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Abstract
Congenital diaphragmatic hernia (CDH) is a rare developmental defect of the diaphragm, characterized by herniation of abdominal contents into the chest that results in varying degrees of pulmonary hypoplasia and pulmonary hypertension (PH). Significant advances in the prenatal diagnosis and identification of prognostic factors have resulted in the continued refinement of the approach to fetal therapies for CDH. Postnatally, protocolized approaches to lung-protective ventilation, nutrition, prevention of infection, and early aggressive management of PH have led to improved outcomes in infants with CDH. Advances in our understanding of the associated left ventricular (LV) hypoplasia and myocardial dysfunction in infants with severe CDH have allowed for the optimization of hemodynamics and management of PH. This article provides a comprehensive review of CDH for the anesthesiologist, focusing on the complex pathophysiology, advances in prenatal diagnosis, fetal interventions, and optimal postnatal management of CDH.
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Affiliation(s)
| | | | - Jason Gien
- Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
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2
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Abbasi N, Cortes MS, Ruano R, Johnson A, Morgan T, Coleman B, Baschat A, Zaretsky M, Lim FY, Bulas D, Benachi A, Ryan G. Variability in antenatal prognostication of fetal diaphragmatic hernia across the North American Fetal Therapy Network (NAFTNet). Prenat Diagn 2019; 40:342-350. [PMID: 31600412 DOI: 10.1002/pd.5560] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 08/22/2019] [Accepted: 09/07/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate variability in antenatal sonographic prognostication of congenital diaphragmatic hernia (CDH) within the North American Fetal Therapy Network (NAFTNet). METHODS NAFTNet centre were invited to complete a questionnaire and participate in videoconference calls, during which participants were observed while measuring lung area by ultrasound using the anteroposterior (AP) method, longest method, and trace method. Each center identified 1-2 experienced fetal medicine specialist(s) or medical imaging specialists locally to participate in the study. Practices were compared among NAFTNet centre within and without the fetal endoscopic tracheal occlusion (FETO) consortium. RESULTS Nineteen participants from 9 FETO center and 30 participants from 17 non-FETO center completed the survey and 31 participants were interviewed and observed while measuring sonographic lung area. All Centres measured observed-to-expected lung-to-head ratio (o/e LHR) or LHR for CDH prognostication. Image selection criteria for lung area measurement were consistent, including an axial section of the chest with clear lung borders and a 4-chamber cardiac view. Lung area measurement methods varied across NAFTNet, with most centre using longest (4/9 FETO vs. 13/29 non-FETO) or trace (3/9 FETO vs. 11/29 non-FETO) method. Centres differed in expected reference ranges for o/e LHR determination and whether the lowest, highest or average o/e LHR was utilized. CONCLUSION Variability in antenatal sonographic prognostication of CDH was identified across NAFTNet, indicating a need for consensus-based standardization.
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Affiliation(s)
- Nimrah Abbasi
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Magda Sanz Cortes
- Department of Obstetrics & Gynecology, Texas Children's Fetal Center. Baylor College of Medicine, Houston, Texas, USA
| | - Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Dept. of Obstetrics & Gynecology, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anthony Johnson
- The Fetal Center, Children's Memorial Hermann Hospital, University of Texas Health Science Centre, Houston, Texas
| | - Tara Morgan
- The Fetal Treatment Center, Department of Radiology, University of California, San Francisco, San Francisco, California
| | - Beverly Coleman
- Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ahmet Baschat
- Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael Zaretsky
- Colorado Fetal Care Center, Colorado Children's Hospital, University of Colorado, Aurora, Colorado
| | - Foong Yen Lim
- Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Dorothy Bulas
- Children's National Medical System, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - 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
| | - Greg Ryan
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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3
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Novoa Y Novoa VA, Sutton LF, Neis AE, Marroquin AM, Coleman TM, Praska KA, Freimund TA, Ruka KL, Warzala VL, Sangi-Haghpeykar H, Ruano R. Reproducibility of Liver-to-Thorax Area Ratio Ultrasound Measurements in Congenital Diaphragmatic Hernia. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:1477-1482. [PMID: 30244491 DOI: 10.1002/jum.14826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 08/02/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES The aim of this study was to investigate the reproducibility of a standardized method to assess the ultrasound liver-to-thoracic area ratio in fetuses with congenital diaphragmatic hernia. METHODS We selected 24 images of 9 fetuses diagnosed with left-sided at our institution between January 2010 and December 2017. Eight operators (1 maternal-fetal medicine specialist and 7 sonographers) reviewed the selected images and assessed the ultrasound liver-to-thoracic area ratio according to a standardized protocol. We evaluated the correlation between operators using the intraclass correlation coefficient and compared agreement between the sonographers and a physician with experience in measuring the ultrasound liver-to-thoracic area ratio using a Bland-Altman analysis. RESULTS Good intraoperator reproducibility was observed for the standardized ultrasound liver-to-thoracic area ratio (intraclass correlation coefficient, 0.78). Good agreement among sonographers and the physician was also observed for the standardized measurements (bias, 0.01; precision, 0.03; limits of agreement, -0.05 to + 0.07). CONCLUSIONS We demonstrated that good intraoperator and interoperator reproducibility of ultrasound liver-to-thoracic area ratio assessment is feasible after standardizing the method in our center.
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Affiliation(s)
- Victoria Arruga Novoa Y Novoa
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Laura F Sutton
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Allan E Neis
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Amber M Marroquin
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Tracey M Coleman
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Kathleen A Praska
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Tamara A Freimund
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Krystal L Ruka
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Vicki L Warzala
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Haleh Sangi-Haghpeykar
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Rodrigo Ruano
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Cruz-Martínez R, Etchegaray A, Molina-Giraldo S, Nieto-Castro B, Gil Guevara E, Bustillos J, Martínez-Rodríguez M, Gámez-Varela A, Saldivar-Rodríguez D, Chávez-González E, Keller R, Russo R, Yepez-García E, Coronel-Cruz F, Torres-Torres J, Rojas-Macedo A, Ibarra-Ríos D, Ordorica-Flores R, Nieto-Zermeño J, Alcocer-Alcocer M. A multicentre study to predict neonatal survival according to lung-to-head ratio and liver herniation in fetuses with left congenital diaphragmatic hernia (CDH): Hidden mortality from the Latin American CDH Study Group Registry. Prenat Diagn 2019; 39:519-526. [PMID: 30980408 DOI: 10.1002/pd.5458] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 03/22/2019] [Accepted: 03/27/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To evaluate natural history of fetuses congenital diaphragmatic hernia (CDH) prenatally diagnosed in countries where termination of pregnancy is not legally allowed and to predict neonatal survival according to lung area and liver herniation. METHODS Prospective study including antenatally diagnosed CDH cases managed expectantly during pregnancy in six tertiary Latin American centres. The contribution of the observed/expected lung-to-head ratio (O/E-LHR) and liver herniation in predicting neonatal survival was assessed. RESULTS From the total population of 380 CDH cases, 144 isolated fetuses were selected showing an overall survival rate of 31.9% (46/144). Survivors showed significantly higher O/E-LHR (56.5% vs 34.9%; P < .001), lower proportion of liver herniation (34.8% vs 80.6%, P < .001), and higher gestational age at birth (37.8 vs 36.2 weeks, P < 0.01) than nonsurvivors. Fetuses with an O/E-LHR less than 35% showed a 3.4% of survival; those with an O/E-LHR between 35% and 45% showed 28% of survival with liver up and 50% with liver down; those with an O/E-LHR greater than 45% showed 50% of survival rate with liver up and 76.9% with liver down. CONCLUSIONS Neonatal mortality in CDH is higher in Latin American countries. The category of lung hypoplasia should be classified according to the survival rates in our Latin American CDH registry.
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Affiliation(s)
- Rogelio Cruz-Martínez
- Unidad de Cirugía Fetal, Hospital de Especialidades del Niño y la Mujer, Queretaro, Mexico
| | - Adolfo Etchegaray
- Unidad de Medicina Fetal, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Saulo Molina-Giraldo
- Unidad de Terapia, Cirugía Fetal y Fetoscopia, División de Medicina Materno Fetal, Departmaneto de Ginecología y Obstetricia, Hospital de San José, Fundación Universitaria de Ciencias de la Salud-FUCS, Bogotá, Colombia
| | - Belen Nieto-Castro
- Unidad de Medicina Materno-Fetal, Hospital Gineco-Obstétrico "Isidro Ayora", Quito, Ecuador
| | - Enrique Gil Guevara
- Instituto Unidad de Medicina Fetal, Peruano de Medicina y Cirugía Fetal, Lima, Peru
| | - Joaquin Bustillos
- Unidad de Medicina Fetal, Hospital CIMA San Jose, San José, Costa Rica
| | | | - Alma Gámez-Varela
- Unidad de Cirugía Fetal, Hospital de Especialidades del Niño y la Mujer, Queretaro, Mexico
| | | | | | - Rodolfo Keller
- Unidad de Medicina Fetal, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Ricardo Russo
- Unidad de Medicina Fetal, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Eduardo Yepez-García
- Unidad de Medicina Materno-Fetal, Hospital Gineco-Obstétrico "Isidro Ayora", Quito, Ecuador
| | - Fausto Coronel-Cruz
- Departamento de Medicina Materno Fetal, Hospital General de México, Mexico City, Mexico
| | | | - Alejandro Rojas-Macedo
- Departamento de Neonatología, Hospital de Especialidades del Niño y la Mujer, Queretaro, Mexico
| | - Daniel Ibarra-Ríos
- Departamento de Cirugía Pediátrica, Hospital Infantil de México "Dr. Federico Gómez", Mexico City, Mexico
| | - Ricardo Ordorica-Flores
- Departamento de Cirugía Pediátrica, Hospital Infantil de México "Dr. Federico Gómez", Mexico City, Mexico
| | - Jaime Nieto-Zermeño
- Departamento de Cirugía Pediátrica, Hospital Infantil de México "Dr. Federico Gómez", Mexico City, Mexico
| | - Manuel Alcocer-Alcocer
- Unidad de Cirugía Fetal, Hospital de Especialidades del Niño y la Mujer, Queretaro, Mexico
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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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Sperling JD, Sparks TN, Berger VK, Farrell JA, Gosnell K, Keller RL, Norton ME, Gonzalez JM. Prenatal Diagnosis of Congenital Diaphragmatic Hernia: Does Laterality Predict Perinatal Outcomes? Am J Perinatol 2018; 35:919-924. [PMID: 29304545 PMCID: PMC6033692 DOI: 10.1055/s-0037-1617754] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objective of this study was to examine laterality as a predictor of outcomes among fetuses with prenatally diagnosed congenital diaphragmatic hernia (CDH). METHODS This is a retrospective cohort study of pregnancies with CDH evaluated at our center from 2008 to 2016 compared cases with right-sided CDH (RCDH) versus left-sided CDH (LCDH). The primary outcome was survival to discharge. Secondary outcomes included ultrasound predictors of poor prognosis (liver herniation, stomach herniation, lung area-to-head circumference ratio [LHR]), concurrent anomalies, hydrops, stillbirth, preterm birth, mode of delivery, small for gestational age, use of extracorporeal membrane oxygenation, and length of stay. Terminations and stillbirths were excluded from analyses of neonatal outcomes. RESULTS In this study, 157 (83%) LCDH and 32 (17%) RCDH cases were identified. Survival to discharge was similar (64 vs. 66.4%, p = 0.49) with regard to laterality. RCDH had higher rates of liver herniation (90.6 vs. 72%, p = 0.03), hydrops fetalis (15.6 vs. 1.3%, p < 0.01), and lower LHR (0.87 vs. 0.99, p = 0.04). LCDH had higher rates of stomach herniation (69.4 vs. 12.5%, p < 0.01). Rates of other outcomes were similar in univariate analyses. Adjusting for microarray abnormalities, the odds for survival to discharge for RCDH compared with LCDH was 0.93 (0.38-2.30, p = 0.88). CONCLUSION Compared with LCDH, fetuses with RCDH had higher rates of adverse ultrasound predictors, but equivalent survival.
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Affiliation(s)
- Jeffrey D. Sperling
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California,Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Teresa N. Sparks
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California,Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Victoria K. Berger
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California,Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Jody A. Farrell
- Division of Pediatric Surgery, Department of Surgery, Fetal Treatment Center, University of California, San Francisco, San Francisco, California
| | - Kristen Gosnell
- Division of Pediatric Surgery, Department of Surgery, Fetal Treatment Center, University of California, San Francisco, San Francisco, California
| | - Roberta L. Keller
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Mary E. Norton
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California,Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Juan M. Gonzalez
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California,Department of Pediatrics, University of California, San Francisco, San Francisco, California
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Novoa Y Novoa VA, Sutton LF, Neis AE, Marroquin AM, Freimund TA, Coleman TM, Praska KA, Ruka KL, Warzala VL, Sangi-Haghpeykar H, Ruano R. Reproducibility of Lung-to-Head Ratio Ultrasound Measurements in Congenital Diaphragmatic Hernia. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:2037-2041. [PMID: 29399860 DOI: 10.1002/jum.14557] [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: 10/14/2017] [Revised: 11/17/2017] [Accepted: 11/18/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES This study investigated the reproducibility of standardization of lung-to-head ratio measurements in congenital diaphragmatic hernia (CDH) at our center among sonographers after we standardized the method. METHODS We reviewed ultrasound images of 12 fetuses with CDH at Mayo Clinic from 2010 to 2016. Nine operators (1 maternal-fetal medicine specialist with experience in measuring the lung-to-head ratio and 8 sonographers), who were blinded to previous findings, reviewed 33 selected images from 12 fetuses with left CDH. The method for lung-to-head ratio measurement was standardized before starting the measurements. The lung-to-head ratio was assessed by different methods to obtain the lung areas: anteroposterior, longest, and area tracing. We evaluated the correlation between operators using the intraclass correlation coefficient (ICC). We also compared agreement between the sonographers and a physician with experience in measuring the lung-to-head ratio using a Bland-Altman analysis. RESULTS The methods with the best interoperator reproducibility were the standardized anteroposterior lung-to-head ratio (ICC, 0.69) and the standardized lung-to-head ratio tracing (ICC, 0.65) compared to the longest lung-to-head ratio (ICC, 0.56). The standardized lung-to-head ratio tracing had the best agreement among sonographers and the physician (bias, 0.11; limits of agreement, -0.27 to +0.49) than the anteroposterior lung-to-head ratio (bias, 0.35; limits of agreement, -0.13 to + 0.83) and the longest lung-to-head ratio (bias, 0.27; limits of agreement, -0.35 to +0.89). CONCLUSIONS We demonstrated that the lung-to-head ratio tracing method has high interoperator reproducibility and the best agreement among the operators at our center. Further multicenter studies are necessary to confirm our results.
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Affiliation(s)
- Victoria Arruga Novoa Y Novoa
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Laura F Sutton
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Allan E Neis
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Amber M Marroquin
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Tamara A Freimund
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Tracey M Coleman
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Kathleen A Praska
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Krystal L Ruka
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Vicki L Warzala
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Haleh Sangi-Haghpeykar
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Isolated impact of liver herniation on outcome in fetuses with congenital diaphragmatic hernia - A matched-pair analysis based on fetal MRI relative lung volume. Eur J Radiol 2018; 105:148-152. [PMID: 30017271 DOI: 10.1016/j.ejrad.2018.05.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 04/09/2018] [Accepted: 05/24/2018] [Indexed: 11/21/2022]
Abstract
PURPOSE To evaluate liver-herniation as individual parameter on outcome in children with congenital diaphragmatic hernia. MATERIALS AND METHODS In a retrospective matched-pair analysis based on observed to expected fetal lung volume (o/e FLV), birth weight, gestational age at time-point of examination, status of tracheal occlusion therapy and side of the defect the individual impact of liver-herniation on survival, need for extracorporeal membrane oxygenation (ECMO) therapy and chronic lung disease (CLD) was investigated. In total 61 pairs (122 patients) were included. Fisher's exact test was used to evaluate influence of liver-herniation and a p-value of <0.05 was defined as statistically significant. The study was approved by the local review board. RESULTS Children with liver-herniation have lower survival rates (78.7% vs. 95.1%; p = 0.0073), need ECMO-therapy more often (41.0% vs. 16.4%; p = 0.0027) and are more likely to develop CLD (71.7% vs. 37.9%; p = 0.0004) than their corresponding matched-pair without liver-herniation. CONCLUSION Liver-herniation itself and not further lung-volume restriction due to liver-herniation is responsible for poor outcome in CDH.
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9
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Partridge EA, Peranteau WH, Herkert L, Rintoul NE, Flake AW, Adzick NS, Hedrick HL. Rate of increase of lung-to-head ratio over the course of gestation is predictive of survival in left-sided congenital diaphragmatic hernia. J Pediatr Surg 2016; 51:703-5. [PMID: 27261559 DOI: 10.1016/j.jpedsurg.2016.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 02/07/2016] [Indexed: 11/16/2022]
Abstract
PURPOSE Congenital diaphragmatic hernia (CDH) is associated with high postnatal mortality because of pulmonary hypoplasia. The prognostic utility of serial lung-to-head circumference measurements as a marker of lung growth has not been described. Our objective was to examine the relationship between the rate of interval increase of LHR and postnatal survival in left-sided CDH. METHODS We retrospectively reviewed charts of all left-sided CDH patients from January 2004 to July 2014. All ultrasound studies performed at our institution (n=473) were reviewed. Categorical and continuous data were analyzed by chi-square and Mann-Whitney t-test, respectively, and slope analysis was performed by linear regression analysis (p<0.05). RESULTS A total of 226 patients were studied, with 154 long-term survivors and 72 non-survivors. Established markers of CDH severity, including intrathoracic liver position and requirement for patch repair, were significantly increased in non-survivors (p<0.0001). The rate of LHR increase as measured by linear regression and slope analysis was significantly increased in long-term survivors (p=0.0175). CONCLUSIONS Our findings indicate that the interval increase in LHR levels over the course of gestation correlate with survival in left-sided CDH patients. Regular ultrasonographic re-evaluation of LHR throughout gestation following diagnosis of CDH may provide prognostic insight and help guide patient management.
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Affiliation(s)
- Emily A Partridge
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, 19104
| | - William H Peranteau
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, 19104
| | - Lisa Herkert
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, 19104
| | - Natalie E Rintoul
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, 19104
| | - Alan W Flake
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, 19104
| | - N Scott Adzick
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, 19104
| | - Holly L Hedrick
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, 19104.
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Abstract
Over the past 20 years, prenatal detection of congenital diaphragmatic hernia (CDH) has improved worldwide, reaching up to 60% in Europe. Pulmonary hypoplasia and persistent pulmonary hypertension are the two main determinants of neonatal mortality and morbidity, so new tools have been focused on their evaluation. Fetal surgery for severe cases requires proper evaluation of the prognosis of fetuses with CDH. Observed-to-expected lung-to-head ratio, liver position, and total lung volume measured by magnetic resonance are the prognostic factors most often used, and have been shown to correlate not only with neonatal mortality but also with morbidity. In daily practice, pulmonary hypertension by itself, although most often associated with lung hypoplasia, is more difficult to predict.
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Kehl S, Siemer J, Brunnemer S, Weiss C, Eckert S, Schaible T, Sütterlin M. Prediction of postnatal outcomes in fetuses with isolated congenital diaphragmatic hernias using different lung-to-head ratio measurements. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:759-767. [PMID: 24764330 DOI: 10.7863/ultra.33.5.759] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES The purpose of this study was to compare different methods for measuring the fetal lung area-to-head circumference ratio and to investigate their prediction of postpartum survival and the need for neonatal extracorporeal membrane oxygenation (ECMO) therapy in fetuses with isolated congenital diaphragmatic hernias. METHODS This prospective study included 118 fetuses of at least 20 weeks' gestation with isolated left-sided congenital diaphragmatic hernias. The lung-to-head ratio was measured with 3 different methods (longest diameter, anteroposterior diameter, and tracing). To eliminate the influence of gestational age, the observed-to-expected lung-to-head ratio was calculated. Receiver operating characteristic (ROC) curves were calculated for the statistical prediction of survival and need for ECMO therapy by the observed-to-expected lung-to-head ratio measured with the different methods. RESULTS For survival and ECMO necessity 118 and 102 cases (16 neonates were not eligible for ECMO) were assessed, respectively. For prediction of postpartum survival and ECMO necessity, the areas under the ROC curves and 95% confidence intervals showed very similar results for the 3 methods for prediction of survival (tracing, 0.8445 [0.7553-0.9336]; longest diameter, 0.8248 [0.7360-0.9136]; and anteroposterior diameter, 0.8002 [0.7075-0.8928]) and for ECMO necessity (tracing, 0.7344 [0.6297-0.8391]; longest diameter, 0.7128 [0.6027-0.8228]; and anteroposterior diameter, 0.7212 [0.6142-0.8281]). Comparisons between the areas under the ROC curves showed that the tracing method was superior to the anteroposterior diameter method in predicting postpartum survival (P = .0300). CONCLUSIONS Lung-to-head ratio and observed-to-expected lung-to-head ratio measurements were shown to accurately predict postnatal survival and the need for ECMO therapy in fetuses with left-sided congenital diaphragmatic hernias. Tracing the limits of the lungs seems to be the favorable method for calculating the fetal lung area.
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Affiliation(s)
- Sven Kehl
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
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Cordier AG, Cannie MM, Guilbaud L, De Laveaucoupet J, Martinovic J, Nowakowska D, Milejska-Lewandowska M, Rodó C, Viaris de Lesegno B, Votino C, Senat MV, Jani JC, Benachi A. Stomach position versus liver-to-thoracic volume ratio in left-sided congenital diaphragmatic hernia. J Matern Fetal Neonatal Med 2014; 28:190-5. [DOI: 10.3109/14767058.2014.906576] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kehl S, Eckert S, Berlit S, Tuschy B, Sütterlin M, Siemer J. New formulas for calculating the lung-to-head ratio in healthy fetuses between 20 and 40 weeks' gestation. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2013; 32:1939-1943. [PMID: 24154897 DOI: 10.7863/ultra.32.11.1939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES The purpose of this study was to develop new formulas for the expected fetal lung area-to-head circumference ratio in normal singleton pregnancies between 20 and 40 weeks' gestation. METHODS The lung-to-head ratio and complete fetal biometric parameters of 126 fetuses between 20 and 40 weeks' gestation were prospectively measured. The lung-to-head ratio was measured by 3 different methods (longest diameter, anteroposterior diameter, and tracing). Formulas for predicting right and left lung-to-head ratios with regard to gestational age and biometric parameters were derived by stepwise regression analysis. RESULTS New formulas for calculating right and left lung-to-head ratios by each measurement method were derived. The formulas included gestational age only and no biometric parameters. CONCLUSIONS The new formulas for estimating the expected lung-to-head ratio by the 3 different methods in normal singleton pregnancies up to 40 weeks' gestation may help improve the prognostic power of observed-to-expected lung-to-head ratio assessment in fetuses with congenital diaphragmatic hernias.
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Affiliation(s)
- Sven Kehl
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
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Kehl S, Becker L, Eckert S, Weiss C, Schaible T, Neff KW, Siemer J, Sütterlin M. Prediction of mortality and the need for neonatal extracorporeal membrane oxygenation therapy by 3-dimensional sonography and magnetic resonance imaging in fetuses with congenital diaphragmatic hernias. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2013; 32:981-988. [PMID: 23716519 DOI: 10.7863/ultra.32.6.981] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To compare different rotation angles for assessment of fetal lung volume by 3-dimensional (3D) sonography with magnetic resonance imaging (MRI) regarding prediction of mortality and the need for neonatal extracorporeal membrane oxygenation (ECMO) therapy in fetuses with congenital diaphragmatic hernias. METHODS One hundred patients with fetal congenital diaphragmatic hernias between 22 and 39 weeks' gestation were examined by 3D sonography and MRI. Sonographic contralateral fetal lung volumes were assessed by the rotational technique (virtual organ computer-aided analysis) at 3 different rotation angles: 6°, 15°, and 30°. The MRI fetal lung volumes were calculated based on multiplanar T2-weighted MRI. To eliminate the influence of gestational age, the observed to expected contralateral fetal lung volume on sonography and the observed to expected fetal lung volume on MRI were calculated. Receiver operating characteristic (ROC) curves were calculated for the statistical prediction of survival and need for ECMO therapy by the observed to expected contralateral fetal lung volume (sonography) and observed to expected fetal lung volume (MRI). RESULTS One hundred cases were assessed for survival and 89 for ECMO necessity (11 neonates were not eligible for ECMO). For prediction of postpartum survival and ECMO necessity, the areas under the ROC curves (AUCs) showed very similar results for MRI and 3D sonography: observed to expected fetal lung volume by MRI, 0.819 (95% confidence interval, 0.730-0.909) and 0.835 (0.748-0.922), respectively; 6° sonography, 0.765 (0.647-0.883) and 0.820 (0.734-0.905); 15° sonography, 0.784 (0.672-0.896) and 0.811 (0.719-0.903); and 30° sonography, 0.732 (0.609-0.855) and 0.772 (0.671-0.872). Comparisons between the AUCs revealed no statistical differences. CONCLUSIONS We have shown the good prognostic value of 3D sonography in fetuses with congenital diaphragmatic hernias compared with MRI, particularly when using small rotation angles. Therefore, it can be an appropriate diagnostic tool when counseling patients for congenital diaphragmatic hernias.
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Affiliation(s)
- Sven Kehl
- Department of Obstetrics and Gynecology, Mannheim University Medical Center, Mannheim, Germany.
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Vivanti A, Fargeon-Guez K, Fries N, Cordier AG, Benachi A. [Survey on the announcement of congenital diaphragmatic hernia by sonographers and evaluation of its prognosis]. J Gynecol Obstet Hum Reprod 2013; 42:282-289. [PMID: 23490408 DOI: 10.1016/j.jgyn.2012.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2012] [Revised: 11/05/2012] [Accepted: 12/05/2012] [Indexed: 06/01/2023]
Abstract
AIM Congenital diaphragmatic hernia (CDH) is a rare disease (1/3000 live births). Carriers display a diaphragmatic defect responsible for an impaired pulmonary development and physiology. The aim of this study was to evaluate the information given to couples whose fetus display a CDH and the current knowledge of French sonographers about this disease. MATERIALS AND METHODS A questionnaire was sent by email to 2000 sonographers, members of the French college of fetal ultrasonography, between May 1st and December 31st of 2010. RESULTS 20,7 % (414) of the sonographers answered. Twenty-four percent are second line sonographers. Thirty-eight percent did not diagnose any diaphragmatic hernia in the last five years (2005-2010) and 42 % diagnosed 1 or 2 during the same period. Information concerning the prognostic remains elusive and most sonographers rapidly referred patients to prenatal diagnostic centers. Fifty-nine percent of sonographer are not aware of the existence in France of a Centre for Rare Disease for CDH. CONCLUSION Accurate assessment of prognosis is essential to provide adequate information to couples and to help them make a decision on whether or not to perform an in utero treatment. The heterogenous results of the survey clearly show the disparities between sonographers on the type of information delivered. A better diffusion of prognostic evaluation in CDH, among sonographers is needed.
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Affiliation(s)
- A Vivanti
- Service de gynécologie obstétrique et médecine de la reproduction, université Paris Sud, hôpital Antoine-Béclère, 157, rue de la Porte-de-Trivaux, 92141 Clamart, France
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Debus A, Hagelstein C, Kilian AK, Weiss C, Schönberg SO, Schaible T, Neff KW, Büsing KA. Fetal Lung Volume in Congenital Diaphragmatic Hernia: Association of Prenatal MR Imaging Findings with Postnatal Chronic Lung Disease. Radiology 2013; 266:887-95. [DOI: 10.1148/radiol.12111512] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Jani JC, Peralta CFA, Nicolaides KH. Lung-to-head ratio: a need to unify the technique. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 39:2-6. [PMID: 22213615 DOI: 10.1002/uog.11065] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Aspelund G, Fisher JC, Simpson LL, Stolar CJH. Prenatal lung-head ratio: threshold to predict outcome for congenital diaphragmatic hernia. J Matern Fetal Neonatal Med 2011; 25:1011-6. [PMID: 21815746 DOI: 10.3109/14767058.2011.608442] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The literature suggests that lung-head ratio (LHR) and liver position may inconsistently predict outcome for congenital diaphragmatic hernia (CDH). We reviewed our inborn neonates with isolated left-sided CDH to determine whether these variables predicted survival and to estimate the optimal LHR threshold. METHODS Prenatal LHR and liver position were obtained from 2002 to 2009. The primary endpoint was survival. RESULTS LHR was greater in survivors after adjusting for gestational age (median 1.40 versus 0.81; p < 0.001). LHR demonstrated excellent diagnostic discrimination, with area under receiver operating characteristic (ROC) curve 0.93 (95% CI 0.86-0.99). LHR threshold of 1.0 was 83% sensitive and 91% specific in predicting survival. An optimal LHR threshold of 0.85 predicted survival with 95% sensitivity and 64% specificity, reducing false negatives (survivors with low LHR). LHR > 0.85 predicted survival after adjustment for gestational age (OR = 33.6, 95% CI = 5.4-209.5). Liver position did not predict survival. CONCLUSIONS Prenatal LHR >0.85 predicts survival for infants with isolated left-sided CDH without compromising discrimination of survivors from non-survivors. The diagnostic utility of LHR may be confounded by gestational age at measurement. Stringent LHR threshold may minimize false-negative attribution and improve utility of this measurement as predictor of survival.
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Affiliation(s)
- Gudrun Aspelund
- Division of Pediatric Surgery, Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia University Medical Center, New York, NY 10032, USA.
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Alfaraj MA, Shah PS, Bohn D, Pantazi S, O'Brien K, Chiu PP, Gaiteiro R, Ryan G. Congenital diaphragmatic hernia: lung-to-head ratio and lung volume for prediction of outcome. Am J Obstet Gynecol 2011; 205:43.e1-8. [PMID: 21529758 DOI: 10.1016/j.ajog.2011.02.050] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Revised: 12/02/2010] [Accepted: 02/14/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate observed/expected (O/E) lung-to-head ratio (LHR) by ultrasound (US) and total fetal lung volume (TFLV) by magnetic resonance imaging as neonatal outcome predictors in isolated fetal congenital diaphragmatic hernia (CDH). STUDY DESIGN We conducted a retrospective study of 72 fetuses with isolated CDH, in whom O/E LHR and TFLV were evaluated as survival predictors. RESULTS O/E LHR on US and O/E TFLV by magnetic resonance imaging were significantly lower in newborn infants with isolated CDH who died compared with survivors (30.3 ± 8.3 vs 44.2 ± 14.2; P < .0001 for O/E LHR; 21.9 ± 6.3 vs 41.5 ± 17.6; P = .001 for O/E TFLV). Area under receiver-operator characteristics curve for survival for O/E LHR was 0.80 (95% confidence interval, 0.70-0.90). On multivariate analysis, O/E LHR predicted survival, whereas hernia side and first neonatal pH did not. For each unit increase in O/E LHR, mortality odds decreased by 11% (95% confidence interval, 4-17%). CONCLUSION In fetuses with isolated CDH, O/E LHR (US) independently predicts survival and may predict severity, allowing management to be optimized.
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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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Prendergast M, Rafferty GF, Davenport M, Persico N, Jani J, Nicolaides K, Greenough A. Three-dimensional ultrasound fetal lung volumes and infant respiratory outcome: a prospective observational study. BJOG 2011; 118:608-14. [PMID: 21291507 DOI: 10.1111/j.1471-0528.2010.02841.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine if fetal lung volumes (FLVs), determined by three-dimensional rotational ultrasound and virtual organ computer-aided analysis software (vocal), correlated with neonatal respiratory outcomes in surviving infants who had a high risk [fetuses with congenital diaphragmatic hernia (CDH)], lower risk [fetuses with anterior wall defects (AWDs)] and no risk (controls) of abnormal antenatal lung growth. DESIGN Prospective observational study. SETTING Tertiary fetal medicine and neonatal intensive care units. POPULATION Sixty fetuses (25 with CDH, 25 with AWDs and ten controls). METHODS FLVs were measured and expressed as the percentage of the observed compared with the expected for gestational age. MAIN OUTCOME MEASURES Neonatal respiratory outcome was determined by the duration of supplemental oxygen, mechanical ventilation and dependencies, and assessment of lung volume using a gas dilution technique to measure functional residual capacity (FRC). RESULTS The infants with CDH had lower FLV results than both the infants with AWDs (P=0.05) and the controls (P<0.05). The infants with CDH had longer durations of mechanical ventilation (P<0.001) and supplementary oxygen (P<0.001) dependence, compared with infants with AWDs. The infants with CDH had a lower median FRC than both the infants with AWDs (P<0.001) and the controls (P<0.001). FLV results correlated significantly with the durations of dependency on ventilation (r= -0.744, P<0.01) and oxygen (r= -0.788, P<0.001), and with FRC results (r=0.429, P=0.001). CONCLUSIONS These results suggest that FLVs obtained using three-dimensional rotational ultrasound might be useful in predicting neonatal respiratory outcome in surviving infants who had varying risks of abnormal lung growth. Larger and more comprehensive studies are needed to clarify the role that lung volume measurements have in assessing lung function and growth.
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Affiliation(s)
- M Prendergast
- Division of Asthma, Allergy and Lung Biology, MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
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Peralta CFA, Sbragia L, Bennini JR, de Fátima Assunção Braga A, Sampaio Rousselet M, Machado Rosa IR, Barini R. Fetoscopic endotracheal occlusion for severe isolated diaphragmatic hernia: initial experience from a single clinic in Brazil. Fetal Diagn Ther 2011; 29:71-7. [PMID: 21325860 DOI: 10.1159/000314617] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Accepted: 04/20/2010] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To report on the initial experience in a single Brazilian university clinic of the use of fetoscopic endotracheal occlusion (FETO) to treat severe isolated congenital diaphragmatic hernia (CDH). METHODS The inclusion criteria for FETO for this prospective study were isolated CDH and intrathoracic herniation of the liver, as well as the lung area to head circumference ratio (LHR) <1.0. The main variables evaluated were LHR and observed to expected (o/e) LHR before and after FETO, gestational age (GA) at FETO, reversal of tracheal occlusion (TO), and birth and discharge of a living child from the hospital. RESULTS Among 8 isolated left-sided CDH cases with normal karyotypes, the median LHR and o/e LHR before FETO were 0.7 (range: 0.6-0.9) and 0.27 (range: 0.22-0.32), respectively. The median LHR and o/e LHR after FETO were 1.2 (range: 0.9-1.8) and 0.45 (0.31-0.67), respectively. The median GA at FETO, reversal of TO and birth were 26.8 (range: 26-29), 32.5 (range: 31.0-34.0) and 37 weeks (range: 35-37), respectively. Neonatal survival at the time of hospital discharge was 50% (4/8). CONCLUSION FETO is feasible at our institution and may help to improve postnatal survival of children with severe CDH in developing countries.
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Affiliation(s)
- Cleisson Fábio Andrioli Peralta
- Department of Obstetrics and Gynecology, Center for Integral Assistance to Women's Health, State University of Campinas Medical School, Campinas, Brazil. cfaperalta @ hotmail.com
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Diagnosis of Congenital Diaphragmatic Hernia. ACTA ACUST UNITED AC 2011. [DOI: 10.1007/174_2010_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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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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Cruz-Martinez R, Figueras F, Moreno-Alvarez O, Martinez JM, Gomez O, Hernandez-Andrade E, Gratacos E. Learning curve for lung area to head circumference ratio measurement in fetuses with congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2010; 36:32-36. [PMID: 20131334 DOI: 10.1002/uog.7577] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To assess the learning curve for the fetal lung area to head circumference ratio (LHR) calculation in fetuses with congenital diaphragmatic hernia (CDH). METHODS Three trainees with the theoretical knowledge, but without prior experience in the LHR measurement, were selected. Each trainee and one experienced examiner measured the observed to expected (O/E)-LHR in the lung contralateral to the side of the hernia by two methods-manual tracing of lung borders and multiplication of the longest diameters-in a cohort of 95 consecutive CDH fetuses. The average difference between the three trainees and the expert in the O/E-LHR measurement was calculated. A difference below 10% was considered to indicate an accurate measurement. The average learning curve was delineated using cumulative sum analysis (CUSUM). RESULTS The CUSUM plots demonstrate that the learning curve was achieved by 77 and 72 tests performed for the area obtained by the manual-tracing and multiplication-of-the-longest-diameter methods, respectively. CONCLUSION The minimum number of scans required for an inexperienced trainee to become competent in examining the LHR is on average 70.
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Affiliation(s)
- R Cruz-Martinez
- Fetal and Perinatal Medicine Research Group, Department of Maternal-Fetal Medicine, Hospital Clinic-IDIBAPS, University of Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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Yamamoto M, Ville Y. Fetal lung assessment in congenital diaphragmatic hernia: evidence for growth. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2010; 35:522-524. [PMID: 20443196 DOI: 10.1002/uog.7653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- M Yamamoto
- Unidad de Medicina Materno Fetal, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
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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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Taylor GA, Atalabi OM, Estroff JA. Imaging of congenital diaphragmatic hernias. Pediatr Radiol 2009; 39:1-16. [PMID: 18607585 DOI: 10.1007/s00247-008-0917-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2008] [Revised: 04/28/2008] [Accepted: 05/19/2008] [Indexed: 11/30/2022]
Abstract
Congenital diaphragmatic hernias are complex and life-threatening lesions that are not just anatomic defects of the diaphragm, but represent a complex set of physiologic derangements of the lung, the pulmonary vasculature, and related structures. Imaging plays an increasingly important role in the care of these infants. Prenatal sonography and MRI have allowed early and accurate identification of the defect and associated anomalies. These tools have also been the key to defining the degree of pulmonary hypoplasia and to predicting neonatal survival and need for aggressive respiratory rescue strategies. In the postnatal period, conventional radiography supplemented by cross-sectional imaging in selected cases can be very useful in sorting out the differential diagnosis of intrathoracic masses, in the detection of associated anomalies, and in the management of complications. Understanding the pathogenesis of diaphragmatic defects, the underlying physiologic disturbances, and the strengths and limitations of current imaging protocols is essential to the effective and accurate management of these complex patients.
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Affiliation(s)
- George A Taylor
- Department of Radiology, Children's Hospital Boston, Harvard Medical School, 300 Longwood Ave., Boston, MA 02115, USA.
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Büsing KA, Kilian AK, Schaible T, Dinter DJ, Neff KW. MR lung volume in fetal congenital diaphragmatic hernia: logistic regression analysis--mortality and extracorporeal membrane oxygenation. Radiology 2008; 248:233-9. [PMID: 18566175 DOI: 10.1148/radiol.2481070934] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To prospectively assess the results of logistic regression analysis that were based on magnetic resonance (MR) image fetal lung volume (FLV) measurements to predict survival and the corresponding need for extracorporeal membrane oxygenation (ECMO) therapy in fetuses with congenital diaphragmatic hernia (CDH) before and after 30 weeks gestation. MATERIALS AND METHODS Written informed consent was obtained and the study was approved by the local research ethics committee. FLV was measured on MR images in 95 fetuses (52 female neonates, 43 male neonates) with CDH between 22 and 39 weeks gestation by using multiplanar T2-weighted half-Fourier acquired single-shot turbo spin-echo MR imaging. On the basis of logistic regression analysis results, mortality and the need for ECMO therapy were calculated for fetuses before and after 30 weeks gestation. RESULTS Overall, higher FLV was associated with improved survival (P < .001) and decreasing probability of need for ECMO therapy (P = .008). Survival at discharge was 29.2% in neonates with an FLV of 5 mL, compared with 99.7% in neonates with an FLV of 25 mL. The corresponding need for ECMO therapy was 56.1% in fetuses with an FLV of 5 mL and 8.7% in fetuses with an FLV of 40 mL. Prognostic power was considerably lower before 30 weeks gestation. CONCLUSION Beyond 30 weeks gestation, logistic regression analysis that is based on MR FLV measurements is useful to estimate neonatal survival rates and ECMO requirements. Prior to 30 weeks gestation, the method is not reliable and the FLV measurement should be repeated, particularly in fetuses with small lung volumes, before a decision is made about therapeutic options.
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Affiliation(s)
- Karen A Büsing
- Department of Clinical Radiology, University Hospital Mannheim, University of Heidelberg, Theodor Kutzer Ufer 1-3, 68167 Mannheim, Germany.
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Büsing KA, Kilian AK, Schaible T, Endler C, Schaffelder R, Neff KW. MR Relative Fetal Lung Volume in Congenital Diaphragmatic Hernia: Survival and Need for Extracorporeal Membrane Oxygenation. Radiology 2008; 248:240-6. [DOI: 10.1148/radiol.2481070952] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Tsukimori K, Masumoto K, Morokuma S, Yoshimura T, Taguchi T, Hara T, Sakaguchi Y, Takahashi S, Wake N, Suita S. The lung-to-thorax transverse area ratio at term and near term correlates with survival in isolated congenital diaphragmatic hernia. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2008; 27:707-713. [PMID: 18424645 DOI: 10.7863/jum.2008.27.5.707] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE The purpose of this study was to determine how well liver position, the lung area-to-head circumference (L/H) ratio, and the lung-to-thorax transverse area (L/T) ratio predicted the need for extra-corporeal membrane oxygenation (ECMO) and survival in fetuses with isolated congenital diaphragmatic hernia (CDH). METHODS Antenatal records of 25 fetuses with isolated left-sided CDH who were born by cesarean delivery under fetal stabilization at this institution were reviewed. The latest determinations of the L/H and L/T ratios before birth (between 34 and 38 weeks' gestation) were compared on the basis of the cutoff points for mortality: less than 1.0 versus 1.0 or greater for the L/H ratio and 0.08 or less versus greater than 0.08 for the L/T ratio. Outcome measures assessed were survival (discharge to home) and the need for ECMO. RESULTS Overall survival was 64% (16/25). Postnatal survival in fetuses with an L/T ratio of 0.08 or less was statistically lower than in those with an L/T ratio of greater than 0.08 (33% versus 81%; P = .0308). The percentage requiring ECMO in the group with an L/T ratio of 0.08 or less was also higher than that of the group with an L/T ratio of greater than 0.08, but the difference was not statistically significant (67% versus 25%; P = .0872). Neither the L/H ratio nor herniation of the fetal liver into the chest affected survival or the need for ECMO. CONCLUSIONS In fetuses with isolated CDH at term or near term, the L/T ratio may be a better predictor of outcome than the L/H ratio or liver herniation.
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Affiliation(s)
- Kiyomi Tsukimori
- Department of Obstetrics and Gynecology, Kyushu University, Maidashi 3-1-1, Higashi-ku, Fukuoka 812, Japan.
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Büsing KA, Kilian AK, Schaible T, Debus A, Weiss C, Neff KW. Reliability and Validity of MR Image Lung Volume Measurement in Fetuses with Congenital Diaphragmatic Hernia and in Vitro Lung Models. Radiology 2008; 246:553-61. [DOI: 10.1148/radiol.2462062166] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Prediction of Mortality and Need for Neonatal Extracorporeal Membrane Oxygenation in Fetuses with Congenital Diaphragmatic Hernia: Logistic Regression Analysis Based on MRI Fetal Lung Volume Measurements. AJR Am J Roentgenol 2007; 189:1307-11. [DOI: 10.2214/ajr.07.2434] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Ba'ath ME, Jesudason EC, Losty PD. How useful is the lung-to-head ratio in predicting outcome in the fetus with congenital diaphragmatic hernia? A systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2007; 30:897-906. [PMID: 17963204 DOI: 10.1002/uog.5164] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVE Fetal surgery to improve lung growth comprises tracheal occlusion in selected 'high-risk' fetuses with congenital diaphragmatic hernia (CDH). Sonographically measured fetal lung-to-head ratio (LHR) is utilized to recruit candidates for fetal surgery. This study provides a meta-analysis of the evidence regarding the prognostic use of lung-to-head ratio measurements in fetal CDH. METHODS MEDLINE, SCOPUS and ISI PROCEEDINGS databases were searched for MeSH terms: lung, head, hernia and ratio. References in retrieved studies were also searched. Studies were categorized as follows: Phase I studies measured normal fetal LHR; Phase II studies compared fetal LHR in CDH survivors and non-survivors (if LHR informed therapy decisions or LHR was not measured during the window for intervention (< 32 weeks' gestation), studies were excluded); Phase III studies used LHR to guide selection for fetal surgery (non-randomized trials were excluded); Phase IV studies measured CDH survival before and after LHR application in clinical practice. RESULTS The one Phase I study showed that LHR varied substantially with gestation and technique. No complete studies met the selection criteria for Phase II: meta-analysis of subgroups revealed similar LHR in CDH survivors and non-survivors. A single Phase III study revealed no benefit for LHR-directed fetal surgery. No Phase IV studies were identified. CONCLUSION The prognostic use of LHR in fetal CDH entered clinical practice prior to publication of robust normal data and is not supported by current evidence. Application of a structured approach to any 'new' prognostic test could improve its validity and clinical application.
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Affiliation(s)
- M E Ba'ath
- Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK
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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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Beck C, Alkasi O, Nikischin W, Engler S, Caliebe A, Leuschner I, von Kaisenberg CS. Congenital diaphragmatic hernia, etiology and management, a 10-year analysis of a single center. Arch Gynecol Obstet 2007; 277:55-63. [PMID: 17680260 DOI: 10.1007/s00404-007-0407-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2007] [Accepted: 06/12/2007] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To analyze congenital diaphragmatic hernia (CDH) during a 10-year period at the University of Kiel, from 1995 through 2004, in order to develop a strategy to improve prenatal diagnosis, to be able to consider endoscopical treatment for selected cases and to assess the current postnatal treatment strategies. METHODS Data were obtained from the fetal medicine ultrasound department, from the birth registry, from the postmortem registry, from the neonatal intensive care unit, from pediatric surgery and from the genetic database. Data were subselected for chromosomes, genetic syndromes, for isolated CDH and for associated anomalies, the lung to head ratio and lung volumes were assessed. Data were analyzed respectively for gestation at diagnosis, the type of CDH, the perinatal management and the postnatal outcome. RESULTS There were 29 cases of CDH, in 10/29 (34%) the parents requested termination of pregnancy of which two had already died during pregnancy, 12/19 (63%) survived, which was defined as discharge from the neonatal intensive care unit, seven newborns 7/19 (37%) died in the hospital, 5 of these 5/7 (71%) were delivered in Kiel. A prenatal diagnosis was performed in 16/29 (55%), 1/16 (6%), 7/16 (43%) and 8/16 (50%) in the 1st, 2nd and 3rd trimester, respectively; in 10/29 (34%) diagnosis was performed postpartum, in 3/29 (10%) the diagnosis was performed at autopsy following termination of pregnancy. When the liver was in the abdomen, 9/10 (90%) of the children survived, compared to only 3/8 (43%) when the liver was located in the thorax. A lung to head ratio of 0.81 at 24 weeks resulted in death due to pulmonary hypoplasia. CONCLUSIONS The overall survival in CDH is around 50%, antenatal endoscopical therapy may only be considered, if the diagnosis is performed in the early second trimester, and selection criteria such as the lung to head ratio, associated defects and the chromosomal status can be applied.
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MESH Headings
- Abortion, Induced
- Autopsy
- Chromosomes, Human, Pair 18
- Female
- Fetal Death
- Germany/epidemiology
- Hernia, Diaphragmatic/diagnosis
- Hernia, Diaphragmatic/mortality
- Hernia, Diaphragmatic/therapy
- Hernias, Diaphragmatic, Congenital
- Hospital Mortality
- Humans
- Infant, Newborn
- Intensive Care Units, Neonatal
- Karyotyping
- Liver/abnormalities
- Lung Volume Measurements
- Pregnancy
- Pregnancy Trimesters
- Prenatal Diagnosis
- Trisomy
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Affiliation(s)
- Cornelia Beck
- Department of Obstetrics and Gynecology, University of Schleswig-Holstein, Campus Kiel, Michaelisstrasse 16, Kiel, Germany
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Yang SH, Nobuhara KK, Keller RL, Ball RH, Goldstein RB, Feldstein VA, Callen PW, Filly RA, Farmer DL, Harrison MR, Lee H. Reliability of the lung-to-head ratio as a predictor of outcome in fetuses with isolated left congenital diaphragmatic hernia at gestation outside 24-26 weeks. Am J Obstet Gynecol 2007; 197:30.e1-7. [PMID: 17618746 DOI: 10.1016/j.ajog.2007.01.016] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2006] [Revised: 10/31/2006] [Accepted: 01/16/2007] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate the relationship between lung-to-head ratio (LHR) and gestational age (GA) in fetuses with isolated left congenital diaphragmatic hernia and to determine the applicability and reliability of LHR to predict postnatal outcome beyond 24-26 weeks of gestation. STUDY DESIGN The institutional review board approved this retrospective review of the University of California, San Francisco, Fetal Treatment Center database for cases with left congenital diaphragmatic hernia who were referred between March 1995 and June 2004. LHR was determined at the initial evaluation. One hundred seven live-born fetuses at 20-34 weeks of gestation (excluding cases that were lost to follow-up, with factors that potentially could influence the LHR measurement or postnatal outcome, or that were terminated electively). RESULTS The median GA at LHR measurement was 25.6 weeks; the median LHR was 1.01; the median GA at birth was 37.7 weeks; and the overall survival rate was 59% (64/107). The median LHR of nonsurvivors was significantly lower than that of survivors, but neither GA at LHR measurement nor at delivery was significantly different between the groups. Multiple logistic regression analysis confirmed LHR to be an independent predictor of postnatal survival, and receiver-operator characteristic curve analysis demonstrated that an LHR of > or = 0.97 has the highest performance in predicting postnatal survival. When fetuses were grouped by GA at initial LHR measurement to determine reliability of LHR, specifically with respect to GA, in the 26-34 and 24-26 weeks of gestation groups, median LHR of survivors was significantly higher than that of nonsurvivors, and receiver-operator characteristic curve analysis confirmed LHR to be a reliable predictor of postnatal survival. However, for fetuses at 20-24 weeks of gestation, there was a trend toward a higher LHR in survivors, although this did not reach statistical significance. CONCLUSION A significant positive linear relationship exists between LHR and GA at the time of measurement, such that LHR reliably predicts postnatal survival in fetuses with left congenital diaphragmatic hernia at 24-34 weeks of gestation and less reliable at 20-24 weeks. However, given the limitations of a retrospective, cross-sectional study, further prospective longitudinal studies that will investigate the change of LHR with GA and its association with fetal outcome are necessary.
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Affiliation(s)
- Soon Ha Yang
- Fetal Treatment Center, University of California, San Francisco, San Francisco, CA 94143-0570, USA
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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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Abstract
Ultrasonography is the screening method of choice for the evaluation of the fetus. It is safe, inexpensive, and easily performed. However, it is operator dependent, and evaluation may be limited because of fetal position, maternal obesity, overlying bone, and/or oligohydramnios. Magnetic resonance imaging is an alternative modality that uses no ionizing radiation, has excellent tissue contrast and a large field of view, is not limited by obesity or overlying bone, and can image the fetus in multiple planes, no matter the fetal lie. Faster scanning techniques allow studies to be performed without sedation in the second and third trimester with minimal motion artifact.
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Affiliation(s)
- Dorothy Bulas
- Department of Diagnostic Imaging and Radiology, Children's National Medical Center, George Washington University School of Medicine, Washington, DC 20010, USA.
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Barnewolt CE, Kunisaki SM, Fauza DO, Nemes LP, Estroff JA, Jennings RW. Percent predicted lung volumes as measured on fetal magnetic resonance imaging: a useful biometric parameter for risk stratification in congenital diaphragmatic hernia. J Pediatr Surg 2007; 42:193-7. [PMID: 17208564 DOI: 10.1016/j.jpedsurg.2006.09.018] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE This study was aimed at determining whether a new method of analyzing lung volumes on fetal magnetic resonance (MR) imaging could be used to predict the degree of pulmonary compromise in congenital diaphragmatic hernia (CDH). METHODS Seventeen fetuses with CDH were prospectively evaluated by MR. Lung volumes were measured using an established technique and expressed as a percentage of the predicted lung volume (PPLV). Predicted lung volume was determined by subtracting measured mediastinal volume from total measured thoracic volume. The PPLV was correlated with postnatal outcomes. Statistical analyses were performed using the Mann-Whitney, Spearman correlation, or Fisher exact tests (P < .05). RESULTS Of the 14 liveborn patients, the PPLV was 20.3+/-10.4 (gestational age at MR, 22.3 +/- 5.7 weeks). The PPLV was significantly associated with extracorporeal membrane oxygenation (ECMO) use, hospital length of stay, and survival. All patients with a PPLV of less than 15 required prolonged ECMO support and had a 40% survival rate. In contrast, only 11% of patients with a PPLV of greater than 15 required ECMO, and survival was 100%. CONCLUSION The PPLV as measured by fetal MR imaging can accurately predict disease severity in CDH. A value of less than 15 is associated with a significantly higher risk for prolonged support and/or death, despite aggressive postnatal management.
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Affiliation(s)
- Carol E Barnewolt
- Department of Radiology, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
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Affiliation(s)
- Ruth B Goldstein
- Division of Ultrasound, Department of Radiology, University of California, San Francisco, CA 94143-0628, USA.
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Jani J, Peralta CFA, Van Schoubroeck D, Deprest J, Nicolaides KH. Relationship between lung-to-head ratio and lung volume in normal fetuses and fetuses with diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2006; 27:545-50. [PMID: 16586473 DOI: 10.1002/uog.2735] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
OBJECTIVE To examine the relationship between the fetal lung area and lung area to head circumference ratio (LHR) and lung volume by three-dimensional (3D) ultrasonography in normal fetuses and in fetuses with unilateral congenital diaphragmatic hernia (CDH). METHODS In 64 fetuses with CDH at median 26 (range, 20-32) weeks of gestation the contralateral lung volume, lung area and LHR were measured and the values were compared to those of 650 normal fetuses at 12-32 weeks. In the normal fetuses both lungs were assessed but in the 64 fetuses with CDH only the contralateral lung was measured because the ipsilateral lung could be visualized adequately in only 40 (62.5%) of the cases. Regression analysis was used to assess the significance of the association between lung volume and lung area or LHR. In the fetuses with CDH, the observed to expected ratios for lung area and LHR were calculated. The expected lung area and LHR were the normal median for a given lung volume. The significance of the differences between the observed to expected lung area and LHR in fetuses with CDH and normal fetuses was determined. In the 64 fetuses with CDH and in 64 normal fetuses, matched for gestational age, the lung length between the apex and the superior aspect of the diaphragm dome was also recorded. RESULTS In normal fetuses the median lung area and LHR in both the left and right lungs increased significantly with lung volume. In the fetuses with CDH, the lung area and lung volume for gestation were substantially lower than in normal fetuses and the ratios of observed to expected lung area and LHR for a given lung volume were significantly lower than the respective values in normal fetuses. Additionally, the mean lung length was 13% greater and the mean lung area was 44% smaller than the respective values in the normal controls matched for gestational age. CONCLUSIONS The finding of a significant association between LHR and lung volume has validated the use of LHR in the assessment of lung growth. However, the study has also demonstrated that in fetuses with CDH, LHR underestimates the actual lung volume, because the herniated viscera cause a greater lateral, rather than vertical, compression of the contralateral lung.
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Affiliation(s)
- J Jani
- University Hospital Gasthuisberg, Leuven, Belgium
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Jani J, Gratacós E, Greenough A, Pieró JL, Benachi A, Harrison M, Nicolaïdes K, Deprest J. Percutaneous fetal endoscopic tracheal occlusion (FETO) for severe left-sided congenital diaphragmatic hernia. Clin Obstet Gynecol 2006; 48:910-22. [PMID: 16286838 DOI: 10.1097/01.grf.0000184774.02793.0c] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- J Jani
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, University Hospital Gasthuisberg, Leuven, Belgium
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Jani J, Keller RL, Benachi A, Nicolaides KH, Favre R, Gratacos E, Laudy J, Eisenberg V, Eggink A, Vaast P, Deprest J. Prenatal prediction of survival in isolated left-sided diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2006; 27:18-22. [PMID: 16374756 DOI: 10.1002/uog.2688] [Citation(s) in RCA: 143] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To investigate the potential value of antenatally determined intrathoracic herniation of the liver and the ratio of fetal lung area to head circumference (LHR) in the prediction of postnatal survival in isolated, left-sided congenital diaphragmatic hernia (CDH). METHODS In this multicenter study, we searched the antenatal-CDH-Registry for fetuses with isolated left-sided CDH that were liveborn after 30 weeks of gestation and were followed up postnatally for at least 3 months after discharge from hospital. The patients were subdivided into those with and those without intrathoracic herniation of the liver and into subgroups according to the LHR that had been measured between 22 + 0 and 28 + 0 weeks of gestation. The rate of survival in each group and subgroup of patients was determined and compared. RESULTS The registry search identified 184 patients that fulfilled the entry criteria. Logistic regression analysis demonstrated that significant predictors of survival were the presence or absence of intrathoracic herniation of the liver and the LHR. In 86 cases there was liver herniation (Group A) and in 98 the liver was confined to the abdomen (Group B). In Group A, the survival rate was 50.0% and was significantly associated with LHR; in Group B the survival rate was 76.5% and was unrelated to LHR. CONCLUSION In isolated, left-sided CDH, the postnatal mortality rate is substantially higher if there is intrathoracic herniation of the liver. In fetuses with liver herniation, measurement of LHR at 22-28 weeks of gestation is useful in the prediction of subsequent survival.
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Affiliation(s)
- J Jani
- Fetal Medicine and Treatment Units of the University Hospital Gasthuisberg, Leuven, Belgium
| | - R L Keller
- Fetal Medicine and Treatment Units of the University of California at San Francisco, San Francisco, CA, USA
| | - A Benachi
- Fetal Medicine and Treatment Units of the Hôpital Necker-Enfants Malades, Paris, France
| | - K H Nicolaides
- Fetal Medicine and Treatment Units of the King's College Hospital, London, UK
| | - R Favre
- Fetal Medicine and Treatment Units of the CMCO de Schiltigheim, Strasbourg, France
| | - E Gratacos
- Fetal Medicine and Treatment Units of the Vall d'Hebron Hospital, Barcelona, Spain
| | - J Laudy
- Fetal Medicine and Treatment Units of the Erasmus Medical Center, Rotterdam, The Netherlands
| | - V Eisenberg
- Fetal Medicine and Treatment Units of the Sheba Medical Center, Tel Hashomer, Israel
| | - A Eggink
- Fetal Medicine and Treatment Units of the UMC Sint Radboud, Nijmegen, The Netherlands
| | - P Vaast
- Fetal Medicine and Treatment Units of the Hôpital Jeanne de Flandre, CHRU Lille, France
| | - J Deprest
- Fetal Medicine and Treatment Units of the University Hospital Gasthuisberg, Leuven, Belgium
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Peralta CFA, Cavoretto P, Csapo B, Vandecruys H, Nicolaides KH. Assessment of lung area in normal fetuses at 12-32 weeks. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2005; 26:718-24. [PMID: 16308896 DOI: 10.1002/uog.2651] [Citation(s) in RCA: 142] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To establish reference intervals with gestation for the right and left lung areas and lung area to head circumference ratio (LHR). METHODS This was a cross-sectional study of 650 normal singleton pregnancies at 12-32 weeks of gestation. We measured the left and right lung areas on the cross-sectional plane of the thorax, used for examination of the four-chamber view of the heart, by three different techniques: firstly, manual tracing of the limits of the lungs; secondly, multiplication of the longest diameter of the lung by its longest perpendicular diameter; thirdly, multiplication of the anteroposterior diameter of the lung at the mid-clavicular line by the perpendicular diameter at the midpoint of the anteroposterior diameter. RESULTS The respective mean left and right lung areas (manual tracing) increased with gestational age, from 36 and 58 mm(2) at 12 weeks to 220 and 325 mm(2) at 20 weeks and 594 and 885 mm(2) at 32 weeks. This 16-fold increase in lung area was accompanied by a four-fold increase in head circumference. Consequently, the left and right LHR increased with gestational age. The most reproducible way of measuring the lung area was by manual tracing of the limits of the lungs and the least reproducible was by multiplying the longest diameter of the lungs by their longest perpendicular diameter. Furthermore, the method employing the longest diameter, compared with the tracing method, overestimated both the left and the right lung areas by about 45% and the method employing the anteroposterior diameter overestimated the area of the right lung by about 35%, but not that of the left lung. CONCLUSIONS In the antenatal prediction of pulmonary hypoplasia by the assessment of lung area it is important to take gestational age into account. Dividing the lung area by the head circumference does not correct for the gestation-related increase in lung area. Reproducible measurement of the lung area is provided by manual tracing of the limits of the lungs, rather than by multiplication of lung diameters.
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Affiliation(s)
- C F A Peralta
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital Medical School, London, UK
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Ruano R, Martinovic J, Dommergues M, Aubry MC, Dumez Y, Benachi A. Accuracy of fetal lung volume assessed by three-dimensional sonography. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2005; 26:725-30. [PMID: 16308897 DOI: 10.1002/uog.2624] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To determine the accuracy and precision of prenatal three-dimensional (3D) ultrasound in estimating fetal lung volume using the rotational multiplanar technique (VOCAL) by comparing it to postmortem volume measurements. METHODS Fetal lung volume was measured during 3D ultrasound examination using a rotational multiplanar technique in eight cases of congenital diaphragmatic hernia (CDH) (six left and two right-sided) and in 25 controls without pulmonary malformation, immediately before termination. Prenatal 3D sonographic estimates of fetal lung volume were compared with postmortem measurement of fetal lung volume achieved by water displacement. RESULTS The intraclass correlation coefficient of fetal lung volume estimated by 3D ultrasound and measured at postmortem examination was 0.95 in CDH cases and 0.99 in controls. Based on Bland-Altman analysis, the bias, precision and limits of agreement were, respectively, 0.35 cm(3), 1.46 cm(3) and between -2.51 and + 3.21 cm(3) in cases with CDH and 0.08 cm(3), 2.80 cm(3) and between -5.41 and + 5.57 cm(3) in controls. The mean relative error of 3D ultrasound fetal lung volume measurement was -7.19% (from -42.70% to + 18.11%) in CDH cases and -0.72% (from -30.25% to + 19.22%) in controls, while the mean absolute error of 3D ultrasound fetal lung volume measurement was 1.40 (range, 0.71-2.52) cm(3) and 2.12 (range, 0.05-4.98) cm(3), respectively. Accuracy of 3D ultrasound for measuring fetal lung volumes was 84.86 (range, 57.30-99.48)% in cases with CDH and 91.38 (range, 69.75-99.45)% in controls. The mean intraobserver variability for lung volume estimated by 3D ultrasound was 0.28 cm(3) in controls and 0.17 cm(3) in CDH cases. CONCLUSION Prenatal 3D ultrasound can estimate accurately fetal lung volume using the rotational multiplanar technique for volume measurements (VOCAL), even in fetuses with very small lungs, such as cases with isolated CDH.
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Affiliation(s)
- R Ruano
- Maternité, Hôpital Necker-Enfants Malades, AP-HP, Université Paris V, Paris, France.
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Congenital diaphragmatic hernia: an evaluation of the prognostic value of the lung-to-head ratio. J Med Ultrason (2001) 2005; 32:115-9. [DOI: 10.1007/s10396-005-0040-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2004] [Accepted: 03/18/2005] [Indexed: 10/25/2022]
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Heling KS, Wauer RR, Hammer H, Bollmann R, Chaoui R. Reliability of the lung-to-head ratio in predicting outcome and neonatal ventilation parameters in fetuses with congenital diaphragmatic hernia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2005; 25:112-118. [PMID: 15660446 DOI: 10.1002/uog.1837] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVES The ratio of the lung area (on the contralateral side of the hernia) to the head circumference, the lung-to-head ratio (LHR), has been proposed as a reliable tool in the assessment of the prognosis of congenital diaphragmatic hernia (CDH). An LHR < 0.6 has been associated with poor outcome whereas one > 1.4 has been associated with survival. We aimed to analyze the role of LHR in predicting fetal outcome and ventilation parameters in cases of isolated CDH in our center. METHODS During the 40-month study period, 22 fetuses with an isolated CDH were delivered alive under optimized conditions at our perinatal center. LHR was measured at the time of diagnosis (median, 27 weeks' gestation). In addition to survival, postnatal ventilation parameters including pCO2, pO2, inspiratory O2 partial pressure, inspiratory pressure and oxygenation index were determined, as was the occurrence of pulmonary hypertension. RESULTS The overall survival rate was 59%. The LHR was not able to predict fetal outcome reliably. There was no correlation between the liver herniation, LHR and fetal outcome. The prenatally determined lung size reflected in the LHR did not show any significant association with individual ventilation parameters. Eleven of 17 infants examined had signs of pulmonary hypertension and the LHR did not predict this condition. CONCLUSION Our study cannot support the optimistic results reported by other groups on the use of LHR as a reliable predictor of outcome in fetuses with CDH. The LHR, as a reflection of lung size, correlates neither with survival patterns nor with various postnatal ventilation parameters.
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Affiliation(s)
- K S Heling
- Fetal Medicine Unit, Department of Gynaecology and Obstetrics, Charité Hospital, Humboldt-Universität, Germany.
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Paddock H, Beierle EA, Chen MK, Mullett T, Wood CM, Kays DW, Langham MR. Administration of prenatal betamethasone suppresses the adrenal-hypophyseal axis in newborns with congenital diaphragmatic hernia. J Pediatr Surg 2004; 39:1176-82. [PMID: 15300522 DOI: 10.1016/j.jpedsurg.2004.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is a condition that is characterized by pulmonary hypoplasia and pulmonary hypertension. Prenatal betamethasone often is administered to fetuses with CDH to improve pulmonary function. In this study, the authors investigate the possible role of the adrenal-hypophyseal axis in CDH in an animal model and subsequently in human infants with CDH. METHODS Twin fetal sheep underwent creation of DH or a sham thoracotomy, and levels of plasma and lung ACTH and plasma cortisol were compared. For the human studies, plasma levels of ACTH, cortisol, and DHEA were measured in cord blood samples collected from 9 CDH (5 that received prenatal betamethasone) and compared with those of 14 normal newborns. In both studies, ACTH and cortisol levels were determined by radioimmunoassay (RIA). Human (DHEA) levels were determined by ELISA. RESULTS Plasma ACTH and cortisol levels were elevated in fetal DH sheep compared with sham-operated controls; however, levels of ACTH in lung tissues were not different. Human newborns with CDH who have been exposed to prenatal steroids have significantly lower plasma ACTH, cortisol, and DHEA levels than normal newborns and CDH newborns not exposed to prenatal betamethasone. CONCLUSIONS In an ovine model of CDH, the adrenal-hypophyseal axis appears up-regulated in DH fetuses compared with sham-operated animals. Conversely, the adrenal-hypophyseal axis in human CDH newborns appears normal but is suppressed by the administration of prenatal betamethasone.
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MESH Headings
- Adrenocorticotropic Hormone/analysis
- Adrenocorticotropic Hormone/blood
- Adult
- Animals
- Animals, Newborn
- Apgar Score
- Betamethasone/pharmacology
- Betamethasone/therapeutic use
- Disease Models, Animal
- Female
- Fetal Blood/chemistry
- Fetal Diseases/drug therapy
- Fetal Diseases/physiopathology
- Gestational Age
- Hernia, Diaphragmatic/blood
- Hernia, Diaphragmatic/drug therapy
- Hernia, Diaphragmatic/embryology
- Hernia, Diaphragmatic/mortality
- Hernia, Diaphragmatic/physiopathology
- Hernias, Diaphragmatic, Congenital
- Humans
- Hydrocortisone/blood
- Infant, Newborn
- Lung/chemistry
- Lung/embryology
- Pituitary-Adrenal System/drug effects
- Pituitary-Adrenal System/physiopathology
- Pregnancy
- Sheep
- Survival Rate
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Affiliation(s)
- Heather Paddock
- Department of Surgery, University of Florida School of Medicine, Shands at Jacksonville, Jacksonville, FL, USA
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Abstract
The ability to identify and confidently diagnose a wide range of congenital fetal thoracic lesions has increased tremendously in the past 2 decades with the emergence of high-resolution sonography and ultrafast MRI sequences. Imaging studies constitute a vital component in the diagnosis of these lesions, whether in the fetal, neonatal or childhood periods. In addition to providing a road map for potential intervention, imaging techniques have provided important information about normal development, natural history, and prognosis. In the prenatal stage, these features aid in family counseling, pregnancy management, and the identification of a subgroup of patients who may benefit from fetal intervention. In the neonatal and childhood periods, imaging studies facilitate timely diagnosis and institution of appropriate therapeutic strategies.
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Affiliation(s)
- Ann M Johnson
- Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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