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Ibarra C, Bergh E, Tsao K, Johnson A. Prenatal diagnostic and intervention considerations in congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151436. [PMID: 39018717 DOI: 10.1016/j.sempedsurg.2024.151436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
Congenital diaphragmatic hernia (CDH) is a life-threatening birth defect with significant morbidity and mortality. The prenatal management of a pregnancy with a fetus affected with CDH is complex and requires a multi-disciplinary team approach. An improved understanding of prenatal diagnosis and management is essential to developing strategies to optimize outcomes for these patients. In this review, we explore the current knowledge on diagnosis, severity stratification, prognostic prediction, and indications for fetal intervention in the fetus with CDH.
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Affiliation(s)
- Claudia Ibarra
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States
| | - Eric Bergh
- Department of Obstetrics and Gynecology, Division of Fetal Intervention, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States.
| | - Kuojen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Anthony Johnson
- Department of Obstetrics and Gynecology, Division of Fetal Intervention, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States
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Horn-Oudshoorn EJJ, Peters NCJ, Franx A, Eggink AJ, Cochius-den Otter SCM, Reiss IKM, DeKoninck PLJ. Termination of pregnancy after a prenatal diagnosis of congenital diaphragmatic hernia: Factors influencing the parental decision process. Prenat Diagn 2023; 43:95-101. [PMID: 36443507 PMCID: PMC10107614 DOI: 10.1002/pd.6274] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/09/2022] [Accepted: 11/22/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the incidence of termination of pregnancies (TOP) and factors associated with the decision for TOP in prenatally detected congenital diaphragmatic hernia (CDH). STUDY DESIGN Single-centre retrospective cohort includes all prenatally detected CDH cases born between January 2009 and December 2021. Parental factors, such as parity, and fetal characteristics, such as disease severity, were collected. Descriptive statistics were used to present the data. Differences between terminated and continued pregnancies were analysed. RESULTS The study population consisted of 278 prenatally detected CDH cases of which 80% detected <24 weeks of gestation. The TOP rate was 28% in cases that were detected <24 weeks of gestation. Twenty continued pregnancies resulted in either intrauterine fetal demise (n = 6), preterm birth <24 weeks (n = 2), or comfort care after birth (n = 12). The survival rate was 70% in the remaining 195 live born cases. Factors associated with the decision for TOP were additional fetal genetic or anatomical abnormalities (p < 0.0001) and expected severity of pulmonary hypoplasia in left-sided CDH (p = 0.0456). CONCLUSION The decision to terminate a pregnancy complicated by fetal CDH depends on the severity of pulmonary hypoplasia and the presence of additional abnormalities. This emphasises the importance of early referral to expertise centres for detailed evaluation and multidisciplinary counselling.
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Affiliation(s)
- Emily J J Horn-Oudshoorn
- Department of Paediatrics, Division of Neonatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Nina C J Peters
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Arie Franx
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Alex J Eggink
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Suzan C M Cochius-den Otter
- Intensive Care and Department of Paediatric Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Department of Paediatrics, Division of Neonatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
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Fetal liver and lung volume index of neonatal survival with congenital diaphragmatic hernia. Pediatr Radiol 2021; 51:1637-1644. [PMID: 33779798 DOI: 10.1007/s00247-021-05049-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 01/28/2021] [Accepted: 03/09/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) assesses pulmonary hypoplasia in fetal congenital diaphragmatic hernia (CDH). Neonatal mortality may occur with CDH. OBJECTIVE To quantify MRI parameters associated with neonatal survival in fetuses with isolated CDH. MATERIALS AND METHODS Fetal MRI for assessing CDH included region of interest (ROI) measurements for total lung volume (TLV), herniated liver volume, herniated other organ volume and predicted lung volume. Ratios of observed lung volume and liver up volume to predicted lung volume (observed to predicted TLV, percentage of the thorax occupied by liver) were calculated and compared to neonatal outcomes. Analyses included Wilcoxon rank sum test, multivariate logistic regression and receiver operating characteristic (ROC) curves. RESULTS Of 61 studies, the median observed to predicted TLV was 0.25 in survivors and 0.16 in non-survivors (P=0.001) with CDH. The median percentage of the thorax occupied by liver was 0.02 in survivors and 0.22 in non-survivors (P<0.001). The association of observed to predicted TLV and percentage of the thorax occupied by liver with survival for gestational age (GA) >28 weeks was greater compared to GA ≤28 weeks. The ROC analysis demonstrated an area under the curve of 0.96 (95% confidence interval 0.91-1.00) for the combined observed to predicted TLV, percentage of the thorax occupied by liver and GA. CONCLUSION The percentage of the thorax occupied by liver and observed to predicted TLV was predictive of neonatal survival in fetuses with CDH.
