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Fetal Pulmonary Response After Fetoscopic Tracheal Occlusion for Severe Isolated Congenital Diaphragmatic Hernia

Ruano, Rodrigo MD, PhD; da Silva, Marcos Marques MD; Campos, Juliana Alvares Duarte Bonini DDS, PhD; Papanna, Ramesha MD; Moise, Kenneth Jr MD; Tannuri, Uenis MD, PhD; Zugaib, Marcelo MD, PhD

doi: 10.1097/AOG.0b013e31823d3aea
Original Research

OBJECTIVE: To estimate the response in lung growth and vascularity after fetal endoscopic tracheal occlusion for severe congenital diaphragmatic hernia in the prediction of neonatal survival.

METHODS: Between January 2006 and December 2010, fetal lung parameters (observed-to-expected lung-to-head ratio; observed-to-expected lung volume; and contralateral lung vascularization index) were evaluated before fetal tracheal occlusion and were evaluated longitudinally every 2 weeks in 72 fetuses with severe isolated congenital diaphragmatic hernia. Thirty-five fetuses underwent fetal endoscopic tracheal occlusion and 37 cases did not.

RESULTS: Survival rate was significantly higher in the fetal endoscopic tracheal occlusion group (54.3%) than in the no fetal endoscopic tracheal occlusion group (5.4%, P<.01). Fetal endoscopic tracheal occlusion resulted in a significant improvement in fetal lung size and pulmonary vascularity when compared with fetuses that did not go to the fetal intervention (increase of the observed-to-expected lung-to-head ratio, observed-to-expected total lung volume, and contralateral pulmonary vascularization index 56.2% compared with 0.3%, 37.9% compared with 0.1%, and 98.6% compared with 0.0%, respectively; P<.01). Receiver operating characteristic curves indicated that the observed-to-expected total fetal lung volume was the single best predictor of neonatal survival before fetal endoscopic tracheal occlusion (cutoff 0.23, area under the curve [AUC] 0.88, relative risk 5.3, 95% confidence interval [CI] 1.4–19.7). However, the contralateral lung vascularization index at 4 weeks after fetal endoscopic tracheal occlusion was more accurate in the prediction of neonatal outcome (cutoff 24.0%, AUC 0.98, relative risk 9.9, 95% CI 1.5–66.9) with the combination of observed-to-expected lung volumes and contralateral lung vascularization index at 4 weeks being the best predictor of outcome (AUC 0.98, relative risk 16.6, 95% CI 2.5–112.3).

CONCLUSION: Fetal endoscopic tracheal occlusion improves survival rate by increasing the lung size and pulmonary vascularity in fetuses with severe congenital diaphragmatic hernia. The pulmonary response after fetal endoscopic tracheal occlusion can be used to predict neonatal survival.

LEVEL OF EVIDENCE: II

Fetal tracheal occlusion improves survival in cases of severe congenital diaphragmatic hernia by stimulating pulmonary growth and vasculature.

From the Obstetrics Department and Pediatric Surgery, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil; Texas Children's Fetal Center and the Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas; and the Social Department, Faculdade de Odontologia, Universidade Estadual Paulista, Araraquara, Brazil.

The present study is funded by the CNPq (Conselho Nacional de Desenvolvimento de Pesquisa e Tecnologia do Brasil).

Presented at the International Fetal Medicine and Surgery Society Meeting, September 25–30, 2010, Tokyo, Japan, and at the 20th World Congress on Ultrasound in Obstetrics and Gynecology, October 10–14, 2010, Prague, Czech Republic.

Corresponding author: Rodrigo Ruano, MD, PhD, Universidade de São Paulo, Faculdade de Medicina, Obstetrics Department, São Paulo, Brazil, Rua Dionisio da Costa, 63, ap 121, Sao Paulo, SP, Brazil, 04117-110; e-mail: rodrigoruano@hotmail.com.

Financial Disclosure The authors did not report any potential conflicts of interest.

© 2012 The American College of Obstetricians and Gynecologists