS) is a devastating fetal condition of complete airway discontinuity resulting in significant hydrops and extreme lung hyperplasia. It is universally fatal with survival reported only in the rare spontaneous fistulization or EXIT intervention (Ex Utero Intrapartum Treatment). Even in these cases, mortality remains high, and current investigations are targeting prenatal interventions. This report describes our experience with management and fetal interventions for CHAOS, including laser laryngotomy. METHODS We retrospectively reviewed all patients diagnosed with CHAOS at a single academic institution between 2006 and 2017. RESULTS Fifteen patients were identified. Eight had obstruction at the trachea and seven at the larynx. In the laryngeal obstructions, three expired shortly after birth, and one survived after spontaneous fistulization and subsequent EXIT to tracheostomy. The remaining three underwent in-utero treatment with laser laryngotomy. One had preterm premature rupture of membranes (PPROM), delivered 3 days post-operatively, and died. Two underwent EXIT to tracheostomy with one surviving to discharge and is currently 2 years old. CONCLUSION Our study demonstrates the outcomes of a large series of patients diagnosed with CHAOS. While mortality remains high, options for fetal intervention are being explored to allow alterations in the prenatal natural history and improve postnatal outcomes. TYPE OF STUDY Retrospective Treatment Study. LEVEL OF EVIDENCE Level IV.
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19
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Fayoux P, Devisme L. Histoanatomical structures of laryngeal atresia: Functional considerations. Laryngoscope 2019; 130:252-256. [DOI: 10.1002/lary.27855] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2019] [Indexed: 11/12/2022]
Affiliation(s)
- Pierre Fayoux
- Department of Pediatric Otolaryngology–Head Neck SurgeryJeanne de Flandre Hospital–CHU Lille Lille France
- CERIM EA2694Lille University Lille France
| | - Louise Devisme
- Department of Anatomy and Pathology–CHU Lille Lille France
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20
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Kumar M, Gupta A, Kumar V, Handa A, Balliyan M, Meena J, Roychoudhary S. Management of CHAOS by intact cord resuscitation: case report and literature review. J Matern Fetal Neonatal Med 2018; 32:4181-4187. [PMID: 29842812 DOI: 10.1080/14767058.2018.1481951] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Background: Congenital high airway obstruction syndrome (CHAOS) is a near fatal condition, except when the ex utero intrapartum treatment (EXIT) procedure is performed as rescue. After antenatal diagnosis of the condition, counseling regarding prognosis and outcome needs to be provided.Case: We describe here a case with CHAOS due to isolated fetal laryngeal atresia, presented at our center at 33-week gestation. After counseling regarding the uncertain outcome, consent for elective caesarean was not given. Intact cord resuscitation (ICR) was done as a rescue by a well-coordinated team during delivery. Tracheostomy was performed successfully under local anesthesia within five minutes, while the cord was still attached to the placenta. The baby had supraglottic stenosis on CT scan. Reconstructive surgery is planned after 8 months. The literature review showed 24 reports of 28 cases with intrinsic airway obstruction managed by EXIT, laryngeal atresia was the most common cause (18/28). The outcome was poor in tracheal agenesis (1/4 survived) whereas those having laryngeal web or small communication (4/4 survived) had better outcome. Tracheal reconstruction was done in 3/28 cases only.Conclusions: The case emphasizes that ICR and tracheostomy during vaginal delivery can rescue the baby. The literature reviewed provided insight into the outcome of CHAOS cases in world literature.
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Affiliation(s)
| | - Amit Gupta
- Lady Hardinge Medical College, New Delhi, India
| | - Vijay Kumar
- Lady Hardinge Medical College, New Delhi, India
| | - Anu Handa
- Lady Hardinge Medical College, New Delhi, India
| | | | - Jyoti Meena
- All India Institute of Medical Sciences, New Delhi, India
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Abstract
Prenatal diagnosis has changed perinatal medicine dramatically, allowing for additional fetal monitoring, referral and counseling, delivery planning, the option of fetal intervention, and targeted postnatal management. Teams participating in the delivery room care of infants with known anomalies should be knowledgeable about specific needs and expectations but also ready for unexpected complications. A small number of neonates will need rapid access to postnatal interventions, such as surgery, but most can be stabilized with appropriate neonatal care. These targeted perinatal interventions have been shown to improve outcome in selected diagnoses.
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Affiliation(s)
- Elizabeth K Sewell
- Emory Children's Center Neonatalogy Offices, 2015 Uppergate Drive-3(rd) floor, Atlanta, GA 30322, USA
| | - Sarah Keene
- Emory Children's Center Neonatalogy Offices, 2015 Uppergate Drive-3(rd) floor, Atlanta, GA 30322, USA.
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22
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Alhajjat A, Shaaban A. Maternal and Fetal Immune Response to in Utero Stem Cell Transplantation. CURRENT STEM CELL REPORTS 2018; 4:182-187. [PMID: 30873337 DOI: 10.1007/s40778-018-0129-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Purpose of Review In Utero Hematopoietic Cellular Transplantation (IUHCT) is a promising intervention for the non-toxic treatment of congenital disease that hinges on the assumption of fetal immunologic immaturity and an inability to reject a hematopoietic allograft. However, clinical IUCHT has failed except in cases where the fetus is severely immunocompromised. The current review examines recent studies of engraftment barriers stemming from either the fetal or maternal immune system. Recent Findings New reports have illuminated roles for maternal humoral and cellular immunity and fetal innate cellular immunity in the resistance to allogeneic IUHCT. These experimental findings have inspired new approaches to overcome these barriers. Despite these advances, postulates regarding a maternal immune barrier to IUHCT provide an inadequate explanation for the well-documented clinical success only in the treatment of fetal immunodeficiency with normal maternal immunity. Summary Characterization of the maternal and fetal immune response to allogeneic IUHCT provides new insight into the complexity of prenatal tolerance. Future work in this area should aim to provide a unifying explanation for the observed patterns of success and failure with clinical IUHCT.
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Affiliation(s)
- Amir Alhajjat
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, Arizona
| | - Aimen Shaaban
- The Chicago Institute for Fetal Health, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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23
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Gonzales SK, Goudy S, Prickett K, Ellis J. EXIT (ex utero intrapartum treatment) in a growth restricted fetus with tracheal atresia. Int J Pediatr Otorhinolaryngol 2018; 105:72-74. [PMID: 29447823 DOI: 10.1016/j.ijporl.2017.12.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 12/04/2017] [Accepted: 12/06/2017] [Indexed: 10/18/2022]
Abstract
Congenital high airway obstruction syndrome (CHAOS) encompasses a heterogeneous group of pathologies leading to poor lung development and difficulty oxygenating the newborn after delivery. While previously uniformly fatal, the ex utero intrapartum therapy (EXIT) procedure has provided a method to treat these patients and provide an airway to potentiate survival. We present a patient diagnosed prenatally with CHAOS secondary to tracheal atresia complicated by severe intra-uterine growth restriction (IUGR) who was successfully delivered via an EXIT procedure at 33-weeks. Multidisciplinary care and planning is paramount.
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Affiliation(s)
- S Kyle Gonzales
- Division of Maternal Fetal Medicine, Emory University, Atlanta, GA, USA.
| | - Steven Goudy
- Division of Otolaryngology, Head & Neck Surgery, Emory University, Atlanta, GA, USA
| | - Kara Prickett
- Division of Otolaryngology, Head & Neck Surgery, Emory University, Atlanta, GA, USA
| | - Jane Ellis
- Division of Maternal Fetal Medicine, Emory University, Atlanta, GA, USA
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24
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Ex utero intrapartum treatment (EXIT) for upper airway obstruction. Curr Opin Otolaryngol Head Neck Surg 2017; 25:119-126. [DOI: 10.1097/moo.0000000000000343] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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25
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Abstract
Congenital tracheobronchial stenosis is a rare disease characterized by complete tracheal rings that can affect variable lengths of the tracheobronchial tree. It causes high levels of morbidity and mortality both due to the stenosis itself and to the high incidence of other associated congenital malformations. Successful management of this complex condition requires a highly individualized approach delivered by an experienced multidisciplinary team, which is best delivered within centralized units with the necessary diverse expertise. In such settings, surgical correction by slide tracheoplasty has become increasingly successful over the past 2 decades such that long-term survival now exceeds 88%, with normalization of quality of life scores for patients with non-syndrome-associated congenital tracheal stenosis. Careful assessment and planning of treatment strategies is of paramount importance for both successful management and the provision of patients and carers with accurate and realistic treatment counseling.
