Jörn Siemer

Actual Outcome in Infants with Congenital Diaphragmatic Hernia: The Role of a Standardized Postnatal Treatment Protocol

Background: Congenital diaphragmatic hernia (CDH) is a severe congenital anomaly with a high rate of mortality and morbidity. Objective: Our aim was to determine a possible effect of standardized treatment on outcome in infants with CDH. Methods: All prenatally diagnosed patients with unilateral CDH born alive between January 2006 and December 2009 at the Erasmus MC or the University Hospital Mannheim were eligible for inclusion. Patients who underwent a fetal tracheal occlusion were excluded. From November 1, 2007, all CDH patients were treated according to a standardized treatment protocol. Patients were divided into two chronological groups according to their date of birth: without standardized treatment (group 1, Jan 2006–Oct 2007) and with standardized treatment (group 2, Nov 2007–Dec 2009). Outcome measures were mortality by day 28, bronchopulmonary dysplasia (BPD), defined as oxygen dependency at day 28, and need for extracorporeal membrane oxygenation (ECMO) therapy. Uni- and multivariate analyses were performed. Results: 167 patients were included. By day 28, 18% of the infants had died. Of the patients who were alive at day 28, 49% had BPD. An ECMO procedure was performed in 31% of the patients. Overall mortality for all included patients was 22%. In group 1, overall mortality was 33% and in group 2 overall mortality was 12% (p = 0.004). A standardized treatment protocol was independently associated with a reduced risk for mortality by day 28 (OR 0.28, 95% CI 0.11–0.68). Higher observed-to-expected lung-to-head ratios were independently associated with a lower risk for mortality by day 28 (OR 0.97, 95% CI 0.95–0.99), BPD (OR 0.97, 95% CI 0.94–0.98) and need for ECMO (OR 0.98, 95% CI 0.96–0.99). An intrathoracic position of the liver was independently associated with an increased risk for BPD (OR 3.12, 95% CI 1.41–6.90) and need for ECMO therapy (OR 3.25, 95% CI 1.54–6.88). Conclusion: Survival rates in patients with CDH increased significantly after the implementation of a standardized treatment protocol.

Associated malformations in congenital diaphragmatic hernia.

Congenital diaphragmatic hernia (CDH) is a severe neonatal anomaly. The aim of this study was to evaluate the frequency and types of malformations associated with CDH. The outcome was compared with that in newborns with CDH alone. The study included 362 fetuses and newborns at a single national center for CDH. Associated malformations and chromosomal aberrations were noted prenatally and postnatally. The neonatal outcome was assessed relative to the use of extracorporeal membrane oxygenation (ECMO) and the mortality rate. At least one associated malformation was diagnosed in 143 cases (39.5%). Altogether, 272 associated malformations were found. Only 50 (18.4%) anomalies were diagnosed antenatally. In 62 (17.1%) cases, 102 major malformations were found along with CDH, with a prenatal detection rate of 35.3%. The associated malformations were very heterogeneous, but cardiovascular malformations were the most common. Newborns with major anomalies, chromosomal aberrations, or syndromes additional to CDH had a significantly lower survival rate than newborns with an isolated CDH. Associated malformations did not affect the rate of ECMO treatment. Associated malformations in CDH are frequent and heterogeneous, and diligent and experienced antenatal and postnatal care is important.

Prediction of chronic lung disease, survival and need for ECMO therapy in infants with congenital diaphragmatic hernia: Additional value of fetal MRI measurements?

INTRODUCTION The lung-to-head ratio (LHR), measured by ultrasound, and the fetal lung volume (FLV), measured by MRI, are both used to predict survival and need for extra corporeal membrane oxygenation (ECMO) in infants with congenital diaphragmatic hernia (CDH). The aim of this study is to determine whether MRI measurements of the FLV, in addition to standard ultrasound measurements of the LHR, give better prediction of chronic lung disease, mortality by day 28 and need for ECMO. MATERIALS AND METHODS Patients with unilateral isolated CDH born between January 2002 and December 2008 were eligible for inclusion. LHR and FLV were expressed as observed-to-expected values (O/E LHR and O/E FLV). Univariate and multivariate analyses were performed. Receiver operating characteristic curves were constructed and areas under the curve (AUC) were calculated to determine predictive values. RESULTS 90 patients were included in the analysis. Combined measurement of the O/E LHR and O/E FLV gave a slightly better prediction of chronic lung disease (AUC=0.83 and AUC=0.87) and need for ECMO therapy (AUC=0.77 and AUC=0.81) than standard ultrasound measurements of the O/E LHR alone. Combined measurement of the O/E LHR and O/E FLV did not improve prediction of early mortality (AUC=0.90) compared to measurement of the O/E LHR alone (AUC=0.89). An intrathoracal position of the liver was independently associated with a higher risk of early mortality (p<0.001), chronic lung disease (p=0.007) and need for ECMO therapy (p=0.001). DISCUSSION Chronic lung disease and need for ECMO therapy are slightly better predicted by combined measurement of the O/E LHR and the O/E FLV. Early mortality is very well predicted by measurement of the O/E LHR alone. CONCLUSION Clinical relevance of additional MRI measurements may be debated.

Combination of misoprostol and mechanical dilation for induction of labour: a randomized controlled trial.

OBJECTIVE To evaluate a combination of oral misoprostol (OM) and mechanical dilation of the cervix to improve efficacy in inducing labour. STUDY DESIGN This prospective, randomized study included 122 term pregnancies with an indication for induced labour. Each woman was randomly assigned to one of two groups. In the study group, a combination of OM and mechