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Park SH, Kim JY, Seol KH, Roh JH, Lee HN, Kim SH, Jeong J, Namgoong JM, Lee BS, Jung E. Pulmonary Artery Measurements as Postnatal Prognostic Tool in Right Congenital Diaphragmatic Hernia. J Pediatr Surg 2024; 59:1077-1082. [PMID: 38168548 DOI: 10.1016/j.jpedsurg.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Right-sided congenital diaphragmatic hernia (RCDH) is a rare and often fatal congenital anomaly, primarily attributed to lung hypoplasia, which is associated with small branch pulmonary artery (PA). This study investigated whether postnatal PA measurements obtained through echocardiography are associated with mortality or the extracorporeal membrane oxygenation (ECMO) requirement in neonates with RCDH. METHODS A retrospective study was conducted on neonates with RCDH born between 2008 and 2022. Echocardiography was performed on the day of birth. The diameter of the main PA (MPA) was measured at the maximal dimension, and the diameters of the left PA (LPA) and right PA (RPA) were measured at the bifurcation. The primary outcome was mortality or ECMO requirement. Parameters, including the LPA:MPA ratio, RPA:MPA ratio, Nakata index, McGoon ratio, and ejection fraction (EF), were analyzed and compared with the observed-to-expected lung-to-head ratio (o/e LHR), initial blood gas, and defect size as predictive values. RESULTS Among 39 neonates with RCDH, 25 (64.1 %) survived without ECMO. The non-survivor or ECMO group exhibited lower o/e LHR, reduced EF, smaller LPA and RPA diameters, and larger MPA diameter than survivors. Lower LPA:MPA ratio, Nakata index, McGoon ratio, and higher initial PaCO2 were associated with adverse outcomes. Notably, the LPA:MPA ratio showed the highest predictive capability (area under the curve, 0.983; p < 0.001). CONCLUSION The LPA:MPA ratio is a promising postnatal predictor of mortality or ECMO requirement in neonates with RCDH. Additionally, Nakata index, McGoon ratio, and initial PaCO2 are significantly correlated with outcomes. LEVEL OF EVIDENCE This is a level III. TYPE OF STUDY Prognostic study.
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Affiliation(s)
- Sung Hyeon Park
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji Yoo Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Keon Hee Seol
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Joo Hyung Roh
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ha Na Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Soo Hyun Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jiyoon Jeong
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung-Man Namgoong
- Department of Pediatric Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Byong Sop Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Euiseok Jung
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Puligandla P, Skarsgard E, Baird R, Guadagno E, Dimmer A, Ganescu O, Abbasi N, Altit G, Brindle M, Fernandes S, Dakshinamurti S, Flageole H, Hebert A, Keijzer R, Offringa M, Patel D, Ryan G, Traynor M, Zani A, Chiu P. Diagnosis and management of congenital diaphragmatic hernia: a 2023 update from the Canadian Congenital Diaphragmatic Hernia Collaborative. Arch Dis Child Fetal Neonatal Ed 2024; 109:239-252. [PMID: 37879884 DOI: 10.1136/archdischild-2023-325865] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/02/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE The Canadian Congenital Diaphragmatic Hernia (CDH) Collaborative sought to make its existing clinical practice guideline, published in 2018, into a 'living document'. DESIGN AND MAIN OUTCOME MEASURES Critical appraisal of CDH literature adhering to Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Evidence accumulated between 1 January 2017 and 30 August 2022 was analysed to inform changes to existing or the development of new CDH care recommendations. Strength of consensus was also determined using a modified Delphi process among national experts in the field. RESULTS Of the 3868 articles retrieved in our search that covered the 15 areas of CDH care, 459 underwent full-text review. Ultimately, 103 articles were used to inform 20 changes to existing recommendations, which included aspects related to prenatal diagnosis, echocardiographic evaluation, pulmonary hypertension management, surgical readiness criteria, the type of surgical repair and long-term health surveillance. Fifteen new CDH care recommendations were also created using this evidence, with most related to the management of pain and the provision of analgesia and neuromuscular blockade for patients with CDH. CONCLUSIONS The 2023 Canadian CDH Collaborative's clinical practice guideline update provides a management framework for infants and children with CDH based on the best available evidence and expert consensus.
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Affiliation(s)
- Pramod Puligandla
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Erik Skarsgard
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Baird
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Elena Guadagno
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Alexandra Dimmer
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Olivia Ganescu
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Nimrah Abbasi
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gabriel Altit
- Neonatology, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Mary Brindle
- Department of Surgery, Section of Pediatric Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Sairvan Fernandes
- Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shyamala Dakshinamurti
- Department of Pediatrics and Child Health, Section of Neonatology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Helene Flageole
- Department of Pediatric Surgery, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Audrey Hebert
- Department of Pediatrics, Division of Neonatology, Laval University, Quebec City, Quebec, Canada
| | - Richard Keijzer
- Department of Pediatric Surgery and Manitoba Institute of Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Dylan Patel
- Department of Pediatric Surgery, Harvey E. Beardmore Division of Pediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Greg Ryan
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Ontario Fetal Centre, Toronto, Ontario, Canada
| | - Michael Traynor
- Department of Anesthesia, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Augusto Zani
- Department of Surgery, Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Priscilla Chiu
- Department of Surgery, Division of Pediatric General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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3
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Tartaglia S, Paciullo C, Visconti D, Lanzone A, De Santis M. Cardiovascular Effects of a Thoracoamniotic Shunt in a Fetus Affected by Isolated Right Congenital Diaphragmatic Hernia and Hydrops. Cureus 2024; 16:e54279. [PMID: 38371432 PMCID: PMC10870193 DOI: 10.7759/cureus.54279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 02/20/2024] Open
Abstract
A thoracoamniotic shunt was placed in a fetus affected by a right congenital diaphragmatic hernia (RCDH) complicated by voluminous nonimmune hydrops (NIH) at 30 weeks of gestation. The fetus showed congestive cardiac failure with a combined cardiac output (CCO) of 460.7 ml/min (Z-score: -1.2). After seven days, no edema, ascites, or pleural effusion was present. CCO increased significantly, reaching a Z-score of -0.2, as well as right and left cardiac output (Z-scores: -0.3 and -0.8, respectively). Two weeks later, the cardiac function and the ascites got worse despite the correct shunt placement, suggesting a possible occlusion. At 33 weeks, a C-section was performed due to labor in breech presentation. Despite the intensive care provided, the newborn died due to pulmonary hypertension and respiratory insufficiency. The thoracoamniotic shunt's effect on fetal circulation and the mechanisms of NIH in the event of RCDH are still unclear. Due to the high mortality rate of this condition and its poorer outcomes compared to left-sided defects, shunting cannot be considered an efficient attempt to improve fetal and neonatal survival rates to date. A close relationship between the amount of lymphatic effacement and cardiac function is clear, but further studies are needed to provide more information about this severe condition and its treatment.