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Affiliation(s)
- Richard J Hewitt
- Department of Ear, Nose and Throat Surgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
| | - Colin R Butler
- Department of Ear, Nose and Throat Surgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; Department of Paediatric Surgery, Stem Cell and Regernerative Medicine Group, UCL Institute of Child Health, London, UK; Lungs for Living Research Centre, UCL Respiratory, Division of Medicine, University College London, London, UK
| | - Elizabeth F Maughan
- Department of Paediatric Surgery, Stem Cell and Regernerative Medicine Group, UCL Institute of Child Health, London, UK; Lungs for Living Research Centre, UCL Respiratory, Division of Medicine, University College London, London, UK
| | - Martin J Elliott
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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26
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Maughan E, Lesage F, Butler CR, Hynds RE, Hewitt R, Janes SM, Deprest JA, Coppi PD. Airway tissue engineering for congenital laryngotracheal disease. Semin Pediatr Surg 2016; 25:186-90. [PMID: 27301606 DOI: 10.1053/j.sempedsurg.2016.02.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Regenerative medicine offers hope of a sustainable solution for severe airway disease by the creation of functional, immunocompatible organ replacements. When considering fetuses and newborns, there is a specific spectrum of airway pathologies that could benefit from cell therapy and tissue engineering applications. While hypoplastic lungs associated with congenital diaphragmatic hernia (CDH) could benefit from cellular based treatments aimed at ameliorating lung function, patients with upper airway obstruction could take advantage from a de novo tissue engineering approach. Moreover, the international acceptance of the EXIT procedure as a means of securing the precarious neonatal airway, together with the advent of fetal surgery as a method of heading off postnatal co-morbidities, offers the revolutionary possibility of extending the clinical indication for tissue-engineered airway transplantation to infants affected by diverse severe congenital laryngotracheal malformations. This article outlines the necessary basic components for regenerative medicine solutions in this potential clinical niche.
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Affiliation(s)
- Elizabeth Maughan
- Stem Cells and Regenerative Medicine Section, DBC, UCL Institute of Child Health, 30 Guilford St, London, UK; Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK
| | - Flore Lesage
- Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK; Department of Development and Regeneration, Biomedical Sciences Group, University of Leuven, Leuven, Belgium
| | - Colin R Butler
- Stem Cells and Regenerative Medicine Section, DBC, UCL Institute of Child Health, 30 Guilford St, London, UK; Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK
| | - Robert E Hynds
- Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK
| | - Richard Hewitt
- Ear, Nose and Throat Department, Great Ormond Street Hospital, London, UK
| | - Sam M Janes
- Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK
| | - Jan A Deprest
- Stem Cells and Regenerative Medicine Section, DBC, UCL Institute of Child Health, 30 Guilford St, London, UK; Department of Development and Regeneration, Biomedical Sciences Group, University of Leuven, Leuven, Belgium; Department of Paediatric Surgery, Great Ormond Street Hospital, London, UK; Department of Obstetrics and Gynaecology, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
| | - Paolo De Coppi
- Stem Cells and Regenerative Medicine Section, DBC, UCL Institute of Child Health, 30 Guilford St, London, UK; Department of Paediatric Surgery, Great Ormond Street Hospital, London, UK.
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27
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Abstract
Since the first human fetal surgery was reported in 1965, several different fetal surgical procedures have been developed and perfected, resulting in significantly improved outcomes for many fetuses. The currently accepted list of fetal conditions for which antenatal surgery is considered include lower urinary tract obstruction, twin-twin transfusion syndrome, myelomeningocele, congenital diaphragmatic hernia, neck masses occluding the trachea, and tumors such as congenital cystic adenomatoid malformation or sacrococcygeal teratoma when associated with developing fetal hydrops. Until recently, it has been difficult to determine the true benefits of several fetal surgeries because outcomes were reported as uncontrolled case series. However, several prospective randomized trials have been attempted and others are ongoing, supporting a more evidence-based approach to antenatal intervention. Problems that have yet to be completely overcome include the inability to identify ideal fetal candidates for antenatal intervention, to determine the optimal timing of intervention, and to prevent preterm birth after fetal surgery. Confronting a fetal abnormality raises unique and complex issues for the family. For this reason, in addition to a maternal-fetal medicine specialist experienced in prenatal diagnosis, a pediatric surgeon, an experienced operating room team including a knowledgeable anesthesiologist, and a neonatologist, the family considering fetal surgery should have access to psychosocial support and a bioethicist.
