OBJECTIVE: To assess feasibility and maternal and infant outcome after fetoscopic tracheal balloon occlusion in patients with severe congenital diaphragmatic hernia. METHODS: We conducted a prospective cohort study of fetuses with congenital diaphragmatic hernia and observed/expected lung/head ratio less than 30%. Eligible women had planned fetoscopic tracheal balloon occlusion at 26 0/7–29 6/7 weeks of gestation and balloon removal 4–6 weeks later. Standardized prenatal and postnatal care was at a single institution. Fetoscopic tracheal balloon occlusion details, lung growth, obstetric complications, birth outcome, and infant outcome details until discharge were evaluated. RESULTS: Of 57 women screened, 14 (25%) were enrolled between 2015 and 2019. The congenital diaphragmatic hernia was left in 12 (86%); the pre–fetoscopic tracheal balloon occlusion observed/expected lung/head ratio was 23.2% (range 15.8–29.0%). At a median gestational age of 28 5/7 weeks (range 27 3/7–29 6/7), fetoscopic tracheal balloon occlusion was successful in all cases, and balloons remained in situ. Removal was elective in 10 (71%) patients, by ultrasound-guided needle puncture in eight (57%), and occurred at a median of 33 4/7 weeks of gestation (range 32 1/7–34 4/7; median occlusion 34 days, range 17–44). The post–fetoscopic tracheal balloon occlusion observed/expected lung/head ratio increased to a median of 62.8% (44.0–108) and fell to a median of 46.6% (range 30–92) after balloon removal (all Mann Whitney U, P<.003). For prevention of preterm birth, all patients received vaginal progesterone; 11 (79%) required additional tocolytics, three (21%) had vaginal pessary placement for cervical shortening, and five (36%) had amnioreduction for polyhydramnios. Median gestational age at birth was 39 2/7 weeks (range 33 6/7–39 4/7), with term birth in eight (57%) patients. Twelve (86%) neonates required high-frequency ventilation, and seven (50%) required extracorporeal membrane oxygenation for a median of 7 days (range 3–19). All neonates needed patch repair. Neonatal survival was 93% (n=13, 95% CI 49–100%), and survival to hospital discharge was 86% (n=12, 95% CI 44–100%). CONCLUSION: Fetoscopic tracheal balloon occlusion for severe congenital diaphragmatic hernia was feasible in our single-center setting, with few obstetric complications and favorable infant outcome. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02710968.
(Obstet Gynecol. 2020;135:511–521) Congenital diaphragmatic hernia, caused by the absence of the diaphragm or part of the diaphragm, leads to impaired fetal lung development as the abdominal contents move into the chest cavity. This is commonly managed with high-frequency oscillatory ventilation, pulmonary vasodilators, and extracorporeal membrane oxygenation, but the survival rate is <20% in cases with an observed lung/head ratio of <25% and intrathoracic liver herniation. In temporary fetoscopic tracheal balloon occlusion (FETO), the lungs are stretched and increase growth in airways and lung vasculature takes place. FETO has demonstrated increased survival rates, but is also associated with adverse outcomes such as preterm labor, rupture of membranes, and preterm birth. This study aimed to determine feasibility of FETO in cases of severe congenital diaphragmatic hernia.
Prenatal ultrasound and Doppler findings of progressing portal hypertension in a fetus with congenital cystic hepatobiliary diseaseA 37-year-old woman, gravida 3 para 0, was referred at 24 + 5 weeks' gestation for suspected fetal ascites. On examination, ascites and hepatomegaly with multiple subcapsular hepatic cysts were noted (Figure 1). The brain, kidneys and lungs, and the hepatic vasculature, umbilical artery (UA), middle cerebral artery (MCA), umbilical vein (UV) and ductus venosus flow velocity waveforms were all normal. Fetal magnetic resonance imaging confirmed the findings and raised concern for hepatic cystic dysplasia with cirrhosis. A diagnostic amniocentesis and fetal paracentesis revealed the predominance of lymphocytes and monocytes in the ascites, normal karyotype, normal microarray analysis and negative viral polymerase chain reaction studies. On follow-up, hepatomegaly and cyst numbers had increased; at 30 weeks' gestation, maternal
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