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Affiliation(s)
- Silvio Tartaglia
- Department of Women's and Children's Health Sciences and Public Health, Fondazione Policlinico Universitario Agostino Gemelli Istituto Di Ricovero e Cura a Carattere Scientifico (IRCSS), Rome, ITA
| | - Carmela Paciullo
- Department of Gynecology and Obstetrics, Università Cattolica del Sacro Cuore, Rome, ITA
| | - Daniela Visconti
- Department of Women's and Children's Health Sciences and Public Health, Fondazione Policlinico Universitario Agostino Gemelli Istituto Di Ricovero e Cura a Carattere Scientifico (IRCSS), Rome, ITA
| | - Antonio Lanzone
- Department of Women's and Children's Health Sciences and Public Health, Fondazione Policlinico Universitario Agostino Gemelli Istituto Di Ricovero e Cura a Carattere Scientifico (IRCSS), Rome, ITA
| | - Marco De Santis
- Department of Women's and Children's Health Sciences and Public Health, Fondazione Policlinico Universitario Agostino Gemelli Istituto Di Ricovero e Cura a Carattere Scientifico (IRCSS), Rome, ITA
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4
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Tho ALW, Rath CP, Tan JKG, Rao SC. Prevalence of symptomatic tracheal morbidities after fetoscopic endoluminal tracheal occlusion: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2023; 109:52-58. [PMID: 37419685 DOI: 10.1136/archdischild-2023-325525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/21/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Fetoscopic endoluminal tracheal occlusion (FETO) has been shown to improve survival of infants with congenital diaphragmatic hernia (CDH). However, there are concerns that FETO may lead to tracheomegaly, tracheomalacia and related complications. METHODS A systematic review was conducted to estimate the prevalence of symptomatic tracheal complications in infants who underwent FETO for CDH. Presence of one or more of the following was considered as tracheal complication: tracheomalacia, stenosis, laceration or tracheomegaly with symptoms such as stridor, effort-induced barking cough, recurrent chest infections or the need for tracheostomy, tracheal suturing, or stenting. Isolated tracheomegaly on imaging or routine bronchoscopy without clinical symptoms was not considered as tracheal morbidity. Statistical analysis was performed using the metaprop command on Stata V.16.0. RESULTS A total of 10 studies (449 infants) were included (6 retrospective cohort, 2 prospective cohort and 2 randomised controlled trials). There were 228 infants who survived to discharge. Prevalence rates of tracheal complications in infants born alive were 6% (95% CI 2% to 12%) and 12% (95% CI 4% to 22%) in those who survived to discharge. The spectrum of severity ranged from relatively mild symptoms such as effort-induced barking cough to the need for tracheostomy/tracheal stenting. CONCLUSION A significant proportion of FETO survivors have symptomatic tracheal morbidities of varying severity. Units that are planning to adopt FETO for managing CDH should consider ongoing surveillance of survivors to enable early identification of upper airway issues. Inventing FETO devices that minimise tracheal injury is needed.
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Affiliation(s)
- Adam Lye Wye Tho
- Neonatology, King Edward Memorial Hospital Neonatal Clinical Care Unit, Subiaco, Western Australia, Australia
- Neonatal Intensive Care Unit, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Chandra Prakash Rath
- Neonatology, King Edward Memorial Hospital Neonatal Clinical Care Unit, Subiaco, Western Australia, Australia
- Neonatal Intensive Care Unit, Perth Children's Hospital, Nedlands, Western Australia, Australia
- Medical School, University of Western Australia, Crawley, Western Australia, Australia
| | - Jason Khay Ghim Tan
- Neonatal Intensive Care Unit, Perth Children's Hospital, Nedlands, Western Australia, Australia
- Neonatal Unit, Paediatrics, Joondalup Health Campus, Perth, Western Australia, Australia
| | - Shripada C Rao
- Neonatal Intensive Care Unit, Perth Children's Hospital, Nedlands, Western Australia, Australia
- Medical School, University of Western Australia, Crawley, Western Australia, Australia
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Horn-Oudshoorn EJJ, Russo FM, Deprest JA, Kipfmueller F, Geipel A, Schaible T, Rafat N, Cordier AG, Benachi A, Abbasi N, Chiu PPL, de Boode WP, Sikkel E, Peters NCJ, Hansen BE, Reiss IKM, DeKoninck PLJ. Survival in very preterm infants with congenital diaphragmatic hernia and association with prenatal imaging markers: A retrospective cohort study. BJOG 2023; 130:1403-1411. [PMID: 37069727 DOI: 10.1111/1471-0528.17497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/03/2023] [Accepted: 03/14/2023] [Indexed: 04/19/2023]
Abstract
OBJECTIVES To describe the outcomes of preterm born infants with congenital diaphragmatic hernia (CDH; ≤32.0 weeks of gestation) and the associations between prenatal imaging markers and survival. DESIGN Retrospective cohort study. SETTING Multicentre study in large referral centres. POPULATION Infants with an isolated unilateral CDH, live born at 32.0 weeks or less of gestation, between January 2009 and January 2020. METHODS Neonatal outcomes were evaluated for infants that were expectantly managed during pregnancy and infants that underwent fetoscopic endoluminal tracheal occlusion (FETO) therapy, separately. We evaluated the association between prenatal imaging markers and survival to discharge. Prenatal imaging markers included observed to expected lung-to-head ratio (o/e LHR), side of the defect, liver position, stomach position grade, and observed to expected total fetal lung volume (o/e TFLV). MAIN OUTCOME MEASURE Survival to discharge. RESULTS We included 53 infants born at 30+4 (interquartile range 29+1 -31+2 ) weeks. Survival in fetuses expectantly managed during pregnancy was 48% (13/27) in left-sided CDH and 33% (2/6) in right-sided CDH. Survival in fetuses that underwent FETO therapy was 50% (6/12) in left-sided CDH and 25% (2/8) in right-sided CDH. The o/e LHR at baseline was positively associated with survival in cases expectantly managed during pregnancy (odds ratio [OR] 1.20, 95% CI 1.07-1.42, p < 0.01), but not in cases that received FETO therapy (OR 1.01, 95% CI 0.88-1.15, p = 0.87). Stomach position grade (p = 0.03) and o/e TFLV were associated with survival (p = 0.02); liver position was not (p = 0.13). CONCLUSIONS In infants with CDH born at or before 32 weeks of gestation, prenatal imaging markers of disease severity were associated with postnatal survival.