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28
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Postmortem magnetic resonance appearances of congenital high airway obstruction syndrome. Pediatr Radiol 2015; 45:556-61. [PMID: 25190454 PMCID: PMC4381089 DOI: 10.1007/s00247-014-3133-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 06/24/2014] [Accepted: 07/16/2014] [Indexed: 10/31/2022]
Abstract
BACKGROUND Congenital high airway obstruction syndrome (CHAOS) is a rare life-threatening condition characterised by complete or near-complete developmental obstruction of the foetal airway. Although antenatal imaging findings have been described, the postmortem MRI findings have not been reported. OBJECTIVE To present postmortem MRI features of CHAOS. MATERIALS AND METHODS We retrospectively reviewed our hospital pathology and imaging databases for cases of CHAOS over a 2-year period. RESULTS We identified two cases of CHAOS. In both cases, postmortem plain radiographs demonstrated gross abdominal distension with distortion and splaying of the rib cage. Both foetuses had characteristic postmortem MRI findings including large-volume fluid-filled lungs on T2-weighted imaging, diaphragmatic eversion, fluid-filled airway dilatation below the level of obstruction, centrally positioned and compressed heart, and massive ascites. One foetus had an associated limb abnormality. CONCLUSION Postmortem MRI in foetuses suspected of having CHAOS allows confirmation of the diagnosis, determination of the anatomical level of the atresia or stenosis, and identification of associated abnormalities without the need for invasive autopsy.
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Walz PC, Schroeder JW. Prenatal diagnosis of obstructive head and neck masses and perinatal airway management: the ex utero intrapartum treatment procedure. Otolaryngol Clin North Am 2014; 48:191-207. [PMID: 25442130 DOI: 10.1016/j.otc.2014.09.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Advances in prenatal imaging in the last 20 years have enabled prenatal diagnosis of obstructive head and neck masses. These advances, coupled with improvements in maternal-fetal anesthesia, have made possible the development of the ex utero intrapartum treatment (EXIT) procedure for management of obstructive head and neck masses, during which the airway is managed in a controlled fashion while maintaining fetal circulation for oxygenation. This review addresses the preoperative and perioperative assessment and management of patients with prenatally diagnosed airway obstruction, indications and contraindications for the EXIT procedure, technical details of the procedure, and outcomes.
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Affiliation(s)
- Patrick C Walz
- Department of Pediatric Otolaryngology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL 60611-2991, USA
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30
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Ruano R, Cass DL, Rieger M, Javadian P, Shamshirsaz AA, Olutoye OO, Belfort MA. Fetal laryngoscopy to evaluate vocal folds in a fetus with congenital high airway obstruction syndrome (CHAOS). ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:102-103. [PMID: 23939717 DOI: 10.1002/uog.13191] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 07/28/2013] [Accepted: 08/02/2013] [Indexed: 06/02/2023]
Affiliation(s)
- R Ruano
- Pavilion for Women Texas Children's Fetal Center, Suite F1020, 6651 Main Street, Houston, Texas, 77030, USA
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31
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Martínez J, Castañón M, Gómez O, Prat J, Eixarch E, Bennasar M, Puerto B, Gratacós E. Evaluation of Fetal Vocal Cords to Select Candidates for Successful Fetoscopic Treatment of Congenital High Airway Obstruction Syndrome: Preliminary Case Series. Fetal Diagn Ther 2013; 34:77-84. [DOI: 10.1159/000350697] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Accepted: 03/07/2013] [Indexed: 11/19/2022]
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32
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Sanford E, Saadai P, Lee H, Slavotinek A. Congenital high airway obstruction sequence (CHAOS): A new case and a review of phenotypic features. Am J Med Genet A 2012; 158A:3126-36. [DOI: 10.1002/ajmg.a.35643] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Accepted: 07/25/2012] [Indexed: 12/22/2022]
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Antón-Pacheco JL. [Paediatric bronchoscopy: from where we came from, to where we are going]. An Pediatr (Barc) 2012; 77:223-5. [PMID: 22902949 DOI: 10.1016/j.anpedi.2012.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 07/09/2012] [Indexed: 11/15/2022] Open
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