Showing papers by "Jan Deprest published in 2005"

Percutaneous fetal endoscopic tracheal occlusion (FETO) for severe left-sided congenital diaphragmatic hernia.

Abstract: Introduction Isolated left-sided congenital diaphragmatic hernia (LCDH) with intrathoracic liver and lung-to-head ratio ,1 (LHR) is associated with high neonatal mortality as a result of pulmonary hypoplasia and hypertension. We describe a percutaneous technique for temporary fetal endoscopic tracheal occlusion (FETO) with a balloon and report on the evolution of the technique and results in a consecutive homogeneous case series of patients treated in the early third trimester. During the study period, the selection criteria were validated. Within a time period of 28 months, FETO was performed between 26 and 28 weeks Correspondence: Jan Deprest, MD, PhD, Department of Obstetrics andGynaecology, Unit of Prenatal andGynaecological Ultrasound and Fetal Therapy, UZ Gasthuisberg, 3000 Leuven, Belgium. E-mail: Jan.Deprest@ uz.kuleuven.ac.be The FETO Task Group includes further: D. Van Schoubroeck, R. Devlieger, M. Vandevelde, C. Vanhole, V. Cossey, M. Cannie, T. Lerut (Belgium); E. Carreras, S. Salcedo,N.Toran,O.Moreno,V.Martinez-Ibanez (Spain), J. Hyett, H. Vandecruys, S. Patel,M.Davenport (U.K.). For the validation study, we collaborated with: R. Favre, J. Matis (Strasbourg, France), R. Keller, D. Farmer (University of California at San Francisco, California). Dr. Jani is recipient of a grant from the EuropeanCommission in its 5th Framework Programme, which also funded the development of endoscopes and other instruments (QLG1 CT2002 01632; EuroTwin2Twin; BMH4 CT97 2383 Eurofoetus). G. Barki and S. Buschle are project leaders at K Storz Endoskope, partner in that project. The authors have no financial interest in this company.

Cervical length as a prognostic factor for preterm delivery in twin-to-twin transfusion syndrome treated by fetoscopic laser coagulation of chorionic plate anastomoses.

Abstract: Objective To evaluate the risk of spontaneous preterm delivery in relation to cervical length in severe cases of twin-to-twin transfusion syndrome (TTTS) diagnosed before 26 weeks of gestation and treated by laser coagulation of the intertwin placental anastomoses. Methods This was an observational study of cases of severe TTTS diagnosed before 26 weeks of gestation and treated by fetoscopic laser coagulation between January 2002 and December 2003 in three centers. Laser was the first-line treatment in all cases. Elective preterm deliveries before 34 weeks' for maternal or fetal indications, including intrauterine death of both fetuses, were excluded. Transvaginal sonographic measurement of cervical length prior to laser treatment and other risk factors of preterm delivery were evaluated by univariate and logistic regression analysis. Results Among the 137 women included, the mean cervical length was 32 and 38 mm in women delivering before and at or after 34 weeks, respectively (P < 0.001). For a cervical length of < 30 mm, the risk of delivery before 34 weeks was 74%. Severity of the disease, deepest vertical pool of amniotic fluid and amniotic fluid volume drained after the procedure were not associated with preterm delivery. Logistic regression analysis identified three independent factors to predict preterm delivery: short cervical length (increased risk), parity (increased risk) and intrauterine death of one twin (decreased risk). Conclusion In TTTS treated by laser, without indications for elective preterm birth, cervical length before treatment is significantly associated with gestational age at delivery, and this is independent of parity, intrauterine death of one fetus and other risk factors. Copyright © 2004 ISUOG. Published by John Wiley & Sons, Ltd.

Remifentanil for fetal immobilization and maternal sedation during fetoscopic surgery: a randomized, double-blind comparison with diazepam