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Affiliation(s)
- Emily J J Horn-Oudshoorn
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Francesca M Russo
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - Jan A Deprest
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - Florian Kipfmueller
- Department of Neonatology and Paediatric Critical Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Annegret Geipel
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Bonn, Germany
| | - Thomas Schaible
- Department of Neonatology, University Hospital Mannheim, Mannheim, Germany
| | - Neysan Rafat
- Department of Neonatology, University Hospital Mannheim, Mannheim, Germany
| | - Anne-Gael Cordier
- Centre Reference Maladie Rare, Hernie de Coupole Diaphragmatique, Clamart, France
- Department of Obstetrics and Gynaecology, Hospital Antoine Béclère, University Paris-Saclay, Clamart, France
| | - Alexandra Benachi
- Centre Reference Maladie Rare, Hernie de Coupole Diaphragmatique, Clamart, France
- Department of Obstetrics and Gynaecology, Hospital Antoine Béclère, University Paris-Saclay, Clamart, France
| | - Nimrah Abbasi
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Priscilla P L Chiu
- Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Willem P de Boode
- Department of Neonatology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Esther Sikkel
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | - Nina C J Peters
- Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Bettina E Hansen
- Department of Epidemiology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Irwin K M Reiss
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Philip L J DeKoninck
- Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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Whitby E, Gaunt T. Fetal lung MRI and features predicting post-natal outcome: a scoping review of the current literature. Br J Radiol 2023:20220344. [PMID: 37314838 DOI: 10.1259/bjr.20220344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023] Open
Abstract
The outcome for infants with fetal lung pathologies not only depends on the nature of the pathology, but the impact it has on the developing lungs. The main prognostic factor is the degree of pulmonary hypoplasia, but this is not detectable pre-natally. Imaging techniques aim to simulate these features with a variety of surrogate measurements, including lung volume and MRI signal intensity. Despite the complexity of the various research studies and lack of consistent methodology, this scoping review aims to summarise current applications, and promising techniques requiring further investigation.
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Affiliation(s)
- Elspeth Whitby
- University of Sheffield and Sheffield Teaching Hospitals NHS foundation Trust, England, United Kingdom
| | - Trevor Gaunt
- Department of Maternal and Fetal Medicine, University College London, London, United Kingdom
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
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7
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Taillieu A, Deprest J, Vergote S, Debeer A, Russo FM, Power B, Meijer F, Crombag N. Patient-reported outcomes for congenital diaphragmatic hernia: A qualitative study. Prenat Diagn 2023; 43:339-354. [PMID: 36598028 DOI: 10.1002/pd.6303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 12/20/2022] [Accepted: 01/02/2023] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To identify Patient-reported outcomes (PROs) for parents with a lived experience of a prenatal diagnosis of isolated congenital diaphragmatic hernia (CDH). METHOD Thematic analysis of in-depth interview transcripts. RESULTS Interviews (n = 26) identified 11 PROs for given time points throughout the CDH trajectory. At the time of diagnosis, acceptable quality of life was selected as relevant PRO to decide whether to continue or terminate the pregnancy. During pregnancy, (neonatal) survival chances and the eligibility for foetal therapy were prominent outcomes with foetal and maternal complications adding distress. After birth, postnatal management options became the next milestone. When survival was deemed likely, post-hospital discharge complications and future care for infant and child became important. In retrospect, impact on family, bonding, parental mental health, and parental satisfaction with care were reported as relevant outcomes. CONCLUSION PROs are relevant in addition to hard medical outcomes, as they help parents to make decisions suiting their unique needs and personal situation. Given the knowledge inherently related to the parent's perspective, our findings provide relevant directions for clinicians to support parents and their family in facing challenging decisions in healthcare. The outcomes impacting parents are essential to prepare parents for the steep journey ahead.
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Affiliation(s)
- Aymara Taillieu
- Department of Development and Regeneration Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium.,Institute of Women's Health, University College London, London, UK
| | - Simen Vergote
- Department of Development and Regeneration Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
| | - Anne Debeer
- Department of Development and Regeneration Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Francesca Maria Russo
- Department of Development and Regeneration Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Neeltje Crombag
- Department of Development and Regeneration Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Utrecht University Medical Center, Utrecht, The Netherlands
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8
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Emam D, Aertsen M, Van der Veeken L, Fidon L, Patkee P, Kyriakopoulou V, De Catte L, Russo F, Demaerel P, Vercauteren T, Rutherford M, Deprest J. Longitudinal MRI Evaluation of Brain Development in Fetuses with Congenital Diaphragmatic Hernia around the Time of Fetal Endotracheal Occlusion. AJNR Am J Neuroradiol 2023; 44:205-211. [PMID: 36657946 PMCID: PMC9891331 DOI: 10.3174/ajnr.a7760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 12/10/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE Congenital diaphragmatic hernia is associated with high mortality and morbidity, including evidence suggesting neurodevelopmental comorbidities after birth. The aim of this study was to document longitudinal changes in brain biometry and the cortical folding pattern in fetuses with congenital diaphragmatic hernia compared with healthy fetuses. MATERIALS AND METHODS This is a retrospective cohort study including fetuses with isolated congenital diaphragmatic hernia between January 2007 and May 2019, with at least 2 MR imaging examinations. For controls, we used images from fetuses who underwent MR imaging for an unrelated condition that did not compromise fetal brain development and fetuses from healthy pregnant women. Biometric measurements and 3D segmentations of brain structures were used as well as qualitative and quantitative grading of the supratentorial brain. Brain development was correlated with disease-severity markers. RESULTS Forty-two fetuses were included, with a mean gestational age at first MR imaging of 28.0 (SD, 2.1) weeks and 33.2 (SD, 1.3) weeks at the second imaging. The mean gestational age in controls was 30.7 (SD, 4.2) weeks. At 28 weeks, fetuses with congenital diaphragmatic hernia had abnormal qualitative and quantitative maturation, more extra-axial fluid, and larger total skull volume. By 33 weeks, qualitative grading scores were still abnormal, but quantitative scoring was in the normal range. In contrast, the extra-axial fluid volume remained abnormal with increased ventricular volume. Normal brain parenchymal volumes were found. CONCLUSIONS Brain development in fetuses with congenital diaphragmatic hernia around 28 weeks appears to be delayed. This feature is less prominent at 33 weeks. At this stage, there was also an increase in ventricular and extra-axial space volume.
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Affiliation(s)
- D Emam
- From the Department of Development and Regeneration (D.E., L.V.d.V., L.D.C., F.R., J.D.), Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
- Department Obstetrics and Gynaecology (D.E., L.F.), Faculty of Medicine, Tanta University, Tanta, Egypt
| | - M Aertsen
- Department of Imaging and Pathology (M.A., P.D.), Clinical Department of Radiology, University Hospitals, KU Leuven, Leuven, Belgium
| | - L Van der Veeken
- From the Department of Development and Regeneration (D.E., L.V.d.V., L.D.C., F.R., J.D.), Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
- Clinical Department Obstetrics and Gynaecology (L.V.d.V., L.D.C., F.R., J.D.), University Hospitals Leuven, Leuven, Belgium
| | - L Fidon
- Department Obstetrics and Gynaecology (D.E., L.F.), Faculty of Medicine, Tanta University, Tanta, Egypt
- Division of Imaging Sciences and Biomedical Engineering, Perinatal Imaging and Health and School of Biomedical Engineering and Imaging Sciences (L.F., T.V., J.D.), King's College London, King's Health Partners, St. Thomas' Hospital, London, UK
| | - P Patkee
- Centre for the Developing Brain (P.P., V.K., M.R., J.D.)
| | | | - L De Catte
- From the Department of Development and Regeneration (D.E., L.V.d.V., L.D.C., F.R., J.D.), Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
- Clinical Department Obstetrics and Gynaecology (L.V.d.V., L.D.C., F.R., J.D.), University Hospitals Leuven, Leuven, Belgium
| | - F Russo
- From the Department of Development and Regeneration (D.E., L.V.d.V., L.D.C., F.R., J.D.), Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
- Clinical Department Obstetrics and Gynaecology (L.V.d.V., L.D.C., F.R., J.D.), University Hospitals Leuven, Leuven, Belgium
| | - P Demaerel
- Department of Imaging and Pathology (M.A., P.D.), Clinical Department of Radiology, University Hospitals, KU Leuven, Leuven, Belgium
| | - T Vercauteren
- Division of Imaging Sciences and Biomedical Engineering, Perinatal Imaging and Health and School of Biomedical Engineering and Imaging Sciences (L.F., T.V., J.D.), King's College London, King's Health Partners, St. Thomas' Hospital, London, UK
| | - M Rutherford
- Centre for the Developing Brain (P.P., V.K., M.R., J.D.)
| | - J Deprest
- From the Department of Development and Regeneration (D.E., L.V.d.V., L.D.C., F.R., J.D.), Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
- Clinical Department Obstetrics and Gynaecology (L.V.d.V., L.D.C., F.R., J.D.), University Hospitals Leuven, Leuven, Belgium
- Centre for the Developing Brain (P.P., V.K., M.R., J.D.)
- Division of Imaging Sciences and Biomedical Engineering, Perinatal Imaging and Health and School of Biomedical Engineering and Imaging Sciences (L.F., T.V., J.D.), King's College London, King's Health Partners, St. Thomas' Hospital, London, UK
- Institute for Women's Health (J.D.), University College London, London, UK
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9
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Sadlecki P, Walentowicz-Sadlecka M. Prenatal diagnosis of fetal defects and its implications on the delivery mode. Open Med (Wars) 2023; 18:20230704. [PMID: 37197356 PMCID: PMC10183726 DOI: 10.1515/med-2023-0704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/28/2023] [Accepted: 04/10/2023] [Indexed: 05/19/2023] Open
Abstract
Congenital malformations are defined as single or multiple defects of the morphogenesis of organs or body parts, identifiable during intrauterine life or at birth. With recent advances in prenatal detection of congenital malformations, many of these disorders can be identified early on a routine fetal ultrasound. The aim of the present systematic review is to systematize the current knowledge about the mode of delivery in pregnancies complicated by fetal anomalies. The databases Medline and Ebsco were searched from 2002 to 2022. The inclusion criteria were prenatally diagnosed fetal malformation, singleton pregnancy, and known delivery mode. After the first round of research, 546 studies were found. For further analysis, studies with full text available concerning human single pregnancy with known neonatal outcomes were considered. Publications were divided into six groups: congenital heart defects, neural tube defects, gastroschisis, fetal tumors, microcephaly, and lung and thorax malformations. Eighteen articles with a descripted delivery mode and neonatal outcome were chosen for further analysis. In most pregnancies complicated by the presence of fetal anomalies, spontaneous vaginal delivery should be a primary option, as it is associated with lower maternal morbidity and mortality. Cesarean delivery is generally indicated if a fetal anomaly is associated with the risk of dystocia, bleeding, or disruption of a protective sac; examples of such anomalies include giant omphaloceles, severe hydrocephalus, and large myelomeningocele and teratomas. Fetal anatomy ultrasound should be carried out early, leaving enough time to familiarize parents with all available options, including pregnancy termination, if an anomaly is detected.
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Affiliation(s)
- Pawel Sadlecki
- Department of Obstetrics and Gynecology, Regional Polyclinical HospitalGrudziadz, Poland
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10
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O'Connor E, Tamura R, Hannon T, Harigopal S, Jaffray B. Congenital diaphragmatic hernia survival in an English regional ECMO center. WORLD JOURNAL OF PEDIATRIC SURGERY 2023; 6:e000506. [PMID: 37143688 PMCID: PMC10152044 DOI: 10.1136/wjps-2022-000506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 03/22/2023] [Indexed: 05/06/2023] Open
Abstract
Introduction Congenital diaphragmatic hernia (CDH) remains a cause of neonatal death. Our aims are to describe contemporary rates of survival and the variables associated with this outcome, contrasting these with our study of two decades earlier and recent reports. Materials and methods A retrospective review of all infants diagnosed in a regional center between January 2000 and December 2020 was performed. The outcome of interest was survival. Possible explanatory variables included side of defect, use of complex ventilatory or hemodynamic strategies (inhaled nitric oxide (iNO), high-frequency oscillatory ventilation (HFOV), extracorporeal membrane oxygenation (ECMO), and Prostin), presence of antenatal diagnosis, associated anomalies, birth weight, and gestation. Temporal changes were studied by measuring outcomes in each of four consecutive 63-month periods. Results A total of 225 cases were diagnosed. Survival was 60% (134 of 225). Postnatal survival was 68% (134 of 198 liveborn), and postrepair survival was 84% (134 of 159 who survived to repair). Diagnosis was made antenatally in 66% of cases. Variables associated with mortality were the need for complex ventilatory strategies (iNO, HFOV, Prostin, and ECMO), antenatal diagnosis, right-sided defects, use of patch repair, associated anomalies, birth weight, and gestation. Survival has improved from our report of a prior decade and did not vary during the study period. Postnatal survival has improved despite fewer terminations. On multivariate analysis, the need for complex ventilation was the strongest predictor of death (OR=50, 95% CI 13 to 224, p<0.0001), and associated anomalies ceased to be predictive. Conclusions Survival has improved from our earlier report, despite reduced numbers of terminations. This may be related to increased use of complex ventilatory strategies.
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Affiliation(s)
- Elizabeth O'Connor
- Paediatric surgery, The Great North Children's Hospital, Newcastle upon Tyne, Tyne & Wear, UK
| | - Ryo Tamura
- Paediatric surgery, The Great North Children's Hospital, Newcastle upon Tyne, Tyne & Wear, UK
| | - Therese Hannon
- Fetal medicine and obstetrics, Royal Victoria Infirmary, Newcastle upon Tyne, Tyne & Wear, UK
| | - Sundeep Harigopal
- Neonatal medicine, Royal Victoria Infirmary, Newcastle upon Tyne, Tyne & Wear, UK
| | - Bruce Jaffray
- Paediatric surgery, The Great North Children's Hospital, Newcastle upon Tyne, Tyne & Wear, UK
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11
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Sananès N, Basurto D, Cordier AG, Elie C, Russo FM, Benachi A, Deprest J. Fetoscopic endoluminal tracheal occlusion with Smart-TO balloon: Study protocol to evaluate effectiveness and safety of non-invasive removal. PLoS One 2023; 18:e0273878. [PMID: 36913364 PMCID: PMC10010565 DOI: 10.1371/journal.pone.0273878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 01/24/2023] [Indexed: 03/14/2023] Open
Abstract
INTRODUCTION One of the drawbacks of fetoscopic endoluminal tracheal occlusion (FETO) for congenital diaphragmatic hernia is the need for a second invasive intervention to reestablish airway patency. The "Smart-TO" (Strasbourg University-BSMTI, France) is a new balloon for FETO, which spontaneously deflates when positioned near a strong magnetic field, e.g., generated by a magnetic resonance image (MRI) scanner. Translational experiments have demonstrated its efficacy and safety. We will now use the Smart-TO balloon for the first time in humans. Our main objective is to evaluate the effectiveness of prenatal deflation of the balloon by the magnetic field generated by an MRI scanner. MATERIAL AND METHODS These studies were first in human (patients) trials conducted in the fetal medicine units of Antoine-Béclère Hospital, France, and UZ Leuven, Belgium. Conceived in parallel, protocols were amended by the local Ethics Committees, resulting in some minor differences. These trials were single-arm interventional feasibility studies. Twenty (France) and 25 (Belgium) participants will have FETO with the Smart-TO balloon. Balloon deflation will be scheduled at 34 weeks or earlier if clinically required. The primary endpoint is the successful deflation of the Smart-TO balloon after exposure to the magnetic field of an MRI. The secondary objective is to report on the safety of the balloon. The percentage of fetuses in whom the balloon is deflated after exposure will be calculated with its 95% confidence interval. Safety will be evaluated by reporting the nature, number, and percentage of serious unexpected or adverse reactions. CONCLUSION These first in human (patients) trials may provide the first evidence of the potential to reverse the occlusion by Smart-TO and free the airways non-invasively, as well a safety data.
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Affiliation(s)
- Nicolas Sananès
- Department of Maternal Fetal Medicine, Strasbourg University Hospital, Strasbourg, France
- INSERM 1121 ’Biomaterials and Bioengineering’, Strasbourg University, Strasbourg, France
- * E-mail:
| | - David Basurto
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Anne-Gaël Cordier
- Department of Maternal fetal Medicine, Antoine–Béclère Hospital - Paris–Saclay University, Clamart, France
| | - Caroline Elie
- Clinical Research Unit/Clinical Investigation Center, Necker-Enfants Malades Hospital, Paris, France
| | - Francesca Maria Russo
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Alexandra Benachi
- Department of Maternal fetal Medicine, Antoine–Béclère Hospital - Paris–Saclay University, Clamart, France
| | - Jan Deprest
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Institute for Women’s Health, University College London, London, United Kingdom
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12
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Horn-Oudshoorn EJJ, Peters NCJ, Franx A, Eggink AJ, Cochius-den Otter SCM, Reiss IKM, DeKoninck PLJ. Termination of pregnancy after a prenatal diagnosis of congenital diaphragmatic hernia: Factors influencing the parental decision process. Prenat Diagn 2023; 43:95-101. [PMID: 36443507 PMCID: PMC10107614 DOI: 10.1002/pd.6274] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/09/2022] [Accepted: 11/22/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the incidence of termination of pregnancies (TOP) and factors associated with the decision for TOP in prenatally detected congenital diaphragmatic hernia (CDH). STUDY DESIGN Single-centre retrospective cohort includes all prenatally detected CDH cases born between January 2009 and December 2021. Parental factors, such as parity, and fetal characteristics, such as disease severity, were collected. Descriptive statistics were used to present the data. Differences between terminated and continued pregnancies were analysed. RESULTS The study population consisted of 278 prenatally detected CDH cases of which 80% detected <24 weeks of gestation. The TOP rate was 28% in cases that were detected <24 weeks of gestation. Twenty continued pregnancies resulted in either intrauterine fetal demise (n = 6), preterm birth <24 weeks (n = 2), or comfort care after birth (n = 12). The survival rate was 70% in the remaining 195 live born cases. Factors associated with the decision for TOP were additional fetal genetic or anatomical abnormalities (p < 0.0001) and expected severity of pulmonary hypoplasia in left-sided CDH (p = 0.0456). CONCLUSION The decision to terminate a pregnancy complicated by fetal CDH depends on the severity of pulmonary hypoplasia and the presence of additional abnormalities. This emphasises the importance of early referral to expertise centres for detailed evaluation and multidisciplinary counselling.
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Affiliation(s)
- Emily J J Horn-Oudshoorn
- Department of Paediatrics, Division of Neonatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Nina C J Peters
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Arie Franx
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Alex J Eggink
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Suzan C M Cochius-den Otter
- Intensive Care and Department of Paediatric Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Department of Paediatrics, Division of Neonatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
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13
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Danzer E, Rintoul NE, van Meurs KP, Deprest J. Prenatal management of congenital diaphragmatic hernia. Semin Fetal Neonatal Med 2022; 27:101406. [PMID: 36456433 DOI: 10.1016/j.siny.2022.101406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Recently, two randomized controlled, prospective trials, the Tracheal Occlusion to Accelerate Lung Growth (TOTAL) trials, reported the outcomes on fetal endoluminal tracheal occlusion (FETO) for isolated left congenital diaphragmatic hernia (CDH). FETO significantly improved outcomes for severe hypoplasia. The effect in moderate cases, where the balloon was inserted later in pregnancy, did not reach significance. In a pooled analysis investigating the effect of the heterogeneity of the treatment effect by the time point of occlusion and severity, the difference may be explained by a difference in the duration of occlusion. Nevertheless, FETO carries a significant risk of preterm birth. The primary objective of this review is to provide an overview of the rationale for fetal intervention in CDH and the results of the randomized trials. The secondary objective is to discuss the technical aspects of FETO. Finally, recent developments of potential alternative fetal approaches will be highlighted.
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Affiliation(s)
- Enrico Danzer
- Stanford University School of Medicine and Lucile Packard Children's Hospital, Division of Neonatal and Developmental Medicine, Palo Alto, CA, USA; Division of Pediatric Surgery, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA.
| | - Natalie E Rintoul
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment and Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Krisa P van Meurs
- Stanford University School of Medicine and Lucile Packard Children's Hospital, Division of Neonatal and Developmental Medicine, Palo Alto, CA, USA
| | - Jan Deprest
- Academic Department Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium; Center for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium; Department of Obstetrics and Gynecology, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium; Institute of Women's Health, University College London Hospitals, London, United Kingdom
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14
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Image-based prenatal predictors of postnatal survival, extracorporeal life support, and defect size in right congenital diaphragmatic hernia. J Perinatol 2022; 42:1202-1209. [PMID: 35922665 DOI: 10.1038/s41372-022-01470-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 06/13/2022] [Accepted: 07/15/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the association between prenatal ultrasound (US) and magnetic resonance imaging (MRI) characteristics in right congenital diaphragmatic hernia (RCDH) with postnatal outcome. STUDY DESIGN CDH Study Group data were reviewed for all RCDH infants (n = 156) born between 2015 and 2019. Prenatal US and MRI lung size measurements were correlated with survival, extracorporeal life support (ECLS), and defect size. RESULT Overall survival was 64.1%. ECLS was required in 40.4%. US and MRI-based prenatal assessment of pulmonary hypoplasia does not predict survival. Prenatal measurement of lung size using either US or MRI correlates with ECLS use. Only MRI-based measures of lung size are associated with defect size. CONCLUSION Image-based prenatal predictors of survival, ECLS, and defect size are of limited value in RCDH. Extrapolation of prenatal survival and morbidity indicators from left to right-sided CDH is not appropriate. There is an urgent need to develop RCDH prenatal prediction models.
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15
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Zani A, Chung WK, Deprest J, Harting MT, Jancelewicz T, Kunisaki SM, Patel N, Antounians L, Puligandla PS, Keijzer R. Congenital diaphragmatic hernia. Nat Rev Dis Primers 2022; 8:37. [PMID: 35650272 DOI: 10.1038/s41572-022-00362-w] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 11/09/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a rare birth defect characterized by incomplete closure of the diaphragm and herniation of fetal abdominal organs into the chest that results in pulmonary hypoplasia, postnatal pulmonary hypertension owing to vascular remodelling and cardiac dysfunction. The high mortality and morbidity rates associated with CDH are directly related to the severity of cardiopulmonary pathophysiology. Although the aetiology remains unknown, CDH has a polygenic origin in approximately one-third of cases. CDH is typically diagnosed with antenatal ultrasonography, which also aids in risk stratification, alongside fetal MRI and echocardiography. At specialized centres, prenatal management includes fetal endoscopic tracheal occlusion, which is a surgical intervention aimed at promoting lung growth in utero. Postnatal management focuses on cardiopulmonary stabilization and, in severe cases, can involve extracorporeal life support. Clinical practice guidelines continue to evolve owing to the rapidly changing landscape of therapeutic options, which include pulmonary hypertension management, ventilation strategies and surgical approaches. Survivors often have long-term, multisystem morbidities, including pulmonary dysfunction, gastroesophageal reflux, musculoskeletal deformities and neurodevelopmental impairment. Emerging research focuses on small RNA species as biomarkers of severity and regenerative medicine approaches to improve fetal lung development.
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Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada. .,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Wendy K Chung
- Department of Paediatrics, Columbia University, New York, NY, USA
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child and Clinical Department of Obstetrics and Gynaecology, University Hospitals, KU Leuven, Leuven, Belgium.,Institute for Women's Health, UCL, London, UK
| | - Matthew T Harting
- Department of Paediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA.,The Comprehensive Center for CDH Care, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Shaun M Kunisaki
- Division of General Paediatric Surgery, Johns Hopkins Children's Center, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, UK
| | - Lina Antounians
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Pramod S Puligandla
- Department of Paediatric Surgery, Harvey E. Beardmore Division of Paediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Richard Keijzer
- Department of Surgery, Division of Paediatric Surgery, Paediatrics & Child Health, Physiology & Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
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16
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Cochius - den Otter S, Deprest JA, Storme L, Greenough A, Tibboel D. Challenges and Pitfalls: Performing Clinical Trials in Patients With Congenital Diaphragmatic Hernia. Front Pediatr 2022; 10:852843. [PMID: 35498783 PMCID: PMC9051320 DOI: 10.3389/fped.2022.852843] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/08/2022] [Indexed: 11/17/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a rare developmental defect of the lungs and diaphragm, with substantial morbidity and mortality. Although internationally established treatment guidelines have been developed, most recommendations are still expert opinions. Trials in patients with CDH, more in particular randomized controlled trials, are rare. Only three multicenter trials in patients with CDH have been completed, which focused on fetoscopic tracheal occlusion and ventilation mode. Another four are currently recruiting, two with a focus on perinatal transition and two on the treatment of pulmonary hypertension. Herein, we discuss major challenges and pitfalls when performing a clinical trial in infants with CDH. It is essential to select the correct intervention and dose, select the appropriate population of CDH patients, and also define a relevant endpoint that allows a realistic duration and sample size. New statistical approaches might increase the feasibility of randomized controlled trials in patients with CDH. One should also timely perform the trial when there is still equipoise. But above all, awareness of policymakers for the relevance of investigator-initiated trials is essential for future clinical research in this rare disease.
