E. Takashi

Prediction and probability of neonatal outcome in isolated congenital diaphragmatic hernia using multiple ultrasound parameters

To evaluate the accuracy and probabilities of different fetal ultrasound parameters to predict neonatal outcome in isolated congenital diaphragmatic hernia (CDH).

Comparison between fetal endoscopic tracheal occlusion using a 1.0-mm fetoscope and prenatal expectant management in severe congenital diaphragmatic hernia.

Objectives: To evaluate if fetal endoscopic tracheal occlusion (FETO) for severe congenital diaphragmatic hernia (CDH) using a 1.0-mm fetoscope improves neonatal outcome. Method: Between January 2006 and December 2008, a controlled study was conducted at a single center in which FETO was proposed for fetuses with severe isolated CDH (lung-to-head ratio <1.0) and liver herniation to the thoracic cavity but no other detectable anomalies at diagnosis (<26 weeks). FETO was performed under maternal epidural and fetal intramuscular anesthesia, guided by ultrasonography and 1.0-mm fetoscope between 26 and 30 weeks. All cases submitted to FETO were delivered by ex utero intrapartum therapy procedure. Postnatal therapy was the same for both treated fetuses and controls. The primary outcome was neonatal survival (up to 28 days after birth). Results: A total of 35 women met the inclusion criteria, and in 17 of them, fetal intervention was intended. However, in 1 case, it was not possible to insert the balloon inside the fetal trachea because of placental bleeding. FETO was therefore successfully performed in 16 fetuses with severe CDH. Eighteen cases received no prenatal intervention and served as the control group. Mean gestational age at diagnosis was similar in both groups (p > 0.05). Delivery occurred at 35.6 (range: 28–38) weeks in the FETO group and at 37.5 (range: 31–40) weeks (p = 0.18) among controls. Nine of 17 (52.9%) infants in the FETO group and 1 of 18 (5.6%) in the control group survived (p < 0.01). Severe pulmonary arterial hypertension was present in 8/17 (47.1%) infants from the FETO group and in 16/18 (88.9%) controls (p = 0.01). Conclusion: The present study shows that FETO using a 1.0-mm fetoscope is feasible and may improve neonatal outcome in severe CDH.

Quantitative Lung Index, Contralateral Lung Area, or Lung-to-Head Ratio to Predict the Neonatal Outcome in Isolated Congenital Diaphragmatic Hernia?

To estimate the accuracy of the quantitative lung index and contralateral lung area for prediction of the neonatal outcome in isolated congenital diaphragmatic hernia in comparison to other available prediction models.

OC20.05: Quantitative lung index, contralateral lung area or lung-to-head ratio to predict neonatal outcome in isolated congenital diaphragmatic hernia?

A. G. den Boogert1, E. de Jong-Pleij1, L. S. Ribbert1, L. R. Pistorius2, M. Bakker4, E. Tromp3, C. M. Bilardo4 1Department of Obstetrics and Gynecology, St. Antonius Hospital, Utrecht, Netherlands; 2Fetal Medicine Unit, University Medical Centre Utrecht, Utrecht, Netherlands; 3Department of Statistics, St. Antonius Hospital, Utrecht, Netherlands; 4Fetal Medicine Unit, University Medical Centre Groningen, Groningen, Netherlands

OC15.06: Probability of neonatal outcomes in isolated congenital diaphragmatic hernia by evaluating fetal pulmonary vasculature

Objectives: To explore the utility of intrapulmonary Doppler in predicting severe neonatal pulmonary hypertension in fetuses with congenital diaphragmatic hernia (CDH) treated with fetoscopic tracheal occlusion (FETO). Methods: A cohort of 51 left-sided CDH fetuses with liver herniation and an observed/expected lung to head ratio (LHR) below 45%, treated with FETO between 26 to 33 weeks of gestation. Intrapulmonary Doppler Pulsatility Index (PI) and the peak early diastolic reversed flow (PEDRF) were evaluated 1 day before FETO, and their isolated and combined value to predict the risk of severe neonatal pulmonary hypertension was evaluated by decision tree analysis and multiple logistic regression adjusted by gestational age at birth. Results: Cases with severe pulmonary hypertension had significantly lower LHR values (25.8 vs. 29.9, P = 0.03) and higher intrapulmonary Doppler PI (5.3 vs. 4.4, P < 0.01). Decision tree analysis identified the intrapulmonary Doppler as the best predictor of severe neonatal pulmonary hypertension. Cases with increased PI (> 95th centile) showed a significantly higher risk (71.4% vs. 25.0%, P = 0.001) than those with normal PI. In the group with normal PI, increased PEDRF (above 2 z-scores) identified a subgroup with significantly higher risk (44.4% vs. 0%, P < 0.05). Similarly, among the 26 fetuses who survived, those with increased PI showed a significant higher frequency of severe pulmonary hypertension (42.9% vs. 8.3%, P < 0.05). All survivors with severe pulmonary hypertension showed either abnormal intrapulmonary PI or increased PEDRF values prenatally. Conclusions: Fetal intrapulmonary Doppler evaluation predicts the risk of severe neonatal pulmonary hypertension in CDH fetuses treated with FETO. OC15.06 ˆProbability of neonatal outcomes in isolated congenital diaphragmatic hernia by evaluating fetal pulmonary vasculature

OP17.09: Probability of neonatal outcomes in isolated congenital diaphragmatic hernia using fetal lung size measurements

Methods: 196 patients who underwent laser therapy for TTTS between 2004 and 2007 were included. Cervical lengths (CL), measured by trans-vaginal ultrasound (TVS), and cervical colonization patterns were analyzed 24 h before laser. All women received a single dose of 1 g Cefazolin i.v. before the procedure. We investigated the association between cervical length, an abnormal smear and spontaneous abortion or PTD leading to fetal loss. Results: 16 women (8.2%) lost both fetuses by miscarriage or extremely PTD leading to immediate neonatal death. CL was significantly shorter in those who aborted. However, 7 women with a CL of < 20 mm gave birth to at least one survivor. Smear results were attributed to 3 groups: local standard flora (1), bacterial vaginosis or other abnormality (2) and (3) presence of fetopathic microorganisms. Of 190 smears, 79 were classified as normal (1), 111 as abnormal (group 2: n = 63, group 3: n = 48). There was no association between an abnormal smear (group 2+3) before laser and pregnancy loss (OR 0.8; P = 0.53). Conclusions: TVS is superior to cervical smears in identifying patients at risk for pregnancy loss. There is no reason to deny laser treatment to any woman with TTTS not in labor on the basis of an abnormal smear or a short cervix. Questionable negative effects of group B streptococci (GBS) infection will undergo further investigation.

OP18.08: Predicting neonatal outcome in 40 fetuses with congenital cystic adenomatoid malformation using fetal lung volumes

Objectives: To evaluate usefulness of sagittal CDUS images for the differential diagnosis of fetal cleft lip (CL) and cleft palate (CP). Methods: We got coronal and axial images of upper lip and maxillary alveolar in 25 fetuses with CL and CP. Existence of defect and malalignment of alveolar was assessed. We assessed existence of hard palate defect on the mid-sagittal image and flow through the defect on CUDS during fetal swallowing. We compared the US findings with postnatal features. We assessed the accuracy of axial and sagittal images in the differential diagnosis of CL and CP. Results: 19 cases had CL and CP. 6 cases had CL without CP. 3 of 6 CL cases had cleft alveolar. Alveolar defect on axial image was detected in 18 of 19 cases with CP and 3 of 6 with CL. Alveolar malalignment was detected in 11 of 19 cases with CP, but in no case with CL. Hard palate defect on the sagittal image was detected in 15 of 19 cases with CP, but in no case with CL. CDUS evaluation of fetal swallowing was possible in 20 of 25 cases. Communicating flow through the palate defect was detected in 14 of 15 cases with CP, but in no case with CL. The accuracy of alveolar defect and malalignment on axial image were 84% and 68%, respectively. Accuracy of hard palate defect and flow on mid-sagittal image were 84% and 95%, respectively. Combined axial and sagittal images correctly diagnosed in all 6 cases with CL and 18 of 19 cases with CP. The accuracy was 96%. Conclusions: Sagittal US evaluation of the fetal hard palate may have additional value in the differential diagnosis of fetal CL and CP.

OP27.02: Prediction of neonatal outcome in 20 fetuses with severe left congenital diaphragmatic hernia submitted to percutaneous fetal tracheal occlusion by the lung‐head ratio

Objectives: To evaluate the potential use of the lung-head ratio (LHR) for the prediction of neonatal outcome in severe left congenital diaphragmatic hernia (CDH) after fetal tracheal occlusion (FETO). Methods: Between January 2006 and December 2009, 20 fetuses with severe, isolated left CDH (LHR < 1.0 and liver-up) were submitted to FETO between 26–30 weeks of gestation. The LHR was evaluated before (26–28 ws) and after (32 ws) FETO procedure and then correlated with neonatal outcome (deaths). Results: Neonatal deaths occurred in 9/20 (45.0%) cases. Significantly lower values of LHR were observed in those cases that died before (0.6 ± 0.3) and after (0.9 ± 0.4) FETO procedures in comparison to those that survived (0.8 ± 0.3 and 1.6 ± 0.4; respectively, P < 0.05). Conclusions: The LHR may be useful to predict neonatal outcome in fetuses with severe left CDH submitted to FETO procedures.

OP27.01: Prediction of neonatal outcome in 20 fetuses with severe left congenital diaphragmatic hernia submitted to percutaneous fetal tracheal occlusion by the observed/expected fetal lung volumes

Objectives: Mesh implants are widely used in surgery for female pelvic organ prolapse. Mesh shrinkage is thought to be common and due to immunological processes, rather than surgical methods or technique. In this study we longitudinally examined postoperative mesh dimensions by translabial 4D ultrasound. Methods: We analysed ultrasound (US) volume datasets obtained from women attending follow-up 3–52 months after placement of PerigeeTM mesh (5.0 × 3.7 cm after trimming of mesh tail). Patients were examined by translabial US, at rest and on Valsalva, supine and after voiding. The datasets of the first and last available postoperative appointments were analysed with post processing software, with the operator blinded against all clinical data and the order in which volumes had been obtained. Results: Of 63 women who had a mesh implanted between May 05 and March 09, 40 women were identified whom we had assessed at least twice, comprising a total of 59.6 woman-years. 37/40 (93%) were satisfied at their last appointment. 18/40 considered themselves cured, and 18/40 felt improved. Objective recurrence (cystocele ICS POP-Q stage 2+) was seen in 16/40, and 11 reported symptoms of prolapse. Table 1 shows measurements obtained at first and last appointments. Conclusions: In this longitudinal study after Perigee mesh we found no evidence of long-term contraction from 3 months after implantation onwards. On the contrary, midsagittal mesh length at rest and on Valsalva increased by almost 10% over a period of 18 months.