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Jantarasaengaram S, Jaisamut P, Yanaranop M, Sriswasdi S. Spectral Doppler Parameters of Fetal Main Branch Pulmonary Artery at 20 to 40 Weeks of Gestation: Reference Ranges and Percentile Calculators. J Am Soc Echocardiogr 2024; 37:439-448. [PMID: 38040062 DOI: 10.1016/j.echo.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/21/2023] [Accepted: 11/21/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND The published reference ranges for Doppler parameters of the fetal pulmonary artery (PA) are usually derived from small sample sizes with no practical standard score or percentile ranking, which hinders systematic comparisons of Doppler figures across different gestational ages (GAs). This study aimed to establish comprehensive reference ranges and provide a percentile ranking solution for key spectral Doppler parameters. METHODS This is a cross-sectional study of 465 uncomplicated singleton pregnancies during 20 to 40 weeks of gestation. Spectral waveforms of the fetal main branch PA were obtained with a pulsed-wave Doppler interrogation site within 5 mm from the vascular origin. Fifteen spectral Doppler parameters were identified. Associations between these parameters with GA and fetal heart rate were assessed and used to develop percentile calculators via different statistical models. The root mean squared error of each model was calculated to determine the best performance solution. RESULTS Acceptable spectral waveforms were obtained for 94.1% (438/465) of the fetuses. All Doppler parameters except pulsatility index, manually traced pulsatility index, peak systolic velocity, and time to systolic notch/acceleration time ratio were significantly correlated with GA, while acceleration time, ejection time, time to systolic notch, peak early-diastolic reversal flow, and peak early-diastolic reversal flow/peak systolic velocity ratio were additionally significantly correlated with fetal heart rate. Support vector machine models with radial basis kernel yield the best percentile estimation (root mean squared error of 2.17-4.08 and R2 of >0.98). Furthermore, the top 5% and bottom 5% outliers could be identified with positive predictive values of 0.71 to 0.97. An online user interface of percentile calculators is available at https://github.com/cmb-chula/fetoPAD. CONCLUSIONS This study presents normal reference ranges and percentile calculators for 15 spectral Doppler parameters of the fetal main branch PA, some of which have not been published. The estimated percentiles enhance comparison and outlier detection of the spectral Doppler figures among fetuses at different GAs.
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Affiliation(s)
- Surasak Jantarasaengaram
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand.
| | - Pemika Jaisamut
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Marut Yanaranop
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Sira Sriswasdi
- Center of Excellence in Computational Molecular Biology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Center for Artificial Intelligence in Medicine, Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Vellvé K, Garcia-Canadilla P, Nogueira M, Youssef L, Arranz A, Nakaki A, Boada D, Blanco I, Faner R, Figueras F, Agustí À, Gratacós E, Crovetto F, Bijnens B, Crispi F. Pulmonary vascular reactivity in growth restricted fetuses using computational modelling and machine learning analysis of fetal Doppler waveforms. Sci Rep 2024; 14:5919. [PMID: 38467666 PMCID: PMC10928161 DOI: 10.1038/s41598-024-54603-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 02/14/2024] [Indexed: 03/13/2024] Open
Abstract
The aim of this study was to investigate the pulmonary vasculature in baseline conditions and after maternal hyperoxygenation in growth restricted fetuses (FGR). A prospective cohort study of singleton pregnancies including 97 FGR and 111 normally grown fetuses was carried out. Ultrasound Doppler of the pulmonary vessels was obtained at 24-37 weeks of gestation and data were acquired before and after oxygen administration. After, Machine Learning (ML) and a computational model were used on the Doppler waveforms to classify individuals and estimate pulmonary vascular resistance (PVR). Our results showed lower mean velocity time integral (VTI) in the main pulmonary and intrapulmonary arteries in baseline conditions in FGR individuals. Delta changes of the main pulmonary artery VTI and intrapulmonary artery pulsatility index before and after hyperoxygenation were significantly greater in FGR when compared with controls. Also, ML identified two clusters: A (including 66% controls and 34% FGR) with similar Doppler traces over time and B (including 33% controls and 67% FGR) with changes after hyperoxygenation. The computational model estimated the ratio of PVR before and after maternal hyperoxygenation which was closer to 1 in cluster A (cluster A 0.98 ± 0.33 vs cluster B 0.78 ± 0.28, p = 0.0156). Doppler ultrasound allows the detection of significant changes in pulmonary vasculature in most FGR at baseline, and distinct responses to hyperoxygenation. Future studies are warranted to assess its potential applicability in the clinical management of FGR.
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Affiliation(s)
- Kilian Vellvé
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Patricia Garcia-Canadilla
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain
- Interdisciplinary Cardiovascular Research Group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - Mariana Nogueira
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Lina Youssef
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Angela Arranz
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ayako Nakaki
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - David Boada
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain
| | - Isabel Blanco
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Pneumology Department, Respiratory Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
- Centre for Biomedical Research on Respiratory Diseases (CIBER-ES), Madrid, Spain
| | - Rosa Faner
- Centre for Biomedical Research on Respiratory Diseases (CIBER-ES), Madrid, Spain
| | - Francesc Figueras
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Àlvar Agustí
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Pneumology Department, Respiratory Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
- Centre for Biomedical Research on Respiratory Diseases (CIBER-ES), Madrid, Spain
- Cathedra Salud Respiratoria, University of Barcelona, Barcelona, Spain
| | - Eduard Gratacós
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain
| | - Francesca Crovetto
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain
| | | | - Fàtima Crispi
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, Sabino Arana 1, 08028, Barcelona, Spain.
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain.
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Moore SS, Keller RL, Altit G. Congenital Diaphragmatic Hernia: Pulmonary Hypertension and Pulmonary Vascular Disease. Clin Perinatol 2024; 51:151-170. [PMID: 38325939 DOI: 10.1016/j.clp.2023.10.001] [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: 02/09/2024]
Abstract
This review provides a comprehensive summary of the current understanding of pulmonary hypertension (PH) in congenital diaphragmatic hernia, outlining the underlying pathophysiologic mechanisms, methods for assessing PH severity, optimal management strategies, and prognostic implications.
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Affiliation(s)
- Shiran S Moore
- Neonatology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Weizamann 6, Tel-Aviv, Jaffa 6423906, Israel.
| | - Roberta L Keller
- Neonatology, UCSF Benioff Children's Hospital, 550 16th Street, #5517, San Francisco, CA 94158, USA; Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Gabriel Altit
- Neonatology, McGill University Health Centre, Montreal Children's Hospital, 1001 Décarie boulevard, Montreal, H4A Quebec; Department of Pediatrics, McGill University, Montreal, Quebec, Canada
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Zalinska A, Respondek-Liberska M, Slodki M. Maternal hyperoxygenation during pregnancy as a tool in fetal disease diagnosis and treatment. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:273-282. [PMID: 36785501 DOI: 10.1002/jcu.23347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/27/2022] [Accepted: 08/30/2022] [Indexed: 06/18/2023]
Abstract
Maternal hyperoxygenation (MHO) consists of giving pregnant women (60% to 100%) oxygen through a facemask and using ultrasound assess or monitor the influence on fetal cardiovascular circulation. This review discusses the findings and the utility of acute and chronic MHO in various fetal diseases.
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Affiliation(s)
- Agnieszka Zalinska
- Department of Prenatal Cardiology, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
- Department of Obstetrics and Perinatology, Chair of Obstetrics, Gynecology and Oncological Gynecology, Medical University of Lodz, Lodz, Poland
| | - Maria Respondek-Liberska
- Department of Prenatal Cardiology, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
- Department of Diagnosis and Prevention of Fetal Malformations, Medical University of Lodz, Lodz, Poland
| | - Maciej Slodki
- Department of Prenatal Cardiology, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
- Faculty of Health Sciences, The Mazovian State University, Plock, Poland
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Utility of Fetal Echocardiography with Acute Maternal Hyperoxygenation Testing in Assessment of Complex Congenital Heart Defects. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020281. [PMID: 36832410 PMCID: PMC9955335 DOI: 10.3390/children10020281] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/22/2023] [Accepted: 01/27/2023] [Indexed: 02/04/2023]
Abstract
Fetal echocardiography is an excellent tool for accurately assessing the anatomy and physiology of most congenital heart defects (CHDs). Knowledge gathered from a thorough initial fetal echocardiogram and serial assessment assists with appropriate perinatal care planning, resulting in improved postnatal outcomes. However, fetal echocardiography alone provides limited information about the status of the pulmonary vasculature, which can be abnormal in certain complex CHDs with obstructed pulmonary venous flow (hypoplastic left heart syndrome with restrictive atrial septum) or excessive pulmonary artery flow (d-transposition of the great arteries, usually with a restrictive ductus arteriosus). Fetuses with these CHDs are at high risk of developing severe hemodynamic instability with the immediate transition from prenatal to postnatal circulatory physiology at the time of birth. Adjunctive use of acute maternal hyperoxygenation (MH) testing in such cases can help determine pulmonary vascular reactivity in prenatal life and better predict the likelihood of postnatal compromise and the need for emergent intervention. This comprehensive review discusses the findings of studies describing acute MH testing in a diverse spectrum of CHDs and congenital diagnoses with pulmonary hypoplasia. We review historical perspectives, safety profile, commonly used clinical protocols, limitations, and future directions of acute MH testing. We also provide practical tips on setting up MH testing in a fetal echocardiography laboratory.