Abstract: Obstetric endoscopy procedures are routinely performed at our institution to treat selected complications of monochorionic twin gestation. We perform these procedures under combined spinal epidural anesthesia plus maternal sedation. In the absence of general anesthesia, fetal immobilization is not achieved. We hypothesized that remifentanil would induce adequate maternal sedation and provide fetal immobilization, which is equal or superior to that induced by diazepam. Fifty-four second trimester pregnant women were included in this randomized, double-blind trial. After combined spinal epidural anesthesia, maternal sedation was initiated using either incremental doses of diazepam or a continuous infusion of remifentanil. Maternal sedation, hemodynamics, side effects, and fetal hemodynamics and immobilization were evaluated before, during, and for 60 min after surgery. Remifentanil produced adequate maternal sedation with mild but clinically irrelevant respiratory depression (respiratory rate 13 +/- 4 breaths/min and Pco(2) 38.6 +/- 4 mm Hg at 40 min of surgery), whereas diazepam resulted in a more pronounced maternal sedation but no respiratory depression (respiratory rate 18 +/- 3 breaths/min and Pco(2) 32.7 +/- 3 mm Hg at 40 min of surgery). Compared with diazepam, fetal immobilization with remifentanil occurred faster and was more pronounced, resulting in improved surgical conditions; the number of gross body and limb movements was 12 +/- 4 (diazepam) versus 2 +/- 1 (remifentanil) at 40 min of surgery. Because of this, the mean (range) duration of surgery was significantly shorter in the remifentanil-treated patients, 60 (54-71) min versus 80 (60-90) min in the diazepam group. We conclude that remifentanil produces improved fetal immobilization with good maternal sedation and only minimal effects on maternal respiration.

Remifentanil for fetal immobilization and maternal sedation during fetoscopic surgery: a randomized, double blind comparison with diazepam

Abstract: Obstetric endoscopy procedures are routinely performed at our institution to treat selected complications of monochorionic twin gestation. We perform these procedures under combined spinal epidural anesthesia plus maternal sedation. In the absence of general anesthesia, fetal immobilization is not achieved. We hypothesized that remifentanil would induce adequate maternal sedation and provide fetal immobilization, which is equal or superior to that induced by diazepam. Fifty-four second trimester pregnant women were included in this randomized, double-blind trial. After combined spinal epidural anesthesia, maternal sedation was initiated using either incremental doses of diazepam or a continuous infusion of remifentanil. Maternal sedation, hemodynamics, side effects, and fetal hemodynamics and immobilization were evaluated before, during, and for 60 min after surgery. Remifentanil produced adequate maternal sedation with mild but clinically irrelevant respiratory depression (respiratory rate 13 ± 4 breaths/min and Pco2 38.6 ± 4 mm Hg at 40 min of surgery), whereas diazepam resulted in a more pronounced maternal sedation but no respiratory depression (respiratory rate 18 ± 3 breaths/min and Pco2 32.7 ± 3 mm Hg at 40 min of surgery). Compared with diazepam, fetal immobilization with remifentanil occurred faster and was more pronounced, resulting in improved surgical conditions; the number of gross body and limb movements was 12 ± 4 (diazepam) versus 2 ± 1 (remifentanil) at 40 min of surgery. Because of this, the mean (range) duration of surgery was significantly shorter in the remifentanil-treated patients, 60 (54–71) min versus 80 (60–90) min in the diazepam group. We conclude that remifentanil produces improved fetal immobilization with good maternal sedation and only minimal effects on maternal respiration.

Laparoscopic hysterectomy for benign diseases.

Abstract: Despite more than 1000 publications on laparoscopic hysterectomy (LH), its role remains difficult to define. LH is not there to replace vaginal hysterectomy, but may be an alternative for abdominal hysterectomy when there are (relative) contraindications for vaginal hysterectomy, including concomitant oophorectomy, previous pelvic surgery and/or risk for adhesions, the larger uterus and nulliparity, and some oncological indications. Randomized trials have demonstrated that, compared to abdominal hysterectomy, LH shortens hospital stay and induces less postoperative pain and quicker recovery at the expense of a longer operation time. LH carries a higher risk for adjacent organ injury, and may be cost-effective, despite higher direct costs, because of the shorter hospital stay and quicker recovery.

Improved surgical outcome by modification of porcine dermal collagen implant in abdominal wall reconstruction in rats.