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Affiliation(s)
- Suzan Cochius - den Otter
- Intensive Care and Department of Pediatric Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Jan A. Deprest
- Department of Obstetrics and Gynaecology, University Hospitals KU Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Institute for Women's Health, University College London, London, United Kingdom
| | - Laurent Storme
- Metrics-Perinatal Environment and Health, University of Lille, Lille, France
- Department of Neonatology, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
- Center of Rare Disease Congenital Diaphragmatic Hernia, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Anne Greenough
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, United Kingdom
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, United Kingdom
- NIHR Biomedical Centre, Guy's and St Thomas NHS Foundation Trust and King's College London, London, United Kingdom
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands
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17
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Van Calster B, Benachi A, Nicolaides KH, Gratacos E, Berg C, Persico N, Gardener GJ, Belfort M, Ville Y, Ryan G, Johnson A, Sago H, Kosiński P, Bagolan P, Van Mieghem T, DeKoninck PLJ, Russo FM, Hooper SB, Deprest JA. The randomized Tracheal Occlusion To Accelerate Lung growth (TOTAL)-trials on fetal surgery for congenital diaphragmatic hernia: reanalysis using pooled data. Am J Obstet Gynecol 2022; 226:560.e1-560.e24. [PMID: 34808130 DOI: 10.1016/j.ajog.2021.11.1351] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/15/2021] [Accepted: 11/15/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Two randomized controlled trials compared the neonatal and infant outcomes after fetoscopic endoluminal tracheal occlusion with expectant prenatal management in fetuses with severe and moderate isolated congenital diaphragmatic hernia, respectively. Fetoscopic endoluminal tracheal occlusion was carried out at 27+0 to 29+6 weeks' gestation (referred to as "early") for severe and at 30+0 to 31+6 weeks ("late") for moderate hypoplasia. The reported absolute increase in the survival to discharge was 13% (95% confidence interval, -1 to 28; P=.059) and 25% (95% confidence interval, 6-46; P=.0091) for moderate and severe hypoplasia. OBJECTIVE Data from the 2 trials were pooled to study the heterogeneity of the treatment effect by observed over expected lung-to-head ratio and explore the effect of gestational age at balloon insertion. STUDY DESIGN Individual participant data from the 2 trials were reanalyzed. Women were assessed between 2008 and 2020 at 14 experienced fetoscopic endoluminal tracheal occlusion centers and were randomized in a 1:1 ratio to either expectant management or fetoscopic endoluminal tracheal occlusion. All received standardized postnatal management. The combined data involved 287 patients (196 with moderate hypoplasia and 91 with severe hypoplasia). The primary endpoint was survival to discharge from the neonatal intensive care unit. The secondary endpoints were survival to 6 months of age, survival to 6 months without oxygen supplementation, and gestational age at live birth. Penalized regression was used with the following covariates: intervention (fetoscopic endoluminal tracheal occlusion vs expectant), early balloon insertion (yes vs no), observed over expected lung-to-head ratio, liver herniation (yes vs no), and trial (severe vs moderate). The interaction between intervention and the observed over expected lung-to-head ratio was evaluated to study treatment effect heterogeneity. RESULTS For survival to discharge, the adjusted odds ratio of fetoscopic endoluminal tracheal occlusion was 1.78 (95% confidence interval, 1.05-3.01; P=.031). The additional effect of early balloon insertion was highly uncertain (adjusted odds ratio, 1.53; 95% confidence interval, 0.60-3.91; P=.370). When combining these 2 effects, the adjusted odds ratio of fetoscopic endoluminal tracheal occlusion with early balloon insertion was 2.73 (95% confidence interval, 1.15-6.49). The results for survival to 6 months and survival to 6 months without oxygen dependence were comparable. The gestational age at delivery was on average 1.7 weeks earlier (95% confidence interval, 1.1-2.3) following fetoscopic endoluminal tracheal occlusion with late insertion and 3.2 weeks earlier (95% confidence interval, 2.3-4.1) following fetoscopic endoluminal tracheal occlusion with early insertion compared with expectant management. There was no evidence that the effect of fetoscopic endoluminal tracheal occlusion depended on the observed over expected lung-to-head ratio for any of the endpoints. CONCLUSION This analysis suggests that fetoscopic endoluminal tracheal occlusion increases survival for both moderate and severe lung hypoplasia. The difference between the results for the Tracheal Occlusion To Accelerate Lung growth trials, when considered apart, may be because of the difference in the time point of balloon insertion. However, the effect of the time point of balloon insertion could not be robustly assessed because of a small sample size and the confounding effect of disease severity. Fetoscopic endoluminal tracheal occlusion with early balloon insertion in particular strongly increases the risk for preterm delivery.
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Affiliation(s)
- Ben Van Calster
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands; EPI-center, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Alexandra Benachi
- Department of Obstetrics and Gynaecology of the Hospital Antoine Béclère, Université Paris Saclay, Clamart, France
| | | | | | | | - Nicola Persico
- Hospital Maggiore Policlinico IRCCS, University of Milan, Milan, Italy
| | | | - Michael Belfort
- Texas Children's Hospital, Baylor College of Medicine Houston, TX
| | | | - Greg Ryan
- Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Haruhiko Sago
- National Center for Child Health and Development, Tokyo, Japan
| | - Przemysław Kosiński
- First Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Pietro Bagolan
- Medical and Surgical Department of the Fetus-Newborn-Infant, Bambino Gesù Children's Hospital, Research Institute, Rome, Italy
| | - Tim Van Mieghem
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium; Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Philip L J DeKoninck
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium; Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Francesca M Russo
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium; Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Jan A Deprest
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium; Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium; Institute for Women's Health, University College London Hospital, London, United Kingdom.
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Russo F, Benachi A, Gratacos E, Zani A, Keijzer R, Partridge E, Sananes N, De Coppi P, Aertsen M, Nicolaides KH, Deprest J. Antenatal Management of Congenital Diaphragmatic Hernia: what's next ? Prenat Diagn 2022; 42:291-300. [PMID: 35199368 DOI: 10.1002/pd.6120] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/19/2022] [Accepted: 02/20/2022] [Indexed: 11/07/2022]
Abstract
Congenital diaphragmatic hernia (CDH) can be diagnosed in the prenatal period and its severity can be measured by fetal imaging. There is now level I evidence that, in selected cases, Fetoscopic Endoluminal Tracheal Occlusion (FETO) increases survival to discharge from the neonatal unit as well as the risk for prematurity. Both effects are dependent on the time point of tracheal occlusion. FETO may also lead to iatrogenic death when done in unexperienced centres. The implementation of the findings from our clinical studies, may also vary based on local conditions. These may be different in terms of available skill set, access to fetal therapy, as well as outcome based on local neonatal management. We encourage prior benchmarking of local outcomes with optimal postnatal management, based on large enough numbers and using identical criteria as in the recent trials. We propose to work further on prenatal prediction methods, and the improvement of fetal intervention. In this manuscript, we describe a research agenda from a fetal medicine perspective. This research should be in parallel with innovation in neonatal and pediatric (surgical) management of this condition. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Francesca Russo
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven and Clinical Department of Obstetrics and Gynaecology, UZ Leuven, Leuven, Belgium
| | - Alexandra Benachi
- Department of Obstetrics and Gynaecology, Hospital Antoine Béclère, Université Paris Saclay, Clamart, France
| | | | - Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Richard Keijzer
- Department of Pediatric Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Emily Partridge
- Department of Pediatric Surgery, Children's Hospital of Philadelphia, PA, USA
| | - Nicolas Sananes
- Department Obstetrics and Gynaecology, University Hospitals Strasbourg, Strasbourg, France
| | | | - Michael Aertsen
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | | | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven and Clinical Department of Obstetrics and Gynaecology, UZ Leuven, Leuven, Belgium.,Institute of Women's Health, University College London, London, United Kingdom
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White BM, Morrisey EE, Peranteau WH. In Utero Gene Editing for Inherited Lung Diseases. CURRENT STEM CELL REPORTS 2022. [DOI: 10.1007/s40778-021-00205-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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The Role of Fetal Brain Magnetic Resonance Imaging in Current Fetal Medicine. J Belg Soc Radiol 2022; 106:130. [PMID: 36569393 PMCID: PMC9756908 DOI: 10.5334/jbsr.3000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/16/2022] [Indexed: 12/15/2022] Open
Abstract
In open spina bifida we studied the use of MRI for the assessment of the posterior fossa and prevalence of supratentorial anomalies before and after in utero repair. New postprocessing techniques were applied to evaluate fetal brain development in this population compared to controls. In fetuses with congenital diaphragmatic hernia, we evaluated the brain development in comparison to controls. Diffusion weighted imaging was applied to study difference between fetuses with proven first trimester cytomegalovirus infection and controls. Finally, we investigated the value of third trimester fetal brain MRI after treatment for complicated monochorionic diamniotic pregnancies.
