APSA Paper
Percent predicted lung volumes as measured on fetal magnetic resonance imaging: a useful biometric parameter for risk stratification in congenital diaphragmatic hernia

Presented at the 37th Annual Meeting of the American Pediatric Surgical Association, May 20–24, 2006, Hilton Head, SC.
https://doi.org/10.1016/j.jpedsurg.2006.09.018Get rights and content

Abstract

Purpose

This study was aimed at determining whether a new method of analyzing lung volumes on fetal magnetic resonance (MR) imaging could be used to predict the degree of pulmonary compromise in congenital diaphragmatic hernia (CDH).

Methods

Seventeen fetuses with CDH were prospectively evaluated by MR. Lung volumes were measured using an established technique and expressed as a percentage of the predicted lung volume (PPLV). Predicted lung volume was determined by subtracting measured mediastinal volume from total measured thoracic volume. The PPLV was correlated with postnatal outcomes. Statistical analyses were performed using the Mann-Whitney, Spearman correlation, or Fisher exact tests (P < .05).

Results

Of the 14 liveborn patients, the PPLV was 20.3±10.4 (gestational age at MR, 22.3 ± 5.7 weeks). The PPLV was significantly associated with extracorporeal membrane oxygenation (ECMO) use, hospital length of stay, and survival. All patients with a PPLV of less than 15 required prolonged ECMO support and had a 40% survival rate. In contrast, only 11% of patients with a PPLV of greater than 15 required ECMO, and survival was 100%.

Conclusion

The PPLV as measured by fetal MR imaging can accurately predict disease severity in CDH. A value of less than 15 is associated with a significantly higher risk for prolonged support and/or death, despite aggressive postnatal management.

Section snippets

Materials and methods

This prospective study was conducted under an approved institutional review board protocol (M02-10-240). From December 2000 to January 2005, 74 fetuses with sonographically diagnosed CDH were referred to the Advanced Fetal Care Center at Children's Hospital Boston. Confirmatory prenatal sonograms (ATL 5000, Philips, Bothell, Wash, or Sequoia, Siemens, Mountain View, Calif) were performed. When gestational age was appropriate and fetal lie permitted, LHR was calculated during these examinations.

Results

There were 12 left-sided and 5 right-sided hernias. Seventy-one percent had prenatal evidence of liver herniation. Three pregnancies were electively terminated, resulting in 14 patients with postnatal outcomes data. The gestational age at MR imaging and gestational age at birth were 22.3 ± 5.7 weeks and 37.3 ± 1.1 weeks, respectively. The birth weight was 2949 ± 414 g. Six patients underwent controlled intubation as part of an EXIT procedure. Forty-seven percent required substantial ECMO

Discussion

Over the past 2 decades, there have been numerous attempts to use prenatal ultrasound as an imaging tool to accurately predict the degree of pulmonary hypoplasia in CDH [1], [18], [19], [20], [21], [22], [23]. Ultrasound markers that have been associated with a higher mortality include a diagnosis before 25 weeks gestation, an intrathoracic stomach, right-sided defect, polyhydraminos, and liver herniation [3], [18]. Additionally, various sonographic biometric parameters, including the LHR, have

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