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Hocq C, Vanhoutte L, Guilloteau A, Massolo AC, Van Grambezen B, Carkeek K, Piersigilli F, Danhaive O. Early diagnosis and targeted approaches to pulmonary vascular disease in bronchopulmonary dysplasia. Pediatr Res 2022; 91:804-815. [PMID: 33674739 DOI: 10.1038/s41390-021-01413-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/25/2021] [Indexed: 01/31/2023]
Abstract
Pulmonary hypertension has emerged as a life-threatening disease in preterm infants suffering from bronchopulmonary dysplasia (BPD). Its development is closely linked to respiratory disease, as vasculogenesis and alveologenesis are closely interconnected. Once clinically significant, BPD-associated pulmonary hypertension (BPD-PH) can be challenging to manage, due to poor reversibility and multiple comorbidities frequently associated. The pulmonary vascular disease process underlying BPD-PH is the result of multiple innate and acquired factors, and emerging evidence suggests that it progressively develops since birth and, in certain instances, may begin as early as fetal life. Therefore, early recognition and intervention are of great importance in order to improve long-term outcomes. Based on the most recent knowledge of BPD-PH pathophysiology, we review state-of-the-art screening and diagnostic imaging techniques currently available, their utility for clinicians, and their applicability and limitations in this specific population. We also discuss some biochemical markers studied in humans as a possible complement to imaging for the detection of pulmonary vascular disease at its early stages and the monitoring of its progression. In the second part, we review pharmacological agents currently available for BPD-PH treatment or under preclinical investigation, and discuss their applicability, as well as possible approaches for early-stage interventions in fetuses and neonates. IMPACT: BPD-associated PH is a complex disease involving genetic and epigenetic factors, as well as environmental exposures starting from fetal life. The value of combining multiple imaging and biochemical biomarkers is emerging, but requires larger, multicenter studies for validation and diffusion. Since "single-bullet" approaches have proven elusive so far, combined pharmacological regimen and cell-based therapies may represent important avenues for research leading to future cure and prevention.
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Affiliation(s)
- Catheline Hocq
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Laetitia Vanhoutte
- Division of Pediatric Cardiology, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Axelle Guilloteau
- Division of Clinical Pharmacy, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Anna Claudia Massolo
- Department of Surgical and Medical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Bénédicte Van Grambezen
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Kate Carkeek
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Fiammetta Piersigilli
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Olivier Danhaive
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium. .,Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA.
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7
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Cox KL, Morris SA, Tacy T, Long J, Becker J, Schoppe RDCS L, Zhang RDCS J, Maskatia SA. The Impact of Maternal Hyperoxygenation on Myocardial Deformation and Loading Conditions in Fetuses With and Without Left-Heart Hypoplasia. J Am Soc Echocardiogr 2022; 35:773-781.e4. [DOI: 10.1016/j.echo.2022.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 01/19/2022] [Accepted: 03/20/2022] [Indexed: 11/30/2022]
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8
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Moon-Grady AJ, Byrne FA, Lusk LA, Keller RL. Expected small left heart size in the presence of congenital diaphragmatic hernia: Fetal values and Z-scores for infants confirmed to have no heart disease postnatally. Front Pediatr 2022; 10:1083370. [PMID: 36561485 PMCID: PMC9763578 DOI: 10.3389/fped.2022.1083370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES In fetuses with left-sided congenital diaphragmatic hernia (CDH), left heart structures may appear small, but usually normalize after birth in the absence of structural cardiac anomalies. To decrease the possibility of an erroneous diagnosis of structural heart disease, we identify normal values for left heart structures in the presence of left CDH and secondarily investigate the relationship of left heart size and survival to neonatal hospital discharge. METHODS Left heart structures [mitral valve (MV) and aortic valve (AoV) annulus diameter, left ventricle (LV) length and width] were measured by fetal echocardiogram in fetuses with left CDH and no congenital heart disease. We generated linear regression models to establish the relationship of gestational age for each left heart structure using data from fetuses who survived after birth. We calculated z-scores (normalized to gestational age), and assessed the relationship of survival to the size of each structure. RESULTS One hundred forty-two fetuses underwent fetal echocardiogram (median 25 weeks' gestation, IQR 23, 27 weeks). Left heart structures were deemed small when using published normative data from unaffected fetuses (z-scores: MV -1.09 ± 1.35, AoV -2.12 ± 1.16, LV length -1.36 ± 1.24, LV width -4.79 ± 0.79). CDH-specific models derived from log-transformed values yielded left-shifted distributions, reflecting the small structures (mean z-score lower by: MV 0.99 ± 0.30, AoV 2.04 ± 0.38, LV length 1.30 ± 0.36, and LV width 4.69 ± 0.28; p < 0.0001 for all comparisons). Non-survivors had worse z-scores than survivors for all measurements, but this did not reach statistical significance. CONCLUSIONS Log-transformed linear models generated new normative data for fetal left heart structures in left CDH, which may be used to allay antenatal concerns regarding structural left heart anomalies. There were no significant differences in z-scores between survivors and non-survivors, suggesting that in the absence of true structural disease, cardiac evaluation is not predictive in isolation and that causes of mortality are likely multifactorial in this population.
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Affiliation(s)
- Anita J Moon-Grady
- Division of Pediatric Cardiology, University of California San Francisco, Benioff Children's Hospital, San Francisco, CA, United States.,Fetal Treatment Center, University of California San Francisco, Benioff Children's Hospital, San Francisco, CA, United States
| | - Francesca A Byrne
- Pacific Cardiovascular Associates, Pediatric Cardiology, Orange, CA, United States
| | - Leslie A Lusk
- Division of Neonatology, Department of Pediatrics UCSF Benioff Children's Hospital, Oakland, CA, United States
| | - Roberta L Keller
- Fetal Treatment Center, University of California San Francisco, Benioff Children's Hospital, San Francisco, CA, United States.,Division of Neonatology, University of California San Francisco, Benioff Children's Hospital, San Francisco CA, United States
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Deng Y, Jin Y, Xu R, Zeng S. Fetal Hemodynamic Response to Maternal Oxygenation in Normal and Complicated Pregnancies. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2021; 42:607-613. [PMID: 32971542 DOI: 10.1055/a-1187-1459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Maternal oxygenation (MO) is widely applied in obstetrics. Scholars have conducted numerous studies on maternal hyperoxygenation and have reported many theoretical and applied achievements and a number of different points of view. The main purpose of this article is to discuss the effect of maternal oxygenation on fetal circulation during normal and complicated pregnancies and to ascertain its potential side effects and research gaps in this field. In complicated pregnancies, the fetus may benefit from oxygen therapy. However, large randomized controlled trials and longitudinal studies are necessary to support the widespread application of maternal oxygenation in this context.
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Affiliation(s)
- Yan Deng
- Department of Ultrasonography, Second Xiangya Hospital, Changsha, China
| | - Ying Jin
- Department of Ultrasonography, Second Xiangya Hospital, Changsha, China
| | - Ran Xu
- Urology, Second Xiangya Hospital, Changsha, China
| | - Shi Zeng
- Department of Ultrasonography, Second Xiangya Hospital, Changsha, China
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10
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Lee FT, Marini D, Seed M, Sun L. Maternal hyperoxygenation in congenital heart disease. Transl Pediatr 2021; 10:2197-2209. [PMID: 34584891 PMCID: PMC8429855 DOI: 10.21037/tp-20-226] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/27/2020] [Indexed: 01/26/2023] Open
Abstract
The importance of prenatal diagnosis and fetal intervention has been increasing as a preventative strategy for improving the morbidity and mortality in congenital heart disease (CHD). The advancements in medical imaging technology have greatly enhanced our understanding of disease progression, assessment, and impact in those with CHD. In particular, there has been a growing focus on improving the morbidity and mortality of fetuses diagnosed with left-sided lesions. The disruption of fetal hemodynamics resulting from poor structural developmental of the left outflow tract during cardiogenesis is considered a major factor in the progressive lethal underdevelopment of the left ventricle (LV). This positive feedback cycle of inadequate flow and underdevelopment of the LV leads to a disrupted fetal circulation, which has been described to impact fetal brain growth where systemic outflow is poor and, in some cases, the fetal lungs in the setting of a restrictive interatrial communication. For the past decade, maternal hyperoxygenation (MH) has been investigated as a diagnostic tool to assess the pulmonary vasculature and a therapeutic agent to improve the development of the heart and brain in fetuses with CHD with a focus on left-sided cardiac defects. This review discusses the findings of these studies as well as the utility of acute and chronic administration of MH in CHD.
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Affiliation(s)
- Fu-Tsuen Lee
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, Canada.,Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Davide Marini
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Mike Seed
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada.,Department of Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Liqun Sun
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
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McHugh A, El-Khuffash A, Franklin O, Breathnach FM. Calling into question the future of hyperoxygenation in pregnancy. Eur J Obstet Gynecol Reprod Biol 2020; 258:93-97. [PMID: 33421817 DOI: 10.1016/j.ejogrb.2020.12.054] [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] [Received: 10/30/2020] [Revised: 12/09/2020] [Accepted: 12/28/2020] [Indexed: 01/07/2023]
Abstract
Maternal hyperoxygenation has been investigated as a potential diagnostic and therapeutic tool since the 1960s. Since then, it has been applied in many obstetric scenarios, both clinically and in the research setting. It is often administered without any determination of pre-hyperoxygenation maternal or fetal oxygen levels. Studies focussing on maternal oxygen therapy for the treatment of fetal growth restriction have been ongoing for over thirty years and there remains no clear evidence of benefit. Studies investigating the potential diagnostic or therapeutic role of maternal oxygen therapy in the setting of fetal congenital cardiac disease have reported varying success rates and some potentially worrying adverse effects. The purpose of this article is to review the effects of maternal hyperoxygenation on fetal and maternal health and to ascertain the safety of undertaking further clinical trials that employ the use of hyperoxygenation in pregnancy.
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Affiliation(s)
- Ann McHugh
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland.
| | - Afif El-Khuffash
- Department of Neonatology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Orla Franklin
- Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Fionnuala M Breathnach
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
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12
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Branch pulmonary artery Doppler parameters predict early survival-non-survival in premature rupture of membranes. J Perinatol 2020; 40:1821-1827. [PMID: 32978527 DOI: 10.1038/s41372-020-00817-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 08/03/2020] [Accepted: 09/10/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Preterm premature rupture of membrane (pPROM) leads to high neonatal mortality due in part to severe lung hypoplasia (LH). In other causes of severe LH, fetal echo-based parameters of smaller branch pulmonary arteries (PA), shorter acceleration to ejection time ratio (AT/ET), increased peak early diastolic reverse flow (PEDRF), and higher pulsatility index (PI) are predictive of worse neonatal outcome. We sought to determine whether these parameters correlated with worse clinical outcome in pPROM. METHODS Twenty-five pregnancies complicated by pPROM were prospectively recruited. Fetal echocardiography was used to evaluate branch PA diameters and Doppler parameters. Clinical records were reviewed. Fetal echo findings were compared between early survivors and non-survivors. RESULTS Of 25 pPROM cases, 5 had early neonatal demise (≤3 days) due to respiratory insufficiency. While gestational age at pPROM, fetal echo, and at birth did not differ, amniotic fluid index (AFI) was significantly lower in early non-survivors compared to survivors (p = 0.05). No difference was observed in PA diameter, PEDRF, or PI; however, branch PA AT/ET was significantly shorter in non-survivors (right PA median 0.12 (0.11-0.16) vs. survivors 0.17 (0.14-0.21), p = 0.046 and left PA 0.12 (0.09-0.13) vs. survivors 0.16 (0.11-0.21), p = 0.042). CONCLUSIONS We found a significantly lower AFI and shorter fetal bilateral branch PA AT/ET to be associated with early neonatal demise following pPROM.
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McHugh A, Breatnach C, Bussmann N, Franklin O, El-Khuffash A, Breathnach FM. Prenatal prediction of neonatal haemodynamic adaptation after maternal hyperoxygenation. BMC Pregnancy Childbirth 2020; 20:706. [PMID: 33213415 PMCID: PMC7678134 DOI: 10.1186/s12884-020-03403-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 11/06/2020] [Indexed: 11/17/2022] Open
Abstract
Abstract The reactivity of the pulmonary vascular bed to the administration of oxygen is well established in the post-natal circulation. The vasoreactivity demonstrated by the fetal pulmonary artery Doppler waveform in response to maternal hyperoxia has been investigated. We sought to investigate the relationship between the reactivity of the fetal pulmonary arteries to hyperoxia and subsequent neonatal cardiac function in the early newborn period. Methods This explorative study with convenience sampling measured pulsatility index (PI), resistance index (RI), acceleration time (AT), and ejection time (ET) from the fetal distal branch pulmonary artery (PA) at baseline and following maternal hyperoxygenation (MH). Oxygen was administered for 10 min at a rate of 12 L/min via a partial non-rebreather mask. A neonatal functional echocardiogram was performed within the first 24 h of life to assess ejection fraction (EF), left ventricular output (LVO), and neonatal pulmonary artery AT (nPAAT). This study was conducted in the Rotunda Hospital, Dublin, Ireland. Results Forty-six women with a singleton pregnancy greater than or equal to 31 weeks’ gestational age were prospectively recruited to the study. The median gestational age was 35 weeks. There was a decrease in fetal PAPI and PARI following MH and an increase in fetal PAAT, leading to an increase in PA AT:ET. Fetuses that responded to hyperoxygenation were more likely to have a higher LVO (135 ± 25 mL/kg/min vs 111 ± 21 mL/kg/min, p < 0.01) and EF (54 ± 9% vs 47 ± 7%,p = 0.03) in the early newborn period than those that did not respond to MH prenatally. These findings were not dependent on left ventricular size or mitral valve (MV) annular diameter but were related to an increased MV inflow. There was no difference in nPAAT. Conclusion These findings indicate a reduction in fetal pulmonary vascular resistance (PVR) and an increase in pulmonary blood flow and left atrial return following MH. The fetal response to hyperoxia reflected an optimal adaptation to postnatal life with rapid reduction in PVR increasing measured cardiac output. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-020-03403-y.
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Affiliation(s)
- Ann McHugh
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland.
| | - Colm Breatnach
- Department of Neonatology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Neidin Bussmann
- Department of Neonatology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Orla Franklin
- Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Afif El-Khuffash
- Department of Neonatology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fionnuala M Breathnach
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
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Rydzewska K, Sylwestrzak O, Krekora M, Słodki M, Respondek-Liberska M. Ebstein's anomaly: epidemiological analysis and presentation of different prenatal management. J Matern Fetal Neonatal Med 2020; 35:3297-3304. [PMID: 32933366 DOI: 10.1080/14767058.2020.1818207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To present the crucial role of echocardiographic examination in perinatal care and analyze influence of prenatal treatment for neonatal outcome. Furthermore, the attempt to answer the question if there was any relationship between the occurrence of fetal Ebstein's anomaly and environmental risk factors in polish population. METHODS Forty-five prenatal diagnoses of Ebstein's anomaly were compiled over the 21-year period (1998‒2018) form our single unit. The analysis included the assessment of maternal parameters (age, past obstetric history, and place of residence) and fetal parameters (sex, gestational age, anatomy, the fetal cardiovascular condition assessed by the CVPS, associated extracardiac anomalies or malformations, prenatal treatment, delivery and follow-up). RESULTS The average age of gravida was 29.5 years (± 5.2 years) and gravidae <35 years of age accounted for 80% . There were 43 singleton pregnancies and 2 cases of multiple pregnancy. Ebstein's anomaly was mostly (averagely) diagnosed at 28th week of gestation. Forty-three fetuses had normal karyotypes and two had trisomy 21. Cardiomegaly was present in 91% (41) of fetuses. The average heart area to chest area ratio was 0.56 (± 0.12). In 21 cases, there was only fetal monitoring - echocardiographic examinations and postnatal mortality was 44.4%. In 5 cases, transplacental digoxin treatment was administered and mortality was: 40%. In another 5 cases, only steroid therapy was applied and postnatal mortality was 100%. Steroids and transplacental digoxin treatment were administered in 11 cases and mortality was 63.6%. In 3 last cases transplacental digoxin treatment, steroids and maternal hyperoxygenation therapy were given and mortality was 0%. Cesarean section rate was 49%. Moreover, due to Ebstein's anomaly regional peak of occurrence benzopyrene was deliberated as environmental risk factor. CONCLUSIONS Fetal Ebstein's anomaly occurred in our population in healthy young women, expecting their first child and malformation was not related to fetus gender, nor to maternal health condition. Our data can be a new signal for the development of novel treatment strategies in therapy in fetuses with Ebstein's anomaly.
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Affiliation(s)
| | | | - Michał Krekora
- Department of Obstetrics and Gynaecology, Polish Mother's Memorial Hospital, Lodz, Poland
| | - Maciej Słodki
- Faculty of Health Sciences, The State University of Applied Sciences, Plock, Poland.,Department of Prenatal Cardiology, Polish Mother's Memorial Hospital-Research Institute, Lodz, Poland
| | - Maria Respondek-Liberska
- Department of Prenatal Cardiology, Polish Mother's Memorial Hospital-Research Institute, Lodz, Poland.,Department of Diagnosis and Prevention of Fetal Malformations, Medical University of Lodz, Lodz, Poland
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15
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Sanapo L, Al-Shargabi T, Ahmadzia HK, Schidlow DN, Donofrio MT, Hitchings L, Khoury A, Larry Maxwell G, Baker R, Bulas DI, Gomez LM, du Plessis AJ. Fetal acute cerebral vasoreactivity to maternal hyperoxia in low-risk pregnancies: a cross-sectional study. Prenat Diagn 2020; 40:813-824. [PMID: 32274806 DOI: 10.1002/pd.5694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 02/03/2020] [Accepted: 03/23/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To establish whether fetal cerebral vasoreactivity (CVRO2 ), following maternal hyperoxia, is predicted by fetal cerebral and uteroplacental Doppler pulsatility indices (PI) at baseline, fetal pulmonary vasoreactivity to oxygen (PVRO2 ), gestational age (GA), or sex. METHODS Pulsatility index of middle (MCA), anterior (ACA), posterior cerebral (PCA), umbilical (UA), uterine (UtA), and branch of the pulmonary arteries (PA) were obtained, by ultrasound, before (baseline), during (hyperoxia) and after 15 minutes of maternal administration of 8 L/min of 100% oxygen, through a non-rebreathing face mask, in normal singleton pregnancies within 20 to 38 weeks' gestation. CVRO2 was defined as changes greater than zero in z score of PI of the cerebral arteries from baseline to hyperoxia. Logistic modeling was applied to identify CVRO2 predictors. RESULTS A total of 97 pregnancies were eligible. In the overall population, median z scores of PI of MCA, ACA, and PCA did not differ between study phases. Based on the logistic model, baseline z scores for cerebral PI and GA were the best predictors of CVRO2 . CONCLUSIONS In low-risk pregnancies, fetal CVRO2 to hyperoxia does not occur uniformly but depends on cerebral PI and GA at baseline. These findings may provide useful reference points when oxygen is administered in high-risk pregnancies.
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Affiliation(s)
- Laura Sanapo
- Women's Medicine Collaborative-Division of Research, The Miriam Hospital, Providence, Rhode Island, USA
| | - Tareq Al-Shargabi
- Division of Fetal and Transitional Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Homa K Ahmadzia
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Science, Washington, District of Columbia, USA
| | - David N Schidlow
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary T Donofrio
- Division of Fetal and Transitional Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Division of Cardiology, Children's National Hospital, Washington, District of Columbia, USA
| | - Laura Hitchings
- Division of Fetal and Transitional Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Alfred Khoury
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Inova Health System, Falls Church, Virginia, USA
| | - G Larry Maxwell
- Department of Obstetrics and Gynecology, Inova Health System, Falls Church, Virginia, USA
| | - Robin Baker
- Department of Neonatology, Fairfax Neonatal Associates, Inova Children's Hospital, Falls Church, Virginia, USA
| | - Dorothy I Bulas
- Division of Diagnostic Imaging and Radiology, Children's National Hospital, Washington, District of Columbia, USA
| | - Luis M Gomez
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Inova Health System, Falls Church, Virginia, USA
| | - Adre J du Plessis
- Division of Fetal and Transitional Medicine, Children's National Hospital, Washington, District of Columbia, USA
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McHugh A, El-Khuffash A, Bussmann N, Doherty A, Franklin O, Breathnach F. Hyperoxygenation in pregnancy exerts a more profound effect on cardiovascular hemodynamics than is observed in the nonpregnant state. Am J Obstet Gynecol 2019; 220:397.e1-397.e8. [PMID: 30849354 DOI: 10.1016/j.ajog.2019.02.059] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/31/2019] [Accepted: 02/27/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Supplemental oxygen is administered to pregnant women in many different clinical scenarios in obstetric practice. Despite the accepted uses for maternal hyperoxygenation, the impact of hyperoxia on maternal hemodynamic indices has not been evaluated. As a result, there is a paucity of data in the literature in relation to the physiological changes to the maternal circulation in response to supplemental oxygen. OBJECTIVE The hemodynamic effects of oxygen therapy are under-recognized and the impact of hyperoxygenation on maternal hemodynamics is currently unknown. Using noninvasive cardiac output monitoring which employs transthoracic bioreactance, we examined the effect of brief hyperoxygenation on cardiac index, systemic vascular resistance, blood pressure, stroke volume, and heart rate in pregnant mothers during the third trimester, compared with those effects observed in a nonpregnant population subjected to the same period of hyperoxygenation. STUDY DESIGN Hemodynamic monitoring was performed in a continuous manner over a 30-minute period using noninvasive cardiac output monitoring. Hyperoxygenation (O2 100% v/v inhalational gas) was carried out at a rate of 12 L/min via a partial non-rebreather mask for 10-minutes. Cardiac index, systemic vascular resistance, stroke volume, heart rate, and blood pressure were recorded before hyperoxygenation, at completion of hyperoxygenation, and 10 minutes after the cessation of hyperoxygenation. Two-way analysis of variance with repeated measures was used to assess the change in hemodynamic indices over time and the differences between the 2 groups. RESULTS Forty-six pregnant and 20 nonpregnant women with a median age of 33 years (interquartile range, 26-38 years) and 32 years (interquartile range, 28-37 years) were recruited prospectively, respectively (P=.82). The median gestational age was 35 weeks (33-37 weeks). In the pregnant group, there was a fall in cardiac index during the hyperoxygenation exposure period (P=.009) coupled with a rise in systemic vascular resistance with no recovery at 10 minutes after cessation of hyperoxygenation (P=.02). Heart rate decreased after hyperoxygenation exposure and returned to baseline by 10 minutes after cessation of therapy. There was a decrease in stroke volume over the exposure period, with no change in systolic or diastolic blood pressure. In the nonpregnant group, there was no significant change in the cardiac index, systemic vascular resistance, stroke volume, heart rate, or systolic or diastolic blood pressure during the course of exposure to hyperoxygenation. CONCLUSION Hyperoxygenation during the third trimester is associated with a fall in maternal cardiac index and a rise in systemic vascular resistance without recovery to baseline levels at 10 minutes after cessation of hyperoxygenation. The hemodynamic changes that were observed in this study in response to hyperoxygenation therapy during pregnancy could counteract any intended increase in oxygen delivery. The observed maternal effects of hyperoxygenation call for a reevaluation of the role of hyperoxygenation treatment in the nonhypoxemic pregnant patient.
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Affiliation(s)
- Ann McHugh
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda, Hospital, Dublin, Ireland.
| | - Afif El-Khuffash
- Department of Neonatology, Royal College of Surgeons in Ireland, Rotunda, Hospital, Dublin, Ireland
| | - Neidin Bussmann
- Department of Neonatology, Royal College of Surgeons in Ireland, Rotunda, Hospital, Dublin, Ireland
| | - Anne Doherty
- Department of Anaesthesia, Royal College of Surgeons in Ireland, Rotunda, Hospital, Dublin, Ireland
| | - Orla Franklin
- Department of Paediatric Cardiology, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Fionnuala Breathnach
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda, Hospital, Dublin, Ireland
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17
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Yamamoto Y, Hirose A, Howley L, Savard W, Jain V, Hornberger LK. Parameters of fetal pulmonary vascular health: baseline trends and response to maternal hyperoxia in the second and third trimesters. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:618-623. [PMID: 27943455 DOI: 10.1002/uog.17383] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 10/20/2016] [Accepted: 12/01/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Several parameters, including branch pulmonary artery (PA) diameter and Doppler-derived PA acceleration-to-ejection time ratio (AT/ET), peak late-systolic/early-diastolic reversed flow (PEDRF) and pulsatility index (PI) response to maternal hyperoxia, have been used to investigate fetal pulmonary health. Lower AT/ET, increased PEDRF and lack of PI response to hyperoxia have been observed in fetuses with severe lung hypoplasia and are considered markers of pulmonary vascular resistance. We sought to further define the evolution of PA diameter and Doppler parameters and their response to maternal hyperoxia in healthy fetuses. METHODS Fifty-four prospectively recruited women with healthy pregnancy underwent fetal echocardiography from 18-36 weeks of gestation. After baseline branch PA diameter and Doppler assessment, oxygen (8-10 L/min) was administered by non-reservoir facemask for 10 min and PA Doppler parameters were reassessed. RESULTS Branch PA diameters and AT/ET increased linearly with gestational age, while PEDRF increased quadratically (P < 0.001 for all) and PA-PI did not change. In response to maternal hyperoxia, although most fetuses demonstrated a significant decrease in PI for both branch PAs (right PA, P = 0.025; left PA, P = 0.040) ≥ 30 weeks, significant variability was observed in PI response with 31% of cases demonstrating either no response or a slight decrease. No other parameter demonstrated a measurable change in response to maternal hyperoxia. CONCLUSIONS From the mid-trimester, fetal branch PA diameters and AT/ET increase linearly and PEDRF increases quadratically, whereas PI remains unchanged. Although maternal hyperoxia triggers a significant decrease in PA-PI after 30 weeks, variability in this response may reduce its utility in clinical practice. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- Y Yamamoto
- Fetal and Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, Women's & Children's Health Research Institute and Mazankowski Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - A Hirose
- Fetal and Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, Women's & Children's Health Research Institute and Mazankowski Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - L Howley
- Fetal and Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, Women's & Children's Health Research Institute and Mazankowski Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - W Savard
- Fetal and Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, Women's & Children's Health Research Institute and Mazankowski Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - V Jain
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - L K Hornberger
- Fetal and Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, Women's & Children's Health Research Institute and Mazankowski Heart Institute, University of Alberta, Edmonton, Alberta, Canada
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada
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18
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Abstract
Pulmonary hypoplasia, although rare, is associated with significant neonatal morbidity and mortality. Conditions associated with pulmonary hypoplasia include those which limit normal thoracic capacity or movement, including skeletal dysplasias and abdominal wall defects; those with mass effect, including congenital diaphragmatic hernia and pleural effusions; and those with decreased amniotic fluid, including preterm, premature rupture of membranes, and genitourinary anomalies. The ability to predict severe pulmonary hypoplasia prenatally aids in family counseling, as well as obstetric and neonatal management. The objective of this review is to outline the imaging techniques that are widely used prenatally to assess pulmonary hypoplasia and to discuss the limitations of these methods.
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19
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Abstract
In congenital diaphragmatic hernia (CDH), herniation of the abdominal organs into the fetal chest causes pulmonary hypoplasia and pulmonary hypertension, the main causes of neonatal mortality. As antenatal ultrasound screening improves, the risk of postnatal death can now be better predicted, allowing for the identification of fetuses that might most benefit from a prenatal intervention. Fetoscopic tracheal occlusion is being evaluated in a large international randomized controlled trial. We present the antenatal imaging approaches that can help identify fetuses that might benefit from antenatal therapy, and review the evolution of fetal surgery for CDH to date.
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Affiliation(s)
- Titilayo Oluyomi-Obi
- Section of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, University of Calgary, 1403 29 Street NW, Calgary, Alberta.
| | - Tim Van Mieghem
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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20
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Arunamata A, Axelrod DM, Bianco K, Balasubramanian S, Quirin A, Tacy TA. Chronic antepartum maternal hyperoxygenation in a case of severe fetal Ebstein's anomaly with circular shunt physiology. Ann Pediatr Cardiol 2017; 10:284-287. [PMID: 28928616 PMCID: PMC5594941 DOI: 10.4103/apc.apc_20_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Perinatal mortality remains high among fetuses diagnosed with Ebstein's anomaly of the tricuspid valve. The subgroup of patients with pulmonary valve regurgitation is at particularly high risk. In the setting of pulmonary valve regurgitation, early constriction of the ductus arteriosus may be a novel perinatal management strategy to reduce systemic steal resulting from circular shunt physiology. We report the use of chronic antepartum maternal oxygen therapy for constriction of the fetal ductus arteriosus and modulation of fetal pulmonary vascular resistance in a late presentation of Ebstein's anomaly with severe tricuspid valve regurgitation, reversal of flow in the ductus arteriosus, and continuous pulmonary valve regurgitation.
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Affiliation(s)
- Alisa Arunamata
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - David M Axelrod
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Katherine Bianco
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Stanford University School of Medicine, Stanford, CA 94304, USA
| | - Sowmya Balasubramanian
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Amy Quirin
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Theresa A Tacy
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
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21
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Sustained maternal hyperoxygenation improves aortic arch dimensions in fetuses with coarctation. Sci Rep 2016; 6:39304. [PMID: 27982102 PMCID: PMC5159786 DOI: 10.1038/srep39304] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 11/22/2016] [Indexed: 12/11/2022] Open
Abstract
The aim was to investigate the impact of maternal hyperoxygenation (HO) on cardiac dimensions in fetuses with isolated Coarctation (CoA). Fetal echocardiography was performed serially in 48 fetuses with CoA and gestation age matched normal fetues. The Z-scores for the mitral valve (MV), tricuspid valve (TV), aortic valve (AV), ascending aorta (AAo), isthmus, pulmonary valve (PV), main pulmonary artery (MPA), and descending aorta (DAo) were measured and compared among normal fetuses, CoA fetuses with oxygen and CoA fetuses with air. In the group with oxygen, 6 L/min oxygen was administered to the mother using a face mask. Regression analyses were performed to identify potential factors for HO outcome. The left heart dimension Z-scores increased gradually during HO therapy periods, especially at 4 weeks after oxygen therapy (P < 0.05). As for the case group with air, the left heart dimension remained unchanged. The duration of HO was associated with aortic arch Z-scores (adjusted R2 = 0.199, 0.60 for AAO and isthmus, respectively). Sustained maternal middle-flow oxygenation can be safely used to improve left heart dimensions in fetuses with isolated CoA. The duration of HO were associated with treatment outcome. These findings may provide useful information for developing novel treatment strategies.
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22
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Lara DA, Morris SA, Maskatia SA, Challman M, Nguyen M, Feagin DK, Schoppe L, Zhang J, Bhatt A, Sexson-Tejtel SK, Lopez KN, Lawrence EJ, Andreas S, Wang Y, Belfort MA, Ruano R, Ayres NA, Altman CA, Aagaard KM, Becker J. Pilot study of chronic maternal hyperoxygenation and effect on aortic and mitral valve annular dimensions in fetuses with left heart hypoplasia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:365-372. [PMID: 26700848 DOI: 10.1002/uog.15846] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 12/14/2015] [Accepted: 12/18/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Acute maternal hyperoxygenation (AMH) results in increased fetal left heart blood flow. Our aim was to perform a pilot study to determine the safety, feasibility and direction and magnitude of effect of chronic maternal hyperoxygenation (CMH) on mitral and aortic valve annular dimensions in fetuses with left heart hypoplasia (LHH) after CMH. METHODS Gravidae with fetal LHH were eligible for inclusion in a prospective evaluation of CMH. LHH was defined as: sum of aortic and mitral valve annuli Z-scores < -4.5, arch flow reversal and left-to-right or bidirectional atrial level shunting without hypoplastic left heart syndrome or severe aortic stenosis. Gravidae with an affected fetus and with ≥ 10% increase in aortic/combined cardiac output flow after 10 min of AMH at 8 L/min 100% fraction of inspired oxygen were offered enrollment. Nine gravidae were enrolled from February 2014 to January 2015. The goal therapy was ≥ 8 h daily CMH from enrollment until delivery. Gravidae who were cared for from July 2012 to October 2014 with fetal LHH and no CMH were identified as historical controls (n = 9). Rates of growth in aortic and mitral annuli over the final trimester were compared between groups using longitudinal regression. RESULTS There were no significant maternal or fetal complications in the CMH cohort. Mean gestational age at study initiation was 29.6 ± 3.2 weeks for the intervention group and 28.4 ± 1.8 weeks for controls (P = 0.35). Mean relative increase in aortic/combined cardiac output after AMH was 35.3% (range, 18.1-47.9%). Median number of hours per day on CMH therapy was 9.3 (range, 6.5-14.6) and median duration of CMH was 48 (range, 33-84) days. Mean mitral annular growth was 0.19 ± 0.05 mm/week compared with 0.14 ± 0.05 mm/week in CMH vs controls (mean difference 0.05 ± 0.05 mm/week, P = 0.33). Mean aortic annular growth was 0.14 ± 0.03 mm/week compared with 0.13 ± 0.03 mm/week in CMH vs controls (mean difference 0.01 ± 0.03 mm/week, P = 0.75). More than 9 h CMH daily (n = 6) was associated with better growth of the aortic annulus in intervention fetuses (0.16 ± 0.03 vs 0.08 ± 0.02 mm/week, P = 0.014). CONCLUSIONS CMH is both safe and feasible for continued research. In this pilot study, the effect estimates of annular growth, using the studied method of delivery and dose of oxygen, were small. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- D A Lara
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - S A Morris
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - S A Maskatia
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX, USA
| | - M Challman
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - M Nguyen
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX, USA
| | - D K Feagin
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - L Schoppe
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX, USA
| | - J Zhang
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX, USA
| | - A Bhatt
- Department of Ophthalmology, Baylor College of Medicine, Houston, TX, USA
| | - S K Sexson-Tejtel
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - K N Lopez
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - E J Lawrence
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - S Andreas
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Y Wang
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - M A Belfort
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - R Ruano
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - N A Ayres
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - C A Altman
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - K M Aagaard
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - J Becker
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Cruz-Martínez R, Cruz-Lemini M, Mendez A, Illa M, García-Baeza V, Martinez JM, Gratacós E. Learning Curve for Intrapulmonary Artery Doppler in Fetuses with Congenital Diaphragmatic Hernia. Fetal Diagn Ther 2015; 39:256-60. [DOI: 10.1159/000441026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 09/03/2015] [Indexed: 11/19/2022]
Abstract
Objective: To assess the learning curve for intrapulmonary artery Doppler in fetuses with congenital diaphragmatic hernia (CDH). Methods: Three fetal medicine fellows with the theoretic knowledge, but without prior experience, in the evaluation of intrapulmonary artery Doppler in CDH fetuses were selected. Each trainee and 1 experienced explorer assessed the intrapulmonary artery in the contralateral lung to the side of the hernia for calculation of 2 Doppler parameters - pulsatility index (PI) and peak early diastolic reversed flow (PEDRF) - in a cohort of 90 consecutive CDH fetuses. The average difference between the 3 trainees and the expert was calculated. A difference below 15% was considered as accurate measurement. The average learning curve was delineated using the cumulative sum analysis (CUSUM). Results: Among the total 270 intrapulmonary artery Doppler measurements performed by the 3 trainees, the number of failed examinations was 14 (15.6%) and 16 (17.8%) for PI and PEDRF, respectively. The CUSUM plots demonstrate that the learning curve was achieved by 53 and 63 tests performed for calculations of the intrapulmonary artery PI and PEDRF, respectively. Conclusion: Competence in Doppler evaluation of the intrapulmonary artery in CDH fetuses is achieved only after intensive continuous training.
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Channing A, Szwast A, Natarajan S, Degenhardt K, Tian Z, Rychik J. Maternal hyperoxygenation improves left heart filling in fetuses with atrial septal aneurysm causing impediment to left ventricular inflow. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:664-669. [PMID: 25296951 DOI: 10.1002/uog.14688] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 09/24/2014] [Accepted: 09/29/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES Aneurysm of the atrial septum (AAS) with excessive excursion of septum primum into the left atrium is an uncommon and relatively benign fetal condition associated with impediment to left ventricular (LV) filling and the appearance of a slender, but apex-forming, LV on fetal echocardiography. Impediment to filling can be severe, creating the image of LV hypoplasia with retrograde aortic flow. We hypothesize that maternal hyperoxygenation alters atrial septal position, improves LV filling, and normalizes aortic flow in fetuses with AAS by increasing fetal pulmonary venous return. METHODS Fetal echocardiography was performed prior to, and at 10 min of, maternal hyperoxygenation in 12 fetuses with AAS who were referred to our center because of LV hypoplasia. Atrial septal excursion (ASE), LV and right ventricular (RV) sphericity index (SI) and direction of flow in the aortic isthmus, as determined by Doppler, were measured. RESULTS With maternal hyperoxygenation, mean ± SD ASE decreased (0.76 ± 0.17 before maternal hyperoxygenation vs 0.53 ± 0.23 after maternal hyperoxygenation; P < 0.01), consistent with increased pulmonary venous return, LV-SI increased (0.29 ± 0.06 vs 0.42 ± 0.06; P < 0.001), indicating increased LV filling, and the direction of aortic isthmus flow changed from retrograde in all cases prior to maternal hyperoxygenation to antegrade in 10 and to bidirectional in two. RV-SI remained unchanged (0.53 ± 0.13 vs 0.52 ± 0.10; P = 0.7). CONCLUSIONS In cases of AAS, short-term maternal hyperoxygenation increases fetal pulmonary venous return, substantially alters LV geometry and promotes antegrade flow in the aortic isthmus. This demonstrates proof-of-concept that maternal hyperoxygenation can improve filling of the left side of the fetal heart in AAS.
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Affiliation(s)
- A Channing
- The Fetal Heart Program, Cardiac Center, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - A Szwast
- The Fetal Heart Program, Cardiac Center, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Division of Cardiology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - S Natarajan
- The Fetal Heart Program, Cardiac Center, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - K Degenhardt
- The Fetal Heart Program, Cardiac Center, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Division of Cardiology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Z Tian
- The Fetal Heart Program, Cardiac Center, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J Rychik
- The Fetal Heart Program, Cardiac Center, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Division of Cardiology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Steurer MA, Moon-Grady AJ, Fineman JR, Sun CE, Lusk LA, Wai KC, Keller RL. B-type natriuretic peptide: prognostic marker in congenital diaphragmatic hernia. Pediatr Res 2014; 76:549-54. [PMID: 25188741 PMCID: PMC4232979 DOI: 10.1038/pr.2014.136] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 06/30/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND B-type natriuretic peptide (BNP) has not been evaluated in newborns with congenital diaphragmatic hernia (CDH). We hypothesized that BNP and severity of pulmonary hypertension (PH) would predict clinical outcome in these infants. METHODS We measured BNP levels and assessed severity of PH by echocardiography at 1 d and 1 wk of life. Outcome was classified by status at 56 d (or prior discharge): Good (n = 13) if alive on room air and Poor (n = 14) if expired or receiving respiratory support. We estimated area under the curve (AUC) and 95% confidence interval (CI). RESULTS BNP levels were higher at 1 d in newborns with Poor outcome (median 220 pg/ml vs. 55 pg/ml, P < 0.01). At 1 wk, there was no significant difference in BNP level (median 547 pg/ml vs. 364 pg/ml, P = 0.70, for Poor and Good outcomes). At 1 d, BNP level predicted outcome (AUC = 0.91, 95% CI = 0.77-1.0), but this relationship dissipated by 1 wk (AUC = 0.55, 95% CI = 0.31-0.79). Severity of PH did not predict outcome at 1 d (AUC = 0.51, 95% CI = 0.27-0.74), but prediction improved at 1 wk (AUC = 0.80, 95% CI = 0.61-0.99). CONCLUSION BNP is a strong predictor of clinical outcome in newborns with CDH at 1 d of life.