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Cruz-Martínez R, Molina-Giraldo S, Etchegaray A, Ventura W, Pavón-Gómez N, Gil-Guevara E, Villalobos-Gómez R, Luna-García J, Gámez-Varela A, Martínez-Rodríguez M, López-Briones H, Chávez-González E. Prediction of neonatal survival according to lung-to-head ratio in fetuses with right congenital diaphragmatic hernia (CDH): A multicentre study from the Latin American CDH Study Group registry. Prenat Diagn 2021; 42:357-363. [PMID: 34861055 DOI: 10.1002/pd.6070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 10/26/2021] [Accepted: 11/17/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate survival outcomes of fetuses with right sided congenital diaphragmatic hernia (CDH) treated in Latin American centres and to assess the utility of left lung area to predict neonatal survival. METHODS A retrospective cohort including isolated right sided CDH cases managed expectantly during pregnancy in six tertiary centers from five Latin American countries. The utility of the observed/expected lung-to-head ratio (O/E-LHR) in predicting neonatal survival was assessed, and the best cut-off to predict prognosis was automatically selected by decision tree analysis. RESULTS A total of 99 right sided CDH cases were recruited, 58 isolated fetuses were selected at a median gestational age of 26.2 weeks, showing an overall survival rate of 26.2%. A linear trend was observed between survival and the O/E-LHR, showing that at higher O/E-LHR, the greater probability of survival (r = 0.56, p < 0.001). O/E-LHR discriminates two groups with different survival outcomes: fetuses with an O/E-LHR ≥65% showed a significantly higher survival rate than those with an O/E-LHR <65% (81.8% vs. 15.6%, p < 0.01). CONCLUSIONS Overall survival rate in right sided CDH is lower in Latin American countries. The severity category of pulmonary hypoplasia should be classified according to lung area and the survival rate in such population.
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Affiliation(s)
- Rogelio Cruz-Martínez
- Department of Fetal Diagnosis, Fetal Medicine and Surgery Center, Medicina Fetal México, Querétaro, México
| | - Saulo Molina-Giraldo
- Section of Fetal Therapy and Fetal Surgery Unit, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Hospital de San José, Fundación Universitaria de Ciencias de la Salud - FUCS, Clínica Colsubsidio 94, FetoNetwork Colombia, Bogotá, Colombia
| | - Adolfo Etchegaray
- Department of Fetal Medicine, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Walter Ventura
- Department of Fetal Medicine, Instituto Nacional Materno Perinatal y Clínica Angloamericana, British Medical Hospital, Lima, Perú
| | - Néstor Pavón-Gómez
- Division of Maternal Fetal Medicine, Hospital Bertha Calderón Roque, Managua, Nicaragua
| | - Enrique Gil-Guevara
- Department of Fetal Diagnosis, Instituto Peruano de Medicina y Cirugía Fetal, Lima, Perú
| | - Rosa Villalobos-Gómez
- Department of Fetal Diagnosis, Fetal Medicine and Surgery Center, Medicina Fetal México, Querétaro, México
| | - Jonahtan Luna-García
- Department of Fetal Diagnosis, Fetal Medicine and Surgery Center, Medicina Fetal México, Querétaro, México
| | - Alma Gámez-Varela
- Department of Fetal Diagnosis, Fetal Medicine and Surgery Center, Medicina Fetal México, Querétaro, México
| | - Miguel Martínez-Rodríguez
- Department of Fetal Diagnosis, Fetal Medicine and Surgery Center, Medicina Fetal México, Querétaro, México
| | - Hugo López-Briones
- Department of Fetal Diagnosis, Fetal Medicine and Surgery Center, Medicina Fetal México, Querétaro, México
| | - Eréndira Chávez-González
- Department of Fetal Diagnosis, Fetal Medicine and Surgery Center, Medicina Fetal México, Querétaro, México
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22
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Russo FM, Debeer A, De Coppi P, Devriendt K, Crombag N, Hubble T, Power B, Benachi A, Deprest J. What should we tell parents? Congenital diaphragmatic hernia. Prenat Diagn 2020; 42:398-407. [PMID: 33599313 DOI: 10.1002/pd.5880] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/13/2020] [Accepted: 11/30/2020] [Indexed: 12/18/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is characterized by a defect in the muscle dividing the thoracic and abdominal cavities. This leads to herniation of the abdominal organs into the thorax and a disturbance of lung development. Two-thirds of cases are identified by prenatal ultrasound in the second trimester, which should prompt referral to a tertiary center for prognosis assessment and counseling by a multidisciplinary team familiar with this condition. In this review, we summarize evidence on prenatal diagnosis and postnatal management of CDH. There is a focus on information that should be provided to expecting parents during prenatal counseling.
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Affiliation(s)
- Francesca M Russo
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - Anne Debeer
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Paolo De Coppi
- Neonatal and Paediatric Surgery Unit, Great Ormond Street Hospital, London, UK.,Stem Cells & Regenerative Medicine Section, NIHR Biomedical Research Center, UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Neeltje Crombag
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium
| | - Talia Hubble
- Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Medical Sciences Division, University of Oxford, Oxford, UK
| | | | - Alexandra Benachi
- Department of Obstetrics and Gynecology, Hôpital Antoine Béclère, AP-HP, Université Paris Saclay, Clamart, France.,Centre Référence Maladie Rare: Hernie de Coupole Diaphragmatique, Clamart, France
| | - Jan Deprest
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Academic Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, UK
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