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Abbasi N, Ryan G, Johnson A, Cortes MS, Sangi-Haghpeykar H, Ye XY, Shah PS, Benachi A, Saada J, Ruano R. Reproducibility of fetal lung-to-head ratio in left diaphragmatic hernia across the North American Fetal Therapy Network (NAFTNet). Prenat Diagn 2019; 39:188-194. [PMID: 30618058 DOI: 10.1002/pd.5413] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 11/19/2018] [Accepted: 12/21/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the antenatal sonographic lung area measurement method in left congenital diaphragmatic hernia (CDH) with the highest interrater agreement among North American Fetal Therapy Network (NAFTNet) centers within and outside the fetoscopic tracheal occlusion (FETO) consortium and in comparison with a European "expert" reviewer (ER). METHODS Nineteen members from nine FETO consortium centers and 29 reviewers from 17 non-FETO centers reviewed ultrasound clips of the chest from 13 fetuses with isolated left CDH and were asked to select a static plane for lung area measurement using anteroposterior (AP), longest, and trace methods. Interrater agreement in lung area measurements was determined using intraclass correlation coefficient (ICC). Bland-Altman analysis was used to evaluate mean difference (bias) between NAFTNet reviewers and ER. RESULTS Among FETO centers, agreement was highest using trace (ICC 0.94; 95% CI, 0.83-0.98), followed by longest (ICC 0.89; 95% CI, 0.75-0.97) and lowest for A-P (ICC 0.83; 95% CI, 0.67-0.94). Similar trends were noted in non-FETO centers. When compared with ER, bias was lowest for trace: 14 ± 38 mm2 and 19 ± 36 mm2 for FETO and non-FETO centers, respectively. CONCLUSION The trace method demonstrated the highest interrater agreement and lowest bias for lung area estimation in left CDH across NAFTNet.
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Affiliation(s)
- Nimrah Abbasi
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Anthony Johnson
- The Fetal Center, Children's Memorial Hermann Hospital, University of Texas Health Science Center, Houston, TX, USA
| | - Magda Sanz Cortes
- Department of Obstetrics & Gynecology, Texas Children's Fetal Center. Baylor College of Medicine, Houston, TX, USA
| | - Haleh Sangi-Haghpeykar
- Department of Obstetrics & Gynecology, Baylor College of Medicine, Houston, Houston, TX, USA
| | - Xiang Y Ye
- Maternal-Infant Care (MiCare) Center, Mount Sinai Hospital, Toronto, Canada
| | - Prakesh S Shah
- Maternal-Infant Care (MiCare) Center, Mount Sinai Hospital, Toronto, Canada.,Department of Paediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Alexandra Benachi
- Centre Maladie Rare: Hernie de Coupole Diaphragmatique, Hôpital Antoine-Béclère, Clamart, France.,Service de Gynécologie-Obstétrique, AP-HP, Hôpital Antoine Béclère, Université Paris-Sud, Clamart, France
| | - Julien Saada
- Centre Maladie Rare: Hernie de Coupole Diaphragmatique, Hôpital Antoine-Béclère, Clamart, France.,Service de Gynécologie-Obstétrique, AP-HP, Hôpital Antoine Béclère, Université Paris-Sud, Clamart, France
| | - Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
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Fang F, Song R, Ling X, Peng M, Xue Z, Cang J. Multiple sevoflurane anesthesia in pregnant mice inhibits neurogenesis of fetal hippocampus via repressing transcription factor Pax6. Life Sci 2017; 175:16-22. [DOI: 10.1016/j.lfs.2017.03.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/24/2017] [Accepted: 03/05/2017] [Indexed: 10/20/2022]
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Olutoye OA, Sheikh F, Zamora IJ, Yu L, Akinkuotu AC, Adesina AM, Olutoye OO. Repeated isoflurane exposure and neuroapoptosis in the midgestation fetal sheep brain. Am J Obstet Gynecol 2016; 214:542.e1-542.e8. [PMID: 26546852 DOI: 10.1016/j.ajog.2015.10.927] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/16/2015] [Accepted: 10/28/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Advances in surgery and technology have resulted in increased in-utero procedures. However, the effect of anesthesia on the fetal brain is not fully known. The inhalational anesthetic agent, isoflurane, other gamma amino butyric acid agonists (benzodiazepines, barbiturates, propofol, other inhalation anesthetics), and N-methyl D aspartate antagonists, eg, ketamine, have been shown to induce neuroapoptosis. The ovine model has been used extensively to study maternal-fetal physiologic interactions and to investigate different surgical interventions on the fetus. OBJECTIVE The purpose of this study was to determine effects of different doses and duration of isoflurane on neuroapoptosis in midgestation fetal sheep. We hypothesized that repeated anesthetic exposure and high concentrations of isoflurane would result in increased neuroapoptosis. STUDY DESIGN Time-dated, pregnant sheep at 70 days gestation (term 145 days) received either isoflurane 2% × 1 hour, 4% × 3 hours, or 2% × 1 hour every other day for 3 exposures (repeated exposure group). Euthanasia occurred following anesthetic exposure and fetal brains were processed. Neuroapoptosis was detected by immunohistochemistry using anticaspase-3 antibodies. Fetuses unexposed to anesthesia served as controls. Another midgestation group with repeated 2% isoflurane exposure was examined at day 130 (long-term group) and neuronal cell density compared to age-matched controls. Representative sections of the brain were analyzed using Aperio Digital imaging (Leica Microsystems Inc, Buffalo Grove, IL). Data, reported by number of neurons per cubic millimeter of brain tissue are presented as means and SEM. Data were analyzed using the Mann-Whitney U and Kruskal-Wallis tests as appropriate. RESULTS A total of 34 fetuses were studied. There was no significant difference in neuroapoptosis observed in fetuses exposed to 2% isoflurane for 1 hour or 4% isoflurane for 3 hours. Increased neuroapoptosis was observed in the frontal cortex following repeated 2% isoflurane exposure compared to controls (1.57 ± 0.22 × 10(6)/mm(3) vs 1.01 ± 0.44 × 10(6)/mm(3), P = .02). Fetuses at 70 days gestation with repeated exposure demonstrated decreased frontal cortex neurons at day 130 when compared to age-matched controls (2.42 ± 0.3 × 10(5)/mm(3) vs 7.32 ± 0.4 × 10(5)/mm(3), P = .02). No significant difference in neuroapoptosis was observed between the repeated exposure group and controls in the hippocampus, cerebellum, or basal ganglia. CONCLUSION Repeated isoflurane exposure in midgestation sheep resulted in increased frontal cortex neuroapoptosis. This persisted into late gestation as decreased neuronal cell density. While animal studies should be extrapolated to human beings with caution, our findings suggest that the number of anesthetic/sedative exposures should be considered when contemplating the risks and benefits of fetal intervention as certain fetal therapies may need to be repeated.
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Affiliation(s)
- Olutoyin A Olutoye
- Department of Anesthesiology, Texas Children's Hospital, Houston, TX; Department of Pediatrics, Texas Children's Hospital, Houston, TX; Baylor College of Medicine, Texas Children's Hospital, Houston, TX; Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX.
| | - Fariha Sheikh
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Houston, TX; Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Irving J Zamora
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Houston, TX; Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Ling Yu
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Houston, TX; Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Adesola C Akinkuotu
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Houston, TX; Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Adekunle M Adesina
- Department of Pediatrics, Texas Children's Hospital, Houston, TX; Department of Pathology, Texas Children's Hospital, Houston, TX; Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Houston, TX; Department of Pediatrics, Texas Children's Hospital, Houston, TX; Baylor College of Medicine, Texas Children's Hospital, Houston, TX; Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX
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Taghavi K, Beasley S. The ex utero intrapartum treatment (EXIT) procedure: application of a new therapeutic paradigm. J Paediatr Child Health 2013; 49:E420-7. [PMID: 23662685 DOI: 10.1111/jpc.12223] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2012] [Indexed: 12/15/2022]
Abstract
The ex utero intrapartum treatment (EXIT) procedure is a term given to a technique that can transform a potentially fatal neonatal emergency to a controlled intervention with an improved outcome. It has revolutionised the care of prenatally diagnosed congenital malformations in which severe upper airway obstruction is anticipated. An extended period of utero-placental circulation can be utilised to avoid profound cardiopulmonary compromise. Its therapeutic applications have been broadened to include fetuses with congenital diaphragmatic hernia after tracheal plugging, high-risk intrathoracic masses, severe cardiac malformations and conjoined twins. It requires the co-ordination of a highly skilled and experienced multidisciplinary team. The recent enthusiasm for the EXIT procedure needs to be balanced against maternal morbidity. Specific indications and guidelines are likely to be refined as a consequence of ongoing advances in fetal intervention and antenatal imaging.
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Engels AC, DeKoninck P, van der Merwe JL, Van Mieghem T, Stevens P, Power B, Nicolaides KH, Gratacos E, Deprest JA. Does website-based information add any value in counseling mothers expecting a baby with severe congenital diaphragmatic hernia? Prenat Diagn 2013; 33:1027-32. [DOI: 10.1002/pd.4190] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 06/06/2013] [Accepted: 06/25/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Alexander C. Engels
- Centre for Surgical Technologies, Faculty of Medicine; Katholieke Universiteit Leuven; B-3000 Leuven Belgium
| | - Philip DeKoninck
- Centre for Surgical Technologies, Faculty of Medicine; Katholieke Universiteit Leuven; B-3000 Leuven Belgium
- Department of Obstetrics and Gynaecology, Division Woman and Child, Fetal Medicine Unit; University Hospitals; B-3000 Leuven Belgium
- Department of Development and Regeneration, Research Unit Fetus Placenta and Neonate, Faculty of Medicine; Katholieke Universiteit Leuven; B-3000 Leuven Belgium
| | - Johannes L. van der Merwe
- Department of Obstetrics and Gynaecology; Stellenbosch University and Tygerberg Hospital; Cape Town South Africa
| | - Tim Van Mieghem
- Centre for Surgical Technologies, Faculty of Medicine; Katholieke Universiteit Leuven; B-3000 Leuven Belgium
- Department of Obstetrics and Gynaecology, Division Woman and Child, Fetal Medicine Unit; University Hospitals; B-3000 Leuven Belgium
- Department of Development and Regeneration, Research Unit Fetus Placenta and Neonate, Faculty of Medicine; Katholieke Universiteit Leuven; B-3000 Leuven Belgium
| | - Petra Stevens
- Department of Development and Regeneration, Research Unit Fetus Placenta and Neonate, Faculty of Medicine; Katholieke Universiteit Leuven; B-3000 Leuven Belgium
| | | | - Kypros H. Nicolaides
- Harris Birthright Research Center; King's College Hospital; London UK
- Department of Fetal Medicine; University College Hospital London; London UK
| | - Eduard Gratacos
- Department of Maternal-Fetal Medicine, ICGON, Hospital Clinic-IDIBAPS; University of Barcelona; Barcelona Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER); Barcelona Spain
| | - Jan A. Deprest
- Centre for Surgical Technologies, Faculty of Medicine; Katholieke Universiteit Leuven; B-3000 Leuven Belgium
- Department of Obstetrics and Gynaecology, Division Woman and Child, Fetal Medicine Unit; University Hospitals; B-3000 Leuven Belgium
- Department of Development and Regeneration, Research Unit Fetus Placenta and Neonate, Faculty of Medicine; Katholieke Universiteit Leuven; B-3000 Leuven Belgium
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Abstract
Congenital diaphragmatic hernia (CDH) is a congenital anomaly that presents with a broad spectrum of severity that is dependent upon components of pulmonary hypoplasia and pulmonary hypertension. While advances in neonatal care have improved the overall survival of CDH in experienced centers, mortality and morbidity remain high in a subset of CDH infants with severe CDH. Prenatal predictors have been refined for the past two decades and are the subject of another review in this issue. So far, all randomized trials comparing prenatal intervention to standard postnatal therapy have shown no benefit to prenatal intervention. Although recent non-randomized reports of success with fetoscopic endoluminal tracheal occlusion (FETO) and release are promising, prenatal therapy should not be widely adopted until a well-designed prospective randomized trial demonstrating efficacy is performed. The increased survival and subsequent morbidity of CDH survivors has resulted in the need to provide resources for the long-term follow up and support of the CDH population.
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Affiliation(s)
- Holly L Hedrick
- Perelman School of Medicine at the University of Pennsylvania, The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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Dighe MK, Peterson SE, Dubinsky TJ, Perkins J, Cheng E. EXIT Procedure: Technique and Indications with Prenatal Imaging Parameters for Assessment of Airway Patency. Radiographics 2011; 31:511-26. [DOI: 10.1148/rg.312105108] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Grushka JR, Al-Abbad S, Baird R, Puligandla P, Kaplan F, Laberge JM. The effect of in vitro tracheal occlusion on branching morphogenesis in fetal lung explants from the rat nitrofen model of congenital diaphragmatic hernia. J Pediatr Surg 2010; 45:943-7. [PMID: 20438932 DOI: 10.1016/j.jpedsurg.2010.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Accepted: 02/02/2010] [Indexed: 11/29/2022]
Abstract
BACKGROUND/PURPOSE Fetal tracheal occlusion (TO) has been investigated as a treatment option for lung hypoplasia secondary to congenital diaphragmatic hernia. Tracheal occlusion has been shown to accelerate lung growth, but its effect on bronchial branching is unknown. In this study, we characterize the effects of in vitro TO on bronchial branch development in fetal lung explants derived from the nitrofen rat model of congenital diaphragmatic hernia. METHODS Rat dams were gavaged nitrofen on gestational day 9.5, and fetal lungs were harvested for explant culture on gestational day 14 (term, 22 days). Four experimental groups were investigated, with TO performed ex vivo using cautery: control, control + TO, nitrofen, and nitrofen + TO. Explants were incubated for 72 hours. Representative photographs were taken at 0, 24, 48, and 72 hours from the time of culture, and the number of distal branches was counted for each explant. The Student t test was used to compare distal branch measurements. RESULTS A minimum of 12 fetal lung explants were cultured for each group. By 24 hours, all explants undergoing TO had more branch iterations than explants that did not. Moreover, TO in nitrofen-exposed explants increased bronchial branching to control levels by 24 hours in culture. CONCLUSION Our results suggest that TO at day 14 increases branching in normal and nitrofen-exposed lung explants. In addition, TO increases airway branching in nitrofen-exposed explants to control levels suggesting that early TO reverses the lung hypoplasia seen in this model.
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Affiliation(s)
- Jeremy R Grushka
- Division of Pediatric Surgery, The Montreal Children's Hospital, Montreal, Quebec, Canada
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Cruz-Martinez R, Moreno-Alvarez O, Hernandez-Andrade E, Castañon M, Done E, Martinez JM, Puerto B, Deprest J, Gratacos E. Contribution of intrapulmonary artery Doppler to improve prediction of survival in fetuses with congenital diaphragmatic hernia treated with fetal endoscopic tracheal occlusion. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2010; 35:572-577. [PMID: 20178111 DOI: 10.1002/uog.7593] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To evaluate the contribution of intrapulmonary artery Doppler in predicting the survival of fetuses with congenital diaphragmatic hernia (CDH) treated with fetoscopic tracheal occlusion (FETO). METHODS A cohort of 41 fetuses (between 24 and 28 weeks of gestation) with CDH was treated with FETO. The observed/expected lung-to-head ratio (O/E-LHR), pulmonary artery pulsatility index (PI), peak early diastolic reversed flow (PEDRF) and peak systolic velocity (PSV) were evaluated before FETO, and their isolated and combined value to predict survival using multiple logistic regression and decision-tree analysis was assessed. RESULTS O/E-LHR and intrapulmonary artery PI and PEDRF were significantly associated with the probability of survival (O/E-LHR > or = 26%, OR 14.2; PI < 1 Z-score, OR 8.4; and PEDRF < 3.5 Z-scores, OR 5.7). Decision-tree analysis showed that O/E-LHR was the best initial predictor of prognosis (O/E-LHR > or = 26%, 90% survival; O/E-LHR < 26%, 45% survival). For fetuses with an O/E-LHR of < 26%, Doppler parameters allowed discrimination of cases with moderate (66-71% survival) and very poor (0% survival) prognosis. CONCLUSION Intrapulmonary artery Doppler evaluation helps to refine the prediction of survival after FETO in fetuses with severe CDH.
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Affiliation(s)
- R Cruz-Martinez
- Department of Maternal-Fetal Medicine, Institute Clínic of Gynecology, Obstetrics and Neonatology, Hospital Clinic-IDIBAPS, University of Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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Hedrick HL. Management of prenatally diagnosed congenital diaphragmatic hernia. Semin Fetal Neonatal Med 2010; 15:21-7. [PMID: 19884051 DOI: 10.1016/j.siny.2009.07.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a congenital anomaly that presents with a broad spectrum of severity dependent upon components of pulmonary hypoplasia and pulmonary hypertension. While advances in neonatal care have improved the overall survival of CDH in experienced centers, mortality and morbidity remain high in a subset of CDH infants with severe CDH. The most important prenatal predictor of outcome in left-sided CDH is liver position. More precise and reproducible prenatal predictive parameters need to be developed to allow standardization of results between centers and appropriate design of clinical trials in CDH. Thus far, all randomized trials comparing prenatal intervention to standard postnatal therapy have shown no benefit to prenatal intervention. Although recent non-randomized reports of success with balloon tracheal occlusion (and release) are promising, prenatal therapy should not be widely adopted until a well-designed prospective randomized trial demonstrating efficacy is performed. The increased survival and subsequent morbidity of CDH survivors has resulted in the need to provide resources for the long-term follow-up and support of the CDH population.
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Affiliation(s)
- Holly L Hedrick
- University of Pennsylvania, Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Affiliation(s)
- Miho Watanabe
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA
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Grisaru-Granovsky S, Rabinowitz R, Ioscovich A, Elstein D, Schimmel MS. Congenital diaphragmatic hernia: review of the literature in reflection of unresolved dilemmas. Acta Paediatr 2009; 98:1874-81. [PMID: 19627259 DOI: 10.1111/j.1651-2227.2009.01436.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is a rare but clinically and scientifically challenging condition. The introduction of ultrasound has enabled early prenatal detection and consequently, hope of early therapeutic intervention. AIM We undertook the task to review the recent developments in understanding the pathology of CDH as well as the history and current management strategies to aid perinatologists in consultations with parents of CDH-affected foetuses. STUDY DESIGN A Medline search was undertaken of all reports and reviews published between 1980 and 2008 using MeSH search terms 'diaphragmatic hernia', 'congenital' and 'newborn'. RESULTS The true incidence of CDH is still difficult to estimate because of the high incidence of hidden mortality of CDH. Complete case ascertainment also poses difficulties in assessment of the impact of new therapeutic modalities on overall survival. Recent improvements in prenatal detection are a milestone in affording time for re-assessments and parental counselling. The true benefit of antenatal therapy is circumscribed and should be offered only in selected cases of isolated severe CDH as defined by existing guidelines. Postnatal intensive respiratory supportive therapy and innovative surgical techniques within specialized tertiary centres has had a major impact on survival of babies with CDH. CONCLUSION The high survival of 'selected cases' that are live births and benefit from optimal care will be difficult to improve by antenatal interventions. The multidisciplinary approach to basic research and randomized clinical trials will further define the best approach to the foetus and neonate with CDH.
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Affiliation(s)
- S Grisaru-Granovsky
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel
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Roubliova XI, Lewi PJ, Verbeken EK, Vaast P, Jani JC, Lu H, Tibboel D, Deprest JA. The effect of maternal betamethasone and fetal tracheal occlusion on pulmonary vascular morphometry in fetal rabbits with surgically induced diaphragmatic hernia: a placebo controlled morphologic study. Prenat Diagn 2009; 29:674-81. [DOI: 10.1002/pd.2243] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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de Buys Roessingh AS, Dinh-Xuan AT. Congenital diaphragmatic hernia: current status and review of the literature. Eur J Pediatr 2009; 168:393-406. [PMID: 19104834 DOI: 10.1007/s00431-008-0904-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Accepted: 12/06/2008] [Indexed: 12/26/2022]
Abstract
Treatment of congenital diaphragmatic hernia (CDH) challenges obstetricians, pediatric surgeons, and neonatologists. Persistent pulmonary hypertension (PPHT) associated with lung hypoplasia in CDH leads to a high mortality rate at birth. PPHT is principally due to an increased muscularization of the arterioles. Management of CDH has been greatly improved by the introduction of prenatal surgical intervention with tracheal obstruction (TO) and by more appropriate postnatal care. TO appears to accelerate fetal lung growth and to increase the number of capillary vessels and alveoli. Improvement of postnatal care over the last years is mainly due to the avoidance of lung injury by applying low peak inflation pressure during ventilation. The benefits of other drugs or technical improvements such as the use of inhaled nitric oxide or extracorporeal membrane oxygenation (ECMO) are still being debated and no single strategy is accepted worldwide. Despite intensive clinical and experimental research, the treatment of newborn with CDH remains difficult.
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Affiliation(s)
- Anthony S de Buys Roessingh
- Service de Chirurgie Pédiatrique, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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Worley KC, Dashe JS, Barber RG, Megison SM, McIntire DD, Twickler DM. Fetal magnetic resonance imaging in isolated diaphragmatic hernia: volume of herniated liver and neonatal outcome. Am J Obstet Gynecol 2009; 200:318.e1-6. [PMID: 19110232 DOI: 10.1016/j.ajog.2008.10.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Revised: 08/07/2008] [Accepted: 10/03/2008] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We sought to use magnetic resonance (MR) imaging (MRI) to estimate percentage of fetal thorax occupied by lung, liver, and other abdominal organs in pregnancies with congenital diaphragmatic hernia (CDH). STUDY DESIGN This was a retrospective study of pregnancies with isolated CDH referred for MRI between August 2000 and June 2006. Four regions of interest were measured in the axial plane by an investigator blinded to neonatal outcome, and volumes were then calculated. The percentages of thorax occupied by lung, liver, and all herniated organs were then compared with neonatal outcomes. RESULTS Fifteen CDH fetuses underwent MRI at a median gestational age of 29 weeks. Liver herniation was found in 93%. When the liver occupied > 20% of the fetal thorax, neonatal deaths were significantly increased. Percentages of lung and other herniated organs were not associated with outcome. CONCLUSION In our MR series of isolated CDH, neonatal deaths were significantly increased when > 20% of the fetal thorax was occupied by liver.
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Affiliation(s)
- Kevin C Worley
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX 75390-9032, USA.
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Deprest JA, Hyett JA, Flake AW, Nicolaides K, Gratacos E. Current controversies in prenatal diagnosis 4: Should fetal surgery be done in all cases of severe diaphragmatic hernia? Prenat Diagn 2009; 29:15-9. [DOI: 10.1002/pd.2108] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Manrique S, Munar F, Andreu E, Montferrer N, de Miguel M, López Gil V, Roigé J. [Fetoscopic tracheal occlusion for the treatment of severe congenital diaphragmatic hernia: preliminary results]. ACTA ACUST UNITED AC 2008; 55:407-13. [PMID: 18853678 DOI: 10.1016/s0034-9356(08)70611-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To evaluate survival and lung growth in fetuses with severe congenital diaphragmatic hernia (CDH) treated with fetoscopic tracheal occlusion (FETO) compared with control fetuses and to analyze possible complications of the anesthetic techniques used. PATIENTS AND METHODS This prospective study was performed on fetuses with CDH. FETO was undertaken before the 29th week of gestation on fetuses with a lung-to-head ratio (LHR) less than 1. FETO was not performed on fetuses with an LHR between 1.0 and 1.5 or those with an LHR less than 1 where consent was not given. Lung growth was monitored by means of LHR. FETO was performed under fetal intramuscular anesthesia and maternal epidural anesthesia and sedation with remifentanil. RESULTS Seventeen fetuses were included in the study. FETO was performed on 11 fetuses and was effective in 9. The median percentage difference between LHR at diagnosis and prior to FETO was 1.15% (P=.183); between diagnosis and before removing the balloon, the difference was 130.5% (P=.003); and between diagnosis and before delivery, 90.18% (P=.003). In the control group (n=6), the median percentage difference between LHR at diagnosis and before delivery was 49.25% (P=.028). No significant hemodynamic or respiratory changes occurred in either mother or fetus during fetoscopy. All the fetuses in the control group died; 45.5% of those in the FETO group survived. CONCLUSIONS The use of FETO in cases of CDH appears to increase survival and lung growth. Fetal anesthesia in association with maternal epidural anesthesia and sedation makes it possible to place and remove the endotracheal balloon via fetoscopy with acceptable maternal comfort and without notable complications.
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Affiliation(s)
- S Manrique
- Servicio de Anestesiología y Reanimación, Area Materno-Infantil, Hospital Universitario Vall d'Hebron, Barcelona.
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Mitanchez D. Traitement anténatal de la hernie de coupole diaphragmatique : le point en 2008. Arch Pediatr 2008; 15:1320-5. [DOI: 10.1016/j.arcped.2008.04.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2007] [Revised: 12/11/2007] [Accepted: 04/18/2008] [Indexed: 11/26/2022]
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Affiliation(s)
- Catherine Garel
- Service de Radiologie Pédiatrique, Hôpital d'Enfants Armand-Trousseau, 26-28 Avenue du Dr Arnold Netter, 75571, Paris Cedex 12, France.
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Abstract
Congenital diaphragmatic hernia (CDH) is a defect in the formation of the diaphragm of the fetus. The diaphragm is the muscle and tissue that separate the chest and the abdominal cavities. In CDH, abdominal organs push into the chest cavity through the defect or herniation, compressing the developing lungs. During the past 10 years, significant changes have occurred in the diagnosis and management of CDH. Despite advances in postnatal care, infants born with a CDH continue to suffer substantial morbidity and mortality. Healthcare providers continue to research therapeutic approaches that will improve the care and optimize survival in these infants. The purpose of this article is to offer an in-depth exploration of neonatal physiology and pathophysiology, providing advanced concepts that expand the scientific basis for neonatal care practices.
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Beurskens N, Klaassens M, Rottier R, de Klein A, Tibboel D. Linking animal models to human congenital diaphragmatic hernia. ACTA ACUST UNITED AC 2007; 79:565-72. [PMID: 17469205 DOI: 10.1002/bdra.20370] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is a major life-threatening malformation, occurring in approximately 1 in 3,000 live births. Over the years, different animal models have been used to gain insight into the etiology of this complex congenital anomaly and to develop treatment strategies. However, to date the pathogenic mechanism is still not understood, and treatment remains difficult because of the associated pulmonary hypoplasia and pulmonary hypertension. METHODS In this review, data available from several animal models will be discussed. The retinoic acid signaling pathway (RA pathway, retinoid pathway) will be addressed as a developmental pathway that is potentially disrupted in the pathogenesis of CDH. Furthermore, genetic factors involved in diaphragm and lung development will be discussed. CONCLUSIONS With this review article, we aim to provide a concise overview of the current most important experimental genetic data available in the field of CDH.
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Affiliation(s)
- Niels Beurskens
- Department of Pediatric Surgery, Erasmus MC, Rotterdam, The Netherlands
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Davey M, Shegu S, Danzer E, Ruchelli E, Adzick S, Flake A, Hedrick HL. Pulmonary arteriole muscularization in lambs with diaphragmatic hernia after combined tracheal occlusion/glucocorticoid therapy. Am J Obstet Gynecol 2007; 197:381.e1-7. [PMID: 17904968 DOI: 10.1016/j.ajog.2007.06.061] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2007] [Revised: 06/01/2007] [Accepted: 06/28/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE A morphometric study was performed to examine the effects of prenatal glucocorticoids, which were administered 48 hours before birth, on muscularization of small pulmonary arterioles (<60 microm diameter) in lambs with diaphragmatic hernia (DH) after fetal tracheal occlusion (TO). STUDY DESIGN DH was created in 23 fetal sheep at 65 days gestation. TO was performed in 16 of 24 fetuses between 110 and 140 days of gestation; 9 of the fetuses were exposed prenatally to betamethasone (0.5 mg/kg body weight) 48 hours before delivery. Six sham-operated animals served as controls. Sections of paraffin that were embedded in lung tissues were stained with Elastin-Van Gieson, and the percentage of medial wall thickness (MWT) was determined. RESULTS The percentage of MWT in DH lambs (29.6% +/- 1.9%) was increased compared with sham animals (18.1% +/- 1.3%) and was not different from that of DH/TO animals (30.3% +/- 1.7%). In DH/TO + glucocorticoid lambs, the percentage of MWT (24.6% +/- 1.2%) was significantly lower than in the DH/TO group but was higher than the sham group. CONCLUSION In fetuses who underwent prolonged TO therapy for severe DH, prenatal glucocorticoid treatment decreased medial hypertrophy of pulmonary arterioles by approximately 19%. We speculate that such structural changes may have contributed to improve gas exchange that was observed in this model.
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Affiliation(s)
- Marcus Davey
- Center of Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Lee YM, Simpson LL. Major fetal structural malformations: the role of new imaging modalities. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2007; 145C:33-44. [PMID: 17290442 DOI: 10.1002/ajmg.c.30117] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Prenatal diagnosis has embraced a recent wave of innovative imaging modalities including three-dimensional (3D) ultrasound and fetal magnetic resonance imaging (MRI). Traditional two-dimensional (2D) ultrasonography remains the standard method by which major structural abnormalities are diagnosed antenatally, but advances in technology are opening new doors. Growth in our knowledge about fetal development, improved patient counseling, and more favorable perinatal outcomes are all potential benefits of incorporating new imaging modalities into clinical practice.
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Affiliation(s)
- Young Mi Lee
- Columbia University Medical Center, Department of Obstetrics and Gynecology, New York, NY 10032, USA.
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Queloz PA, Crettaz D, Thadikkaran L, Sapin V, Gallot D, Jani J, Deprest J, Lémery D, Barelli S, Tissot JD. Proteomic analyses of amniotic fluid: Potential applications in health and diseases. J Chromatogr B Analyt Technol Biomed Life Sci 2007; 850:336-42. [PMID: 17182292 DOI: 10.1016/j.jchromb.2006.12.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Revised: 11/21/2006] [Accepted: 12/03/2006] [Indexed: 11/23/2022]
Abstract
Amniotic fluid (AF) is a potential source of biomarkers for many disorders which may occur during pregnancy. The purpose of this study was to evaluate the place of two-dimensional gel electrophoresis (2-DE) technologies to compare AF in both normal and pathological situations. Two-dimensional fluorescence difference gel electrophoresis (2D-DIGE; Ettan DIGE) as well as two-dimensional gel electrophoresis and silver staining followed by image analysis were used. Differentially expressed proteins were identified by mass spectrometry. This approach was used to study electrophoregrams of normal AF obtained at 17 weeks of gestation and at term, as well as AF from fetuses presenting with congenital diaphragmatic hernia. Finally, the potential of two-dimensional electrophoresis was assessed by studying the protein profile of plasma containing AF proteins in a model of premature rupture of the membranes (PROM). Our results clearly show that two-dimensional electrophoresis technologies still have place for analyzing biological fluids such as AF.
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Deprest J, Jani J, Lewi L, Ochsenbein-Kölble N, Cannie M, Doné E, Roubliova X, Van Mieghem T, Debeer A, Debuck F, Sbragia L, Toelen J, Devlieger R, Lewi P, Van de Velde M. Fetoscopic surgery: encouraged by clinical experience and boosted by instrument innovation. Semin Fetal Neonatal Med 2006; 11:398-412. [PMID: 17056307 DOI: 10.1016/j.siny.2006.09.003] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Today, modern ultrasound equipment and the wide implementation of screening programmes allow the timely diagnosis of many congenital anomalies. For some of these, fetal surgery may be a life-saving option. In Europe, open fetal surgery became poorly accepted because of its invasiveness and the high incidence of postoperative premature labour and rupture of the fetal membranes. In the 1990s, the merger of fetoscopy and advanced video-endoscopic surgery formed the basis for endoscopic fetal surgery. We review the current applications of fetal surgery via both methods of access. The first clinical fetoscopic surgeries were interventions on the umbilical cord and the placenta, often referred to as obstetrical endoscopy. The outcome of a randomized clinical trial demonstrating that fetoscopic laser coagulation of chorionic plate vessels is the most effective treatment for twin-twin transfusion syndrome (TTTS) has revived interest in endoscopic fetal therapy. Operating on the fetus is another more challenging enterprise. Clinical fetal surgery programmes were virtually non-existent in Europe until minimally invasive fetoscopic surgery made such operations clinically possible as well as maternally acceptable. At present, most experience has been gathered with fetal tracheal occlusion as a therapy for severe congenital diaphragmatic hernia. As in other fields, minimally invasive surgery has pushed back boundaries and now allows safe operations to be performed on the fetal patient. Whereas minimal access seems to solve the problem of preterm labour, all procedures remain invasive, and carry a risk to the mother and a substantial risk of preterm prelabour rupture of the membranes (PPROM). The latter problem may prove to be a bottleneck for further developments, although treatment modalities are currently being evaluated.
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Affiliation(s)
- Jan Deprest
- Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospital Leuven, 3000 Leuven, Belgium.
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