Abstract: Aim We earlier showed in rats that fascial repair with Pelvicol, a porcine dermal collagen implant, was associated with a lesser inflammatory response but lower tensile strength in the early postoperative period as compared to Prolene. Herein we wanted to evaluate whether creation of pores in Pelvicol, facilitating ingrowth of fibrous tissue and vessels, would result in a higher tensile strength at d30 without compromising longer term results. Methods First tensile strength of Pelvicol modified with different pore sizes was evaluated ex vivo. In a second step, Pelvicol implants with pores were used to cover full-thickness abdominal wall defects in 36 rats. Implants were either Pelvicol (non-porous) or with pores of Φ : 0.7, 1.2, or 2.0 mm (n = 6 each). Animals were sacrificed on d30 and 90 to evaluate the presence of herniation, infection, adhesions, change in thickness and tensile strength. Histopathology was performed to assess inflammatory response and collagen deposition. Data were compared to available data on Prolene implanted animals at same time points. Results Pelvicol with pore diameter of 2.5 mm was significantly weaker ex vivo. Animals repaired with non-porous material did develop seroma (2/6) or clinical infection (1/6) whereas none in the other groups did. There was a trend for increasing tensile strength at 30 d with increasing pore diameter, being significant in the 2.0-mm pore size group. This difference disappeared by 90 d, where all materials were equally strong as Prolene. The foreign body reaction was less intense in a pore-size dependent manner, with more abundant neo-vascularization and collagen deposition passing through the pores. Conclusion Creation of pores in Pelvicol promotes neo-vascularization, collagen deposition, and fibrous tissue ingrowth, and at pore size 2.0 mm tensile strength was increased at d30 whereafter all materials had comparable strength. Neurourol. Urodynam. 24:362–368, 2005. © 2005 Wiley-Liss, Inc.

Accuracy of magnetic resonance imaging for measuring fetal sheep lungs and other organs

Abstract: Objective Lung volume measurement by fetal magnetic resonance imaging (fetMRI) has been used to predict survival of fetuses with isolated congenital diaphragmatic hernia (CDH). So far, the accuracy and precision of fetMRI for volumetry of either the normal or hypoplastic developing lung has not been formally studied. Methods A total of nine sheep carrying 14 fetuses underwent fetMRI under general anesthesia at a mean of 118 days' gestational age (term = 145 days). A total of 61 organs were measured in nine normal fetal sheep and five that underwent surgical creation of diaphragmatic hernia (DH), so as to induce pulmonary hypoplasia. Lungs were measured on T2-WI (weighted images) in three different planes, while liver and kidneys were measured in the axial (T1-WI) and sagittal (T2-WI) planes, respectively. Necropsy was done within 24 h after fetMRI to determine the volume postmortem by the water displacement method. Values were linearly correlated and a Bland and Altman analysis was done for volume measurement comparison, calculating means ± SD, bias (mean of the difference of volume measurements), precision (SD of the difference) and absolute and proportionate limits of agreement for both methods. The accuracy of fetMRI volume measurement was determined for different organ groups by calculating the median relative error and precision index, both being measures of error in proportion to the magnitude of the volume measured, as a clinically relevant proxy of potential errors. Results The fetMRI volume measurements were on average larger than postmortem volumes, except for the kidneys. Kidney volume determination had a relative error of 29%, while measurements of larger organs had larger relative errors (42% for liver). Normal lungs were less accurately measured in the coronal or sagittal than in the axial plane (relative error 53%, 73% and 38%, respectively; P < 0.05 for sagittal vs. axial). Axially-measured lung volumes were more accurate for lungs of normal sheep compared to DH lungs (relative error 38% vs. 73%, respectively; P < 0.05). Conclusion FetMRI measured systematically higher volumes for organs such as fetal liver or lung. This may be related to fluid loss or lack of perfusion at the time of necropsy. Measurement of lung volume by fetMRI was most accurate in the axial plane. Measurements of lung and liver volumes by fetMRI in normal sheep were both in agreement with volumes measured at necropsy. Loss of accuracy for DH-lungs in comparison with the accuracy when measuring other similarly small organs, such as kidneys, suggests that fetMRI measurements can be less accurate for hypoplastic lungs related to CDH. With improving hardware, it might become easier to render the fetal lung and determine its volume reliably. Copyright © 2005 ISUOG. Published by John Wiley & Sons, Ltd.

Progress in intrauterine assessment of the fetal lung and prediction of neonatal function.

Abstract: The human lung is a complex and highly specialized organ with over 40 differentiated cell types. Optimal lung function is determined prenatally and an in utero adverse event may interfere with the delicate lung development process and lead to variable degrees of pulmonary hypoplasia1. Disturbances in the pseudoglandular period (7–16 weeks) interfere with bronchial and arterial branching. When lung development is hampered during the cannalicular phase (16–26 weeks), complexity of the respiratory acinus is reduced and lung maturation may be impaired. Pulmonary effects thus differ according to the underlying disease and a few typical examples immediately come to mind. Renal agenesis simply causes lethal pulmonary hypoplasia. Oligohydramnios due to ruptured membranes prior to 25 weeks will cause pulmonary hypoplasia in 85% of cases, half of them dying from respiratory failure in the neonatal period. Congenital diaphragmatic hernia (CDH) is lethal in 40% of newborns due to neonatal ventilatory problems as well as pulmonary hypertension. CDH is present as early as 9 weeks and interferes with airway and vascular development from that point onwards, leading to progressively more complex lung pathology than that resulting from premature rupture of membrane, which occurs later in gestation. Today, thanks to screening programs and highresolution ultrasound equipment, lung developmental problems are readily diagnosed. However, diagnosis is only the start. Given the variable consequences of these conditions, reliable methods are required to quantify the extent of disturbance of lung development. Prospective parents expect us to predict the level of morbidity as well as mortality associated with what we have diagnosed. Furthermore, we associate clinical consequences with a certain diagnosis and prognosis. Optimal perinatal care involving in utero referral can be planned or, in cases of lethal forms, termination or antenatal intervention may be considered. The prenatal examination thus evolves from a diagnostic to a prognostic process. Diagnostic tests need to be highly accurate, reproducible, and wherever possible technically and economically acceptable and non-invasive. In this and the following issue of the White Journal, there are several articles dedicated to different aspects of antenatal evaluation of lung problems. We would like to take this opportunity to discuss the potential and limitations of prenatal lung assessment. First, we would like to draw your attention to some generic issues related to the validation of a predictive test for lung hypoplasia. Any prenatal imaging test considered will have inherent limitations as such tests measure tissue features, and their accuracy relies on good spatial resolution of that imaging technique. Resolution differs between imaging methods and will no doubt improve as technology advances over time. Any measurement used in the test will be prone to intraand interobserver variability, and what may be efficient under certain circumstances may no longer be so when applied on a larger scale. However, even if the reliability of the measurement technique has been established it is very likely that measurements, hence the test, will be most accurate late in gestation. Early in gestation, observed changes may be so minimally different from what is expected in normal subjects, that overlap of normal and lethal is unavoidable. In other words, a predictive test may only become highly accurate so late in gestation that its clinical implications are minimal or even nil. There are also limitations imposed by, and unique to, the particular pathology under investigation. Each lung developmental condition has its own, yet usually ill-defined natural history. This is in part due to their rarity and the paucity of reliable data. Reported numbers are prone to observation bias that is present in the pathological, obstetric, neonatological or pediatric surgery literature. The discrepancy in mortality rates, according to whether they are quoted by prenatal or postnatal specialists, explains what is known as ‘hidden mortality’2. Today, many studies in the obstetric literature should be considered as interventional because termination of pregnancy (TOP) is an option. TOP is more likely to be offered to those patients with what is perceived to be a dismal prognosis, based precisely on the parameters that are to be validated. Furthermore, lung development diseases may cover a heterogeneous spectrum, with large variability. Both lungs may not be affected similarly and the time course of effects on the lung may change throughout gestation. For instance, lung hypoplasia in CDH is worse on the ipsilateral side, and the disease has been shown to be progressive throughout pregnancy. This means that predictive tests will need different cut-off values for variable gestational ages3. Finally, with advances in neonatal care these diseases are ‘moving targets’ and what is lethal today may no longer be so tomorrow. Despite all these limitations, predicting prognosis is a clinical need. The first goal of a lung assessment method should be to predict viability. Definitions of pulmonary hypoplasia come from the dark rooms of the department of pathology dealing only with non-survivors. Lung development is typically quantified by assessing lung weight as a proportion of total body weight4. Microscopic definitions, based on morphometric evaluation of the

Fetoscopic tracheal occlusion (FETO) for severe congenital diaphragmatic hernia : Evolution of a technique and preliminary results

Abstract: Approximately half of fetuses having isolated congenital diaphragmatic hernia (CDH) survive after postnatal surgery. The other half die of pulmonary hypoplasia and pulmonary hypertension. Animal studies have shown that pulmonary hypoplasia and hypertension can be reversed by intrauterine repair that restores herniated viscera to the abdomen. The authors describe a minimally invasive and reversible technique of fetoscopic tracheal balloon occlusion (FETO) designed for use in fetuses with severe CDH (Fig. 1). A prospective study enrolled 21 consecutive severely affected fetuses who were otherwise normal anatomically and chromosomally. Intrathoracic herniation of the liver was present in all cases. Under general or combined spinal-epidural anesthesia, the fetal position is altered if necessary to maximize access to the trachea. A flexible Teflon cannula containing a pyramidal trocar is placed in the amniotic cavity through the abdominal wall and uterine wall and directed toward the fetal mouth. The trocar is withdrawn and special fetoscopic instruments are inserted: a sheath loaded with a fiber endoscope and a catheter loaded with a detachable gold valve balloon. There also is a side connector permitting amnioinfusion with Hartmann solution. After passing the endoscope through the vocal cords to the trachea, the catheter is positioned to deliver the balloon just above it. The balloon is inflated with isotonic Omniscan, a magnetic resonance imaging contrast agent. The balloon is removed at approximately 34 weeks gestation, either by fetal tracheoscopy or by puncturing the balloon with an ultrasound-guided needle. The balloon was correctly placed in all 21 cases, on the first try in 16 of them. There were no serious maternal complications. The lungs were more echogenic within 48 hours, and the lung area-to-head circumference ratio improved from a median of 0.7 to 1.8 within 2 weeks. The median gestational age at delivery was 34 weeks, and in approximately three fourths of cases, it was more than 32 weeks. Nine newborn infants died from complications of pulmonary hypoplasia. Ten of 12 infants having surgical repair of CDH were doing well after a median of 18 months. Survival improved from 30% in the first 10 cases to 64% in the next 11, corresponding to a shift in the timing of FETO from the third to the second trimester, and also the use of epidural rather than general anesthesia. Only 1 of 12 control infants not given prenatal therapy lived to be discharged. This experience means that fetal surgery is feasible in cases of severe CDH when using a minimally invasive technique. Postnatal survival may improve as a result.

Pulmonary circulation of fetal sheep with lung hyperplasia following tracheal occlusion

Abstract: Objectives To determine the alteration of blood flow velocity profile in the pulmonary arteries (PAs) of fetal sheep after tracheal occlusion (TO). Methods Doppler ultrasound investigations of the PAs, the pulmonary trunk and the ductus arteriosus were performed weekly in nine ewes (gestational age 92–98 days, term 145 days) with singleton pregnancies after TO (n = 5) and in control fetuses (n = 4). Histological examinations with morphometry of pulmonary arterial vessels and of airways were performed in both groups. Results In the control group the experiments lasted 38 ± 6 days (mean ± SD), and in the TO group 25 ± 7 days. Relative lung weight was significantly higher in the TO group compared with the control group (14.5 ± 3.4% and 4.0 ± 0.5% of body weight). There were no significant differences in the Doppler parameters (pulsatility index, resistance index, the systolic peak, the diastolic minimum, time averaged maximum velocity) between groups. When the Doppler values of PAs in TO and control fetuses were combined, no significant differences between the left and right PA could be detected. The external diameter of peripheral PAs was significantly higher in the TO group as compared to control group (105.7 ± 2.5 µm vs. 96.9 ± 1.3 µm). Conclusions We found a threefold increase of fetal lung volume after TO without significant changes of blood flow velocity profiles in the PAs of fetal sheep. Copyright © 2004 ISUOG. Published by John Wiley & Sons, Ltd.

Magnetic resonance imaging of the feto-placentar unit after fetoscopic laser coagulation for twin-to-twin transfusion syndrome.

Abstract: Twin‐to‐twin transfusion syndrome (TTTS) is a severe complication in monochorionic twin pregnancies that results from a hemodynamical imbalance of placentar vascular anstomoses that connect the circulation of both fetuses. In TTTS, a poly/oligohydramnios sequence with high fetal morbidity and mortality rates occurs. Fetoscopic laser coagulation of the placentar anastomoses can limit or prevent fetal injury. The purpose of this report is to present and discuss fetal magnetic resonance imaging as a postoperative imaging tool after fetoscopic laser coagulation.

P09.15: Recurrence of twin–twin transfusion syndrome (TTTS) and feto-fetal hemorrhage: two complications of laser treatment with distinct ultrasound features

Abstract: Quintero’s stage 3 was sub-classified into two groups according to visible or non-visible donor bladder; Stage 3 atypical was defined as abnormal Doppler flow in either twin WITH visible donor bladder, Stage 3 classical as abnormal Doppler flow in either twin WITHOUT visible donor bladder. Results: Fifty-five cases (98%) was completed surgery (median gestational age 21.6 weeks and range 16.7 to 25.9, median operating time 85 minutes and range 34 to 210). Median gestational age at delivery was 32.1 weeks (range 18.0 to 38.6) and interval from procedure to delivery was 70 days (range 0 to 123). There were 90 of 112 survivors (80.4%) and 2 of 90 live infants had cystic periventricular leukomalacia (2.2%). There were 2 cases (3.6%) of miscarriage before 22 weeks gestation. Two survivors per mother were 87.5% in Stage 2, 64.9% in Stage 3 and 63.6% in Stage 4, however, 46.7% of two survivors in Stage 3 atypical in contrast to 77.3% in Stage 3 classical. There were 4.5% (1/22) of intrauterine fetal demise of donor in Stage 3 classical comparing to 46.7% (7/15) in Stage 3 atypical (p < 0.01). Conclusions: Our Japanese experience of FLP was almost as equal perinatal mortality and morbidity as previous report. Subclassification of Stage 3 with-/without donor bladder is considered reasonable and proper by means of perinatal outcome.

Synthetic and biodegradable prostheses in pelvic floor surgery

Abstract: Pelvic organ prolapse is an increasingly frequent problem and surgical repair remains the mainstay of therapy. Failure rates are as high as 30%, probably because the connective tissue used for repair is by definition qualitatively insufficient. There is therefore a lot of interest for augmentation of fascial repairs with implants. Experimental studies play an important role in the evaluation of such materials, documenting in vivo tensile strength, the host response to these foreign materials, particularly over longer periods. Non-reabsorbable synthetic implants lead to a permanent repair but the host usually develops a chronic inflammatory reaction which can be associated with bothersome side effects. Biological materials on the other hand have been much less studied and little is known about their long-term tissue response. They may, however, have their role as they may lead to less local side effects which may be mastered conservatively. The ultimate test for any material is obviously the clinical trial, defining its role in practice.

182 Improving Results with Percutaneous Fetal Endoscopic Tracheal Occlusion (FETO) for Severe Left Congenital Diaphragmatic Hernia.

Abstract: 182 Improving Results with Percutaneous Fetal Endoscopic Tracheal Occlusion (FETO) for Severe Left Congenital Diaphragmatic Hernia.

P04.24: Lung volume assessment at midgestation with 3D ultrasound to predict pulmonary hypoplasia in fetuses with isolated congenital diaphragmatic hernia

Abstract: villi with trophoblastic proliferation though the villi in nonmolar abortions have less pronounced edema. Subchorionic hematoma is very common in early pregnancy may show various kinds of US findings from huge solid mass to multilocular cyst. Hematoma occurred shortly after dilatation and curettage of uterus for abortion may mimic pathologic condition as hydatidiform mole or invasive mole. Understanding of pathophysiology of the hydatidiform mole and various kinds of US findings of hydatidiform mole and molar mimicker can aid to the work-up and management of molar gestation to illustrate the various kinds of US findings of hydatidiform mole and molar mimicker as incomplete abortion, subchorionic hematoma and hematoma after dilatation and curettage of the uterus.

OC14.02: Lung‐to‐head ratio and liver position to predict outcome in early diagnosed isolated left sided diaphragmatic hernia fetuses: a multicenter study

Abstract: DIAGNOSED ISOLATED LEFT SIDED DIAPHRAGMATIC HERNIA FETUSES: A MULTICENTER STUDY JACQUES JANI, ALEXANDRA BENACHI, RENE FAVRE, ROBERTA KELLER, HILDE VANDECRUYS, JULIAN DELGADO, MICHAEL HARRISON, JACQUELINE MATIS, EDUARD GRATACOS, KYPROS NICOLAIDES, JAN DEPREST, University Hospital Gasthuisberg, Obstetrics and Gynecology, Leuven, Belgium, Hopital Necker-Enfants Malades, Obstetrics and Gynaecology, Paris, France, CHRU Strasbourg, Obstetrics and Gynecology, Schiltigheim, France, University of California, San Francisco, Neonatology/Pediatrics, San Francisco, California, King’s College London, Harris Birthright Research Centre, London, United Kingdom, Hospital Universitari Vall Hebron, Obstetrics and Gynecology, Barcelona, Spain, University of California, San Francisco, Surgery & Pediatrics, San Francisco, California, CHRU Strasbourg, Neonatology, Schiltigheim, France OBJECTIVE: Congenital diaphragmatic hernia (CDH) is associated to high neonatal mortality. Accurate prediction of outcome is crucial in counselling parents about management options. We evaluated Lung-to-Head Ratio (LHR) and liver position in prediction of outcome of isolated Left CDH. STUDY DESIGN: Retrospective review of consecutive patients diagnosed with isolated LCDH %28 weeks, evaluated at 6 tertiairy units from 1995 onwards. Only patients with LHR measurements by experienced sonographers and with known liver position by ultrasound or MRI, both %28 wks, were included. Outcome measure was survival at discharge from NICU. RESULTS: 134 cases had an LHR obtained at 24.4 G 2.8 wks. 11 patients (8%) opted for termination after evaluation, all with LHR !1.4. There were no postnatal diagnoses of chromosomal anomalies. Overall survival was 43% (58/ 134), after substraction of antenatal losses 47% (58/123). In case of liver herniation survival was 35 %. LHR correlated to survival irrespective of liver position but combination of both variables predicted neonatal outcome better: liver up & LHR !1 predicted a survival of 9%. When LHR !0.8 and liver up, there were no survivors, but with liver down (37% of cases) survival was 40%. When LHR !0.6 there were no survivors irrespective of liver position. CONCLUSION: Combination of liver up& LHR !1 at %28 wks predicts a !10 % chance of survival, dropping to 0% if LHR !0.8. 8% of patients opted for termination after second opinion, all with LHR !1.4, but only in half this coincided with the above poor prognostic indicators.

183 Lung-To-Head Ratio and Liver Position to Predict Outcome in Early Diagnosed Isolated Left Sided Diaphragmatic Hernia Fetuses: A Multicenter Study.

Abstract: Objective: In utero diagnosed congenital diaphragmatic hernia (CDH) is associated to high antenatal and neonatal loss rates. Accurate prediction of outcome is crucial in counselling parents about management options. We evaluated Lung-to-Head Ratio (LHR) and liver position in prediction of outcome of isolated Left CDH.

P04.26: Evolution of antenatal detection and outcome in congenital diaphragmatic hernia (CDH): an 18 year French registry‐based evaluation

Abstract: Objective: A retrospective analysis of the prognostic significance of the lung-to-head ratio (LHR) and other ultrasound parameters on the outcome of fetuses with left-sided congenital diaphragmatic hernia (CDH). Methods: 25 fetuses with CDH. The LHR was obtained by measuring the right lung at the level of the four chamber view of the heart in the transverse plane. Mean gestational age of diagnosis was 30 ± 5 weeks. Results: 11 (44%) fetuses had isolated CDH, 6 (24%) had heart defects with extracardiac anomalies (meningocele-1, omphalocele1, multicystic kidney-1, hydronephrosis-2, cleft lip and palate-1). 6 (24%) had isolated heart defects, 2 (9%) – only extracardiac anomalies (meningocele-1, hydronephrosis-1). VSD was diagnosed in 5 cases, AVSD – in 2, HLHS – 1, PS – 1, AT – 1, TOF – 2. 3 fetuses had trisomy 18 and were excluded from further analysis, 1 of them died in utero, 1 died after delivery, 1 pregnancy is ongoing. LHR was measured in 18 fetuses. 13 fetuses had LHR < 0.9 – all of them died: 8 after delivery, 5 after operation. 3 had LHR between 0.9 and 1.2–1 pregnancy was terminated, 2 newborns are alive after operation. 2 fetuses had LHR > 1.2–1 child survived after operation, 1 pregnancy is ongoing. Overall, just 3 (13.6%) children out of 22 are alive after the operation, all without heart defects, one had hydronephrosis. Conclusion: LHR proved to be a good predictor for fetal outcome. Co-existence of heart defect and CDH is poor prognostic factor. Outcome of fetuses with CDH is poor, so new methods of prenatal treatment should be considered.