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Affiliation(s)
- Martina A. Steurer
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | | | - Jeff R. Fineman
- Department of Pediatrics, University of California, San Francisco, CA, USA,Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Christine E. Sun
- Department of Pediatrics, University of California, San Francisco, CA, USA,Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Leslie A. Lusk
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Katherine C. Wai
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Roberta L. Keller
- Department of Pediatrics, University of California, San Francisco, CA, USA
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Frommelt MA. Challenges and controversies in fetal diagnosis and treatment: hypoplastic left heart syndrome. Clin Perinatol 2014; 41:787-98. [PMID: 25459774 DOI: 10.1016/j.clp.2014.08.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Today, almost 70% of babies with hypoplastic left heart syndrome (HLHS) will survive into adulthood, although significant long-term morbidity and mortality still exists. Prenatal diagnosis of HLHS is increasingly common, allowing improved counseling, and the potential for fetal intervention if indicated. Exciting progress continues to be made in the area of fetal diagnosis and intervention, specifically catheter intervention for intact atrial septum or severe aortic stenosis. Pediatric cardiologists should be keenly aware of the flaws of staged palliation for the treatment of HLHS, and need to keep abreast of the emerging data regarding fetal diagnosis and intervention.
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Affiliation(s)
- Michele A Frommelt
- Division of Cardiology, Children's Hospital of Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI 53201, USA.
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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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Doppler parameters of fetal lung hypoplasia and impact of sildenafil. Am J Obstet Gynecol 2014; 211:263.e1-8. [PMID: 24631434 DOI: 10.1016/j.ajog.2014.03.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 01/10/2014] [Accepted: 03/06/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Congenital diaphragmatic hernia (CDH) is clinically challenging because of associated lung hypoplasia (LH). There have been no validated parameters to evaluate fetal LH severity. Sildenafil has been shown to improve LH mass in nitrofen-induced pulmonary artery (PA) models, but the pulmonary vascular tone has not been evaluated in vivo. The aim of this study was to identify the PA Doppler parameter that best predicts LH severity and to investigate the efficacy of antenatal sildenafil treatment in experimental CDH. STUDY DESIGN Nitrofen (50-60% CDH in offspring) or vehicle on E9.5 and sildenafil or vehicle on E11.5-20.5 were administrated to pregnant rats. On E20.5, PA Doppler indices were investigated with and without maternal hyperoxia. The presence/absence of CDH, lung/body weight ratio and radial saccular count were assessed at E20.5. RESULTS At baseline, CDH rats had lower PA Doppler acceleration/ejection time ratios and pulsatility index (PI). Maternal hyperoxia resulted in a significant decrease in the PA/PI suggesting pulmonary vasodilation. In contrast, in CDH fetuses, the ipsilateral PA/PI showed little or no response to hyperoxia (P > .05), and in those with LH, PI response to maternal hyperoxia correlated positively with hernia, lung/body weight ratio (r = 0.70, P = .01). Maternal sildenafil therapy significantly improved PA response to hyperoxia and lung growth in CDH fetuses (P < .01). CONCLUSION Pulmonary vasodilation that occurs in E20.5 fetal rats in response to maternal hyperoxia is blunted in CDH. Change in PA/PI with hyperoxia is a useful predictor of LH severity. Sildenafil improves pulmonary vascular response and lung growth in fetal CDH.
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DeKoninck P, Jimenez J, Russo FM, Hodges R, Gratacós E, Deprest J. Assessment of pulmonary vascular reactivity to oxygen using fractional moving blood volume in fetuses with normal lung development and pulmonary hypoplasia in congenital diaphragmatic hernia. Prenat Diagn 2014; 34:977-81. [DOI: 10.1002/pd.4408] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 04/27/2014] [Accepted: 05/07/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Philip DeKoninck
- Fetal Medicine Unit, Department of Obstetrics and Gynecology; University Hospitals Leuven; Brussels Belgium
- Cluster Organ Systems, Department of Development and Regeneration; KU Leuven; Leuven Belgium
| | - Julio Jimenez
- Fetal Medicine Unit, Department of Obstetrics and Gynecology; University Hospitals Leuven; Brussels Belgium
- Cluster Organ Systems, Department of Development and Regeneration; KU Leuven; Leuven Belgium
| | - Francesca M. Russo
- Fetal Medicine Unit, Department of Obstetrics and Gynecology; University Hospitals Leuven; Brussels Belgium
- Cluster Organ Systems, Department of Development and Regeneration; KU Leuven; Leuven Belgium
| | - Ryan Hodges
- Fetal Medicine Unit, Department of Obstetrics and Gynecology; University Hospitals Leuven; Brussels Belgium
- Cluster Organ Systems, Department of Development and Regeneration; KU Leuven; Leuven Belgium
| | - Eduard Gratacós
- Maternal-Fetal Medicine Department; Institut Clínic de Ginecologia, Obstetrícia i Neonatologia (ICGON), Hospital Clínic; Barcelona Spain
- Institut d'Investigacions Biomèdiques Augusto Pi i Sunyer (IDIBAPS); University of Barcelona; Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER); Barcelona Spain
| | - Jan Deprest
- Fetal Medicine Unit, Department of Obstetrics and Gynecology; University Hospitals Leuven; Brussels Belgium
- Cluster Organ Systems, Department of Development and Regeneration; KU Leuven; Leuven Belgium
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Peyvandi S, Rychik J, McCann M, Soffer D, Tian Z, Szwast A. Pulmonary artery blood flow patterns in fetuses with pulmonary outflow tract obstruction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:297-302. [PMID: 23554091 PMCID: PMC4527155 DOI: 10.1002/uog.12472] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 02/06/2013] [Accepted: 03/18/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVES Fetuses with pulmonary outflow tract obstruction (POTO) have altered blood flow to the pulmonary vasculature. We sought to determine whether pulmonary vascular impedance, as assessed by the pulsatility index (PI), is different in fetuses with POTO compared with normal controls. METHODS Branch pulmonary artery PI was evaluated in age-matched normal control fetuses (n=22) and 20 POTO fetuses (pulmonary stenosis n=15, pulmonary atresia n=5). Pulsed-wave Doppler was performed in the proximal (PA1), mid (PA2) and distal (PA3) branch pulmonary artery. The direction of flow in the ductus arteriosus was noted. The study and control groups were compared with Student's t-test and ANOVA. A linear mixed model evaluated the relationship between PI and ductus arteriosus flow patterns. RESULTS There was no difference in PI between control, pulmonary stenosis and pulmonary atresia subjects at PA1 and PA2; however, there was a significant difference at PA3. Subjects with pulmonary atresia had a lower PI at PA3 than did controls (P=0.003) and pulmonary stenosis subjects (P=0.003). Subjects with retrograde flow in the ductus arteriosus had lower PIs in PA2 and PA3 than did those with antegrade flow (P=0.01 and 0.005, respectively). The PI in PA3 was lower in fetuses that required prostaglandin postnatally than in those that did not (P=0.008). CONCLUSIONS Fetuses with pulmonary atresia or severe pulmonary stenosis with retrograde flow in the ductus arteriosus have decreased PI in the distal pulmonary vasculature. Our findings indicate the capacity of the fetal pulmonary vasculature to vasodilate in response to anatomical obstruction of flow.
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Affiliation(s)
- Shabnam Peyvandi
- Fetal Heart Program at the Cardiac Center at The Children’s Hospital of Philadelphia, Philadelphia, PA
- Division of Cardiology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jack Rychik
- Fetal Heart Program at the Cardiac Center at The Children’s Hospital of Philadelphia, Philadelphia, PA
- Division of Cardiology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Margaret McCann
- Fetal Heart Program at the Cardiac Center at The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Debbra Soffer
- Fetal Heart Program at the Cardiac Center at The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Zhiyun Tian
- Fetal Heart Program at the Cardiac Center at The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Anita Szwast
- Fetal Heart Program at the Cardiac Center at The Children’s Hospital of Philadelphia, Philadelphia, PA
- Division of Cardiology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Effects of maternal hyperoxygenation in a case of severe congenital diaphragmatic hernia accompanied by hydrops fetalis. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2014. [DOI: 10.1016/j.epsc.2013.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Fetal production of growth factors and inflammatory mediators predicts pulmonary hypertension in congenital diaphragmatic hernia. Pediatr Res 2013; 74:290-8. [PMID: 23770923 PMCID: PMC4164304 DOI: 10.1038/pr.2013.98] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 01/17/2013] [Indexed: 12/04/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) represents a spectrum of lung hypoplasia, and consequent pulmonary hypertension (PH) is an important cause of postnatal morbidity and mortality. We studied biomarkers at the maternal-fetal interface to understand factors associated with the persistence of PH. METHODS Maternal and cord blood samples from fetuses with CDH and unaffected controls were analyzed using a human 39plex immunoassay kit. Cellular trafficking between the mother and the fetus was quantified using quantitative real-time PCR for nonshared alleles. Biomarker profiles were then correlated with CDH severity on the basis of the degree of PH. RESULTS Cord blood levels of epidermal growth factor, platelet-derived growth factor, and several inflammatory mediators increased significantly as the severity of CDH increased, whereas maternal levels of growth factors and mediators decreased significantly with CDH severity. Maternal cells were increased in fetuses with severe CDH as compared with controls, with elevated levels of the CXC chemokine ligand-10 in patients with the highest trafficking. CONCLUSION Patients with CDH demonstrate proinflammatory and chemotactic signals in fetal blood at the time of birth. Because some of these molecules have been implicated in the development of PH, prenatal strategies targeting specific molecular pathways may be useful adjuncts to current fetal therapies.
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DeKoninck P, Lewi P, Done E, Richter J, Gucciardo L, Mieghem TV, Deprest JA. Sonographic evaluation of vascular pulmonary reactivity following oxygen administration in fetuses with normal lung development. Prenat Diagn 2012; 32:1300-4. [DOI: 10.1002/pd.4000] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Philip DeKoninck
- Fetal Medicine Unit, Department of Obstetrics and Gynecology; University Hospitals Leuven; Leuven Belgium
| | - Paul Lewi
- Fetal Medicine Unit, Department of Obstetrics and Gynecology; University Hospitals Leuven; Leuven Belgium
| | - Elisa Done
- Fetal Medicine Unit, Department of Obstetrics and Gynecology; University Hospitals Leuven; Leuven Belgium
| | - Jute Richter
- Fetal Medicine Unit, Department of Obstetrics and Gynecology; University Hospitals Leuven; Leuven Belgium
| | - Léonardo Gucciardo
- Fetal Medicine Unit, Department of Obstetrics and Gynecology; University Hospitals Leuven; Leuven Belgium
| | - Tim Van Mieghem
- Fetal Medicine Unit, Department of Obstetrics and Gynecology; University Hospitals Leuven; Leuven Belgium
| | - Jan A. Deprest
- Fetal Medicine Unit, Department of Obstetrics and Gynecology; University Hospitals Leuven; Leuven Belgium
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Szwast A, Rychik J. The use of reconstructive surgery to improve quality of life and survival in prenatal hypoplastic left heart syndrome. Future Cardiol 2012; 8:215-25. [PMID: 22413981 DOI: 10.2217/fca.12.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Outcomes for hypoplastic left heart syndrome have improved substantially in the era of prenatal diagnosis. Current stage 1 survival rates are in excess of 90% in the absence of risk factors. However, fetuses with an intact atrial septum continue to have poor postnatal survival. Accurate diagnosis of these fetuses with an intact atrial septum relies upon careful assessment of the patent foramen ovale, pulmonary venous Doppler flow patterns and branch pulmonary artery Doppler flow patterns. Prenatal and perinatal interventions, such as the placement of an atrial stent in utero or delivery at a center where a stent may be placed immediately after birth to relieve left atrial hypertension, may improve survival in this particularly high-risk group.
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Affiliation(s)
- Anita Szwast
- The Fetal Heart Program at the Children's Hospital of Philadelphia, 34th & Civic Center Boulevard, Philadelphia, PA, USA
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Cavoretto P. Prediction of pulmonary hypoplasia in mid-trimester preterm prelabor rupture of membranes: research or clinical practice? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 39:489-494. [PMID: 22539491 DOI: 10.1002/uog.11172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
MESH Headings
- Abnormalities, Multiple/diagnostic imaging
- Abnormalities, Multiple/embryology
- Female
- Fetal Membranes, Premature Rupture/diagnostic imaging
- Fetal Membranes, Premature Rupture/physiopathology
- Humans
- Infant, Newborn
- Lung/abnormalities
- Lung/diagnostic imaging
- Lung/embryology
- Lung Diseases/diagnostic imaging
- Lung Diseases/embryology
- Organ Size
- Predictive Value of Tests
- Pregnancy
- Pregnancy Trimester, Second
- Pulmonary Artery/diagnostic imaging
- Pulmonary Artery/embryology
- Reproducibility of Results
- Ultrasonography, Doppler, Color
- Ultrasonography, Doppler, Pulsed
- Ultrasonography, Prenatal/methods
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Affiliation(s)
- Paolo Cavoretto
- San Raffaele Scientific Centre, Obstetrics and Gynaecology Department, Via Olgettina, 60, Milan 20132, Italy.
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Benachi A, Saada J, Martinovic J, de Lagausie P, Storme L, Jani J. Hernie congénitale du diaphragme : prise en charge anténatale. Rev Mal Respir 2011; 28:800-8. [DOI: 10.1016/j.rmr.2010.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 12/30/2010] [Indexed: 10/18/2022]
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Cannie M, Jani J, De Keyzer F, Roebben I, Breysem L, Deprest J. T2 quantifications of fetal lungs at MRI-normal ranges. Prenat Diagn 2011; 31:705-11. [DOI: 10.1002/pd.2746] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2010] [Revised: 02/16/2011] [Accepted: 02/17/2011] [Indexed: 11/09/2022]
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38
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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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Knox E, Lissauer D, Khan K, Kilby M. Prenatal detection of pulmonary hypoplasia in fetuses with congenital diaphragmatic hernia: a systematic review and meta-analysis of diagnostic studies. J Matern Fetal Neonatal Med 2010; 23:579-88. [PMID: 20085507 DOI: 10.3109/14767050903551400] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Fetuses with congenital diaphragmatic hernia (CDH) are at risk of death from pulmonary hypoplasia at birth. OBJECTIVE To determine the value of prenatal imaging parameters for predicting lethal pulmonary hypoplasia in fetuses with CDH. SEARCH STRATEGY Relevant papers were identified by searching MEDLINE (1966-2008), EMBASE (1988-2008) and the Cochrane Library (2008 issue 3). SELECTION CRITERIA Selected studies examined diagnostic tests for the prenatal prediction of lethal pulmonary hypoplasia in fetuses with CDH. The primary outcome measure was perinatal survival. RESULTS Twenty-one studies fulfilled the entry criteria, of which six examined entirely unique heterogeneous parameters and the remaining 15 examined lung-head ratios (LHR) and/or the presence of liver in the fetal thorax. The strongest association was that of LHR > or = 0.6 compared to <0.6 (OR: 17.02; 95% CI: 2.10-137.89), although more clinically relevant was that of LHR >1.0 (OR: 5.07; 95% CI: 2.94-8.74). The finding of liver in the fetal chest was a poor prognostic feature (survival OR: 0.32; 95% CI: 0.21-0.49). CONCLUSION In CDH, LHR and the presence of liver in the fetal thorax may be a useful predictive indicator of perinatal survival. Future usage of developing techniques needs careful evaluation prior to usage to guide therapy.
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Affiliation(s)
- Ellen Knox
- Department of Fetal Medicine, Birmingham Women's Foundation NHS Trust, Edgbaston, Birmingham, UK
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Szwast A, Tian Z, McCann M, Donaghue D, Rychik J. Vasoreactive response to maternal hyperoxygenation in the fetus with hypoplastic left heart syndrome. Circ Cardiovasc Imaging 2009; 3:172-8. [PMID: 20044513 DOI: 10.1161/circimaging.109.848432] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Cardiopulmonary interactions play an important role in the pathophysiology of hypoplastic left heart syndrome (HLHS). Pulmonary vasculopathy has been identified, especially in those with restrictive/intact atrial septum. Responsiveness of the pulmonary vasculature to maternal hyperoxygenation (MH) may provide a tool to assess the degree of pulmonary vasculopathy present before birth. METHODS AND RESULTS Doppler echocardiography was performed in 27 normal and 43 HLHS fetuses. In HLHS, sampling was repeated after 10 minutes of MH with 60% FiO(2) and after 5 minutes of recovery. Sampling was performed in the proximal, midportion, and distal branch pulmonary artery (PA). Pulsatility index (PI) was used as a measure of vascular impedance. Of the HLHS fetuses, 34 had an open interatrial septum and 9 had a restrictive/intact atrial septum. At birth, 5 fetuses underwent immediate intervention on the interatrial septum. Middle cerebral artery PI was lower in HLHS versus normal fetuses (P<0.001). There was no difference in UA, DA, or branch PA PI between normal fetuses and those with HLHS. MH led to a significant decrease in PI at each of the PA sites sampled in fetuses with an open atrial septum (P<0.001); however, there no was significant change in the PI in fetuses that required immediate intervention on the atrial septum at birth. Using a cutoff value of <10% vasoreactivity, the sensitivity of MH testing for determining need for immediate intervention at birth is 100% (0.46 to 1.0); specificity, 94% (0.78 to 0.99); positive predictive value, 71% (0.30 to 0.95); and negative predictive value, 100% (0.86 to 1.0). No untoward effects were seen with MH. CONCLUSIONS PA vasoreactivity to MH occurs in the fetus with HLHS. MH testing accurately identifies fetuses requiring urgent postnatal intervention at birth and may be used to select candidates for fetal atrial septoplasty.
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Affiliation(s)
- Anita Szwast
- The Fetal Heart Program at Cardiac Center at The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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Cannie M, Jani J, De Keyzer F, Roebben I, Dymarkowski S, Deprest J. Diffusion-weighted MRI in lungs of normal fetuses and those with congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 34:678-686. [PMID: 19866446 DOI: 10.1002/uog.7326] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To prospectively determine apparent diffusion coefficient (ADC) values of normally developing fetal lungs over gestation, as obtained by diffusion-weighted (DW) magnetic resonance imaging (MRI) and to investigate its potential application in fetuses with congenital diaphragmatic hernia (CDH). METHODS Informed consent was obtained for this cross-sectional study of 93 fetuses with normal lungs and 14 with isolated left-sided CDH, assessed between 18 and 40 weeks of gestation. MRI delineation of left and right lungs was performed on the native DW image, b0, and three values of ADC, corresponding to the overall value (ADC(avg)), and values for low and high values of b (ADC(low) and ADC(high), respectively) were calculated. Regression analysis was used to assess the relationship between gestational age and b0-values as well as calculated ADC values. The b0 and ADC values of normal and CDH fetuses were compared with normal ranges using the Mann-Whitney U-test. RESULTS In fetuses with normal lungs, there was a negative correlation between gestational age and b0 values as well as with ADC(high), a positive correlation with ADC(low) but no correlation with ADC(avg). When measurable, ADC(high) values were lower in CDH as compared to fetuses with normal lungs and ADC(low) values were higher. ADC(low) was unrelated to lung volume. CONCLUSIONS There is a significant relationship between ADC(low) and ADC(high) values and gestational age in normal fetal lungs. This relationship is most probably explained by developmental changes during the last three stages of lung development, which involve intense peripheral growth of airways and vessels as well as maturation. In CDH, measurement of ADC(low) might be useful as a predictor of postnatal outcome that is independent of lung volume.
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Affiliation(s)
- M Cannie
- Department of Radiology, University Hospital Gasthuisberg, Leuven, Belgium.
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Deprest JA, Gratacos E, Nicolaides K, Done E, Van Mieghem T, Gucciardo L, Claus F, Debeer A, Allegaert K, Reiss I, Tibboel D. Changing perspectives on the perinatal management of isolated congenital diaphragmatic hernia in Europe. Clin Perinatol 2009; 36:329-47, ix. [PMID: 19559323 DOI: 10.1016/j.clp.2009.03.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Congenital diaphragmatic hernia (CDH) should be diagnosed in the prenatal period and prompt referral to a tertiary referral center for imaging, genetic testing, and multidisciplinary counseling. Individual prediction of prognosis is based on the absence of additional anomalies, lung size, and liver herniation. In severe cases, a prenatal endotracheal balloon procedure is currently being offered at specialized centers. Fetal intervention is now also offered to milder cases within a trial, hypothesizing that this may reduce the occurrence of bronchopulmonary dysplasia in survivors. Postnatal management has been standardized by European high-volume centers for the purpose of this and other trials.
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Affiliation(s)
- Jan A Deprest
- Woman and Child Division, Fetal Medicine Unit, University Hospital Gasthuisberg, Leuven, Belgium.
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Gorincour G, Bach-Segura P, Ferry-Juquin M, Eurin D, Chaumoitre K, Bouvenot J, Bourliere-Najean B, tous les membres du G.R.R.I.F.. Signal pulmonaire fœtal en IRM : valeurs normales et application à la hernie diaphragmatique congénitale. ACTA ACUST UNITED AC 2009; 90:53-8. [DOI: 10.1016/s0221-0363(09)70078-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Doné E, Gucciardo L, Van Mieghem T, Jani J, Cannie M, Van Schoubroeck D, Devlieger R, Catte LD, Klaritsch P, Mayer S, Beck V, Debeer A, Gratacos E, Nicolaides K, Deprest J. Prenatal diagnosis, prediction of outcome and in utero therapy of isolated congenital diaphragmatic hernia. Prenat Diagn 2008; 28:581-91. [PMID: 18634116 DOI: 10.1002/pd.2033] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Congenital diaphragmatic hernia (CDH) can be associated with genetic or structural anomalies with poor prognosis. In isolated cases, survival is dependent on the degree of lung hypoplasia and liver position. Cases should be referred in utero to tertiary care centers familiar with this condition both for prediction of outcome as well as timed delivery. The best validated prognostic indicator is the lung area to head circumference ratio. Ultrasound is used to measure the lung area of the index case, which is then expressed as a proportion of what is expected normally (observed/expected LHR). When O/E LHR is < 25% survival chances are < 15%. Prenatal intervention, aiming to stimulate lung growth, can be achieved by temporary fetal endoscopic tracheal occlusion (FETO). A balloon is percutaneously inserted into the trachea at 26-28 weeks, and reversal of occlusion is planned at 34 weeks. Growing experience has demonstrated the feasibility and safety of the technique with a survival rate of about 50%. The lung response to, and outcome after FETO, is dependent on pre-existing lung size as well gestational age at birth. Early data show that FETO does not increase morbidity in survivors, when compared to historical controls. Several trials are currently under design.
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Affiliation(s)
- Elisa Doné
- Fetal Medicine Unit of University Hospitals Leuven, Leuven, Belgium
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Pasquali R, Potier A, Gorincour G. [Fetal lung imaging]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2008; 36:587-602. [PMID: 18486517 DOI: 10.1016/j.gyobfe.2008.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2008] [Accepted: 03/31/2008] [Indexed: 05/26/2023]
Abstract
Exponential improvements in imaging techniques over the last ten years, through patients' and physicians' wishes for less invasive fetal work-up, now allow us to better explore and understand fetal lung physiology during pregnancy. Diagnostic and prognostic consequences at stake are huge, especially for fetuses at risk of pulmonary hypoplasia. We will decline in three parts (normal lung, malformative lung and pulmonary hypoplasia), through a review of the literature and at the light of our experience, the potentialities and limitations of all imaging modalities (Ultrasound, Doppler, 3D, MRI). Then, we will dwell on future leads and the need for large-scale collaborative studies.
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Affiliation(s)
- R Pasquali
- Service de radiologie pédiatrique, hôpital de la Timone-Enfants, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France
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Gucciardo L, Deprest J, Done' E, Van Mieghem T, Van de Velde M, Gratacos E, Jani J, Peralta F, Nicolaides K. Prediction of outcome in isolated congenital diaphragmatic hernia and its consequences for fetal therapy. Best Pract Res Clin Obstet Gynaecol 2008; 22:123-38. [DOI: 10.1016/j.bpobgyn.2007.08.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Jani J, Nicolaides KH, Benachi A, Moreno O, Favre R, Gratacos E, Deprest J. Timing of lung size assessment in the prediction of survival in fetuses with diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2008; 31:37-40. [PMID: 18069722 DOI: 10.1002/uog.5198] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVES To investigate whether the prediction of postnatal outcome of fetuses with isolated congenital diaphragmatic hernia depends on the gestational age at assessment using the fetal observed to expected (O/E) lung area to head circumference ratio (LHR), by comparing the performance of the test at 22-23 weeks with that at 32-33 weeks of gestation. METHODS Following prenatal diagnosis of isolated diaphragmatic hernia before 22 weeks, we evaluated the O/E LHR at 22-32 weeks and again at 32-33 weeks of gestation. Only cases liveborn beyond 34 weeks of gestation and with postnatal follow-up available until discharge from the hospital were included. Regression analysis was used to examine the effect on postnatal survival of O/E LHR, gestational age at delivery, side of the diaphragmatic hernia and intrathoracic position of the liver. Wilcoxon rank test for paired samples was used to compare median O/E LHR at 22-23 weeks and 32-33 weeks, in babies who survived and in those who died. Receiver-operating characteristics (ROC) curves were constructed for the prediction of survival by O/E LHR at 22-23 weeks and at 32-33 weeks. RESULTS In total, 53 pairs of measurements could be assessed. Univariate logistic regression analysis demonstrated that significant predictors of survival were the presence or absence of intrathoracic herniation of the liver, the O/E LHR at 22-23 weeks and the O/E LHR at 32-33 weeks of gestation. Multivariate logistic regression analysis demonstrated that only O/E LHR at 22-23 weeks or 32-33 weeks provided significant independent prediction of survival. The median O/E LHR at 22-23 weeks was not significantly different from that at 32-23 weeks either in survivors or in babies that subsequently died in the neonatal period (P = 0.25 and P = 0.09, respectively). The area under the ROC curve for prediction of postnatal survival from the O/E LHR at 22-23 weeks was 0.789 (P < 0.001) and that for prediction from the O/E LHR at 32-33 weeks was 0.842 (P < 0.001). CONCLUSIONS In isolated diaphragmatic hernia, O/E LHR measurement at 22-23 weeks as well as at 32-33 weeks provides useful independent prediction of subsequent survival. The prediction of postnatal survival using O/E LHR is independent of the timing of assessment.
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Affiliation(s)
- J Jani
- Fetal Medicine Units of University Hospital Gasthuisberg, Leuven, Belgium
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Hedrick HL, Danzer E, Merchant AM, Bebbington MW, Zhao H, Flake AW, Johnson MP, Liechty KW, Howell LJ, Wilson RD, Adzick NS. Liver position and lung-to-head ratio for prediction of extracorporeal membrane oxygenation and survival in isolated left congenital diaphragmatic hernia. Am J Obstet Gynecol 2007; 197:422.e1-4. [PMID: 17904987 DOI: 10.1016/j.ajog.2007.07.001] [Citation(s) in RCA: 198] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2007] [Revised: 05/08/2007] [Accepted: 07/01/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the ability of liver position and lung-to-head ratio to predict outcome in isolated left congenital diaphragmatic hernia. STUDY DESIGN We reviewed prenatal studies and postnatal outcomes of congenital diaphragmatic hernia between January 1996 and January 2006. RESULTS Eighty-nine patients received prenatal and postnatal care at 1 institution. In fetuses with liver up, extracorporeal membrane oxygenation was required in 39 of 49 fetuses (80%), compared with 10 of 40 fetuses (25%) for those with liver down (P < .0001). Overall survival rate was 45%, compared with 93% for those with liver down (P < .00005). Low lung-to-head ratio (<1.0) predicted increased incidence of extracorporeal membrane oxygenation (75%; P = .036) and lower survival (35%; P = .0003). However, when measured at <24 weeks of gestation, lung-to-head ratio was not predictive of outcome (extracorporeal membrane oxygenation, P = .108; survival, P = .150); liver position remained highly predictive (extracorporeal membrane oxygenation, P = .006; survival, P = .001). CONCLUSION Liver position is the best prenatal predictor of outcome in isolated left congenital diaphragmatic hernia. Lung-to-head ratio alone should not be used to counsel families regarding mid gestational management choices.
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Affiliation(s)
- Holly L Hedrick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Keller RL. Antenatal and postnatal lung and vascular anatomic and functional studies in congenital diaphragmatic hernia: implications for clinical management. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2007; 145C:184-200. [PMID: 17436304 DOI: 10.1002/ajmg.c.30130] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Congenital diaphragmatic hernia is characterized by fetal and neonatal lung hypoplasia as well as vascular hypoplasia. Antenatal imaging studies have been performed that attempt to quantify the degree of hypoplasia and its impact on infant prognosis. Prenatal and perinatal growth of the lung and vasculature are interdependent and their continued coordinated growth is critical for survival after birth in this patient population. Lung protection strategies appear to improve survival in newborns with diaphragmatic hernia, but a subset of infants remain who demonstrate sufficiently severe lung hypoplasia that we are unable to provide support long-term after birth. Fetal intervention is a strategy designed to enhance fetal lung growth towards improving survival in this most severely affected group, though other therapies to enhance postnatal lung and vascular growth should be concurrently investigated. However, any of these interventions will require careful selection of those infants at risk for poor outcome and thorough follow up, since long-term morbidity is significant in children with diaphragmatic hernia.
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Abstract
Advances in prenatal ultrasound have revealed the poor natural history of fetal congenital diaphragmatic hernia (CDH) and its hidden mortality during gestation and immediately after birth. Attempts to improve this poor outcome led to the development of prenatal surgical intervention for severe CDH by Harrison and his colleagues at the University of California San Francisco. Prenatal surgical intervention for CDH has seen four phases: open fetal surgical repair, open surgical tracheal occlusion, endoscopic external tracheal occlusion, and endoscopic endoluminal tracheal occlusion. After extensive work in the laboratory, prenatal intervention has been applied in humans since 1984. With the most recent techniques, maternal risk is significantly reduced as is the incidence of preterm labor. In the meantime, the survival rate of fetuses with CDH without fetal intervention has improved mainly due to the minimization of iatrogenic lung injury by gentle ventilation, first described in 1985. However, the morbidity of the survivors with severe CDH remains high. Prenatal intervention for CDH will be justified if improvement in survival or morbidity can be demonstrated when compared to planned delivery and postnatal management with gentle ventilation strategy.
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Affiliation(s)
- Yoshihiro Kitano
- Division of General Surgery, Saitama Children's Medical Center, Saitama, Japan.
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