Predictive value of gestational age at diagnosis for outcomes in prenatally diagnosed congenital diaphragmatic hernia

Prenatal diagnostic and intervention considerations in congenital diaphragmatic hernia

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.

Development of a prediction nomogram for 1-month mortality in neonates with congenital diaphragmatic hernia

OBJECTIVES

Although many prognostic factors in neonates with congenital diaphragmatic hernia (CDH) have been described, no consensus thus far has been reached on which and how many factors are involved. The aim of this study is to analyze the association of multiple prenatal and postnatal factors with 1-month mortality of neonates with CDH and to construct a nomogram prediction model based on significant factors.

METHODS

A retrospective analysis of neonates with CDH at our center from 2013 to 2022 was conducted. The primary outcome was 1-month mortality. All study variables were obtained either prenatally or on the first day of life. Risk for 1-month mortality of CDH was quantified by odds ratio (OR) with 95% confidence interval (CI) in multivariable logistic regression models.

RESULTS

After graded multivariable adjustment, six factors were found to be independently and consistently associated with the significant risk of 1-month mortality in neonates with CDH, including gestational age of prenatal diagnosis (OR, 95% CI, P value: 0.845, 0.772 to 0.925, < 0.001), observed-to-expected lung-to-head ratio (0.907, 0.873 to 0.943, < 0.001), liver herniation (3.226, 1.361 to 7.648, 0.008), severity of pulmonary hypertension (6.170, 2.678 to 14.217, < 0.001), diameter of defect (1.560, 1.084 to 2.245, 0.017), and oxygen index (6.298, 3.383 to 11.724, < 0.001). Based on six significant factors identified, a nomogram model was constructed to predict the risk for 1-month mortality in neonates with CDH, and this model had decent prediction accuracy as reflected by the C-index of 94.42%.

CONCLUSIONS

Our findings provide evidence for the association of six preoperational and intraoperative factors with the risk of 1-month mortality in neonates with CDH, and this association was reinforced in a nomogram model.

Development and internal validation of a prediction model to predict survival for congenital diaphragmatic hernia in the early postnatal period

PURPOSE

To develop an easily applied predictive model to predict survival rate for infants with congenital diaphragmatic hernia (CDH) in the early postnatal period according to the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD) guideline.

METHODS

The retrospective study was conducted including 225 neonates with prenatal or postnatal diagnosed CDH between 2001 and 2018. Patients did not receive the therapy of fetal endoscopic tracheal occlusion and extracorporeal membrane oxygenation. The study took into consideration these variables that are easily available in most centers within the first 1 h after admission. A multivariable prediction model to predict the survival rate for CDH was generated and its performance was analyzed.

RESULTS

The multiple logistic regression analysis was generated using five clinical variables that are routinely available in most centers, including birth weight, 1-min Apgar score, side of hernia, presence of liver herniation, and PaCO₂ in the admission arterial blood analysis. The area under the receiver operating characteristic curve value for this model was 0.912, which was greater than that of a single biomarker in predicting the survival rate of CDH. This model had a sensitivity of 90.6% and a specificity of 74.6%. This model demonstrated good calibration (Hosmer-Lemeshow goodness-of-fit test, p = .410). Besides, the model had a better discriminative ability compared to the previously established predictive models of CDH.

CONCLUSIONS

The simple and generalizable model was developed by five predictors for CDH in the early period using the TRIPOD checklist. It demonstrated good performance in predicting the survival rate of infants with CDH, holding promise for future clinical application.

Ex utero intrapartum therapy in infants with congenital diaphragmatic hernia: a propensity score matching analysis

Objective

Previous studies have shown that ex utero intrapartum therapy (EXIT) is safe and feasible for newborns with congenital diaphragmatic hernia (CDH). This study reports our experience with EXIT in fetuses with CDH in an attempt to explore the efficacy of EXIT on the survival rate of this population.

Methods

A retrospective analysis of the clinical data of 116 children with CDH was conducted. The children were assigned to EXIT and non-EXIT groups. Propensity score matching (PSM) toward clinical data was performed, and the clinical characteristics and outcomes were compared. Taking survival at discharge as the main outcome, logistic regression analysis was carried out to explore the efficacy of EXIT on survival.

Results

During the study period, 30 of 116 children received EXIT. After PSM, the survival rates of the EXIT group and the non-EXIT group were 82.76% (24/29) and 48.28% (14/29), respectively (p=0.006). EXIT (OR=0.083, 95% CI=0.013to 0.525, p=0.008), liver herniation (OR=16.955, 95% CI=2.342 to 122.767, p=0.005), and gestational age at diagnosis (OR=0.662, 95% CI=0.497 to 0.881, p=0.005) were independent mortality-related risk factors of all children with CDH. Ninety-nine of 116 children underwent surgery. After PSM, the postoperative survival rates of the EXIT group and non-EXIT group were 84.6% (22/26) and 76.9% (20/26), respectively (p=0.754). Liver herniation (OR=10.451, 95% CI=1.641 to 66.544, p=0.013) and gestational age at diagnosis (OR=0.736, 95% CI=0.577 to 0.938, p=0.013) were independent mortality-related risk factors of children after surgery.

Conclusion

EXIT can be performed safely for selected prenatally diagnosed CDH neonates with potentially better survival and does not cause more maternal complications compared with traditional cesarean section.

Estrogen-regulated CD200 inhibits macrophage phagocytosis in endometriosis

OBJECTIVES

Endometriosis (EMS) is a benign disease that is related to estrogen, immune disorders and inflammation. The purpose of this research was to determine the expression of CD200 in EMS and to clarify its role in the pathogenesis of the disease.

METHODS

The levels of serum CD200 in patients with and without EMS were determined by ELISA. Furthermore, the expression of CD200 in normal eutopic endometrium and ectopic endometrium was detected by immunohistochemistry and western blotting. The CD200 receptor (CD200R) in macrophages in peritoneal fluid (pMØ) obtained from controls and patients with EMS was examined by western blotting. CD200 expression in human endometrial stromal cells (HESCs) stimulated with 17β-estradiol (E₂) was measured by western blotting. Furthermore, macrophages were stimulated with different concentrations of CD200 and the effect on phagocytosis was analyzed.

RESULTS

The plasma CD200 levels of patients with EMS was significantly increased compared with controls (P = 0.0173, 95%CI [18.75, 159.6]). Compared with normal eutopic endometrium, the expression of CD200 was significantly increased in ectopic endometrial tissues. The CD200R expression in pMØ obtained from patients with EMS was increased compared with the controls (P = 0.0244). CD200 expression in HESCs stimulated with E₂ was up-regulated. As the levels of CD200 increased, macrophage phagocytosis in vitro gradually decreased.

CONCLUSIONS

CD200 is an estrogen-induced molecule that impairs macrophage phagocytosis and may contribute to the immune escape of ectopic lesions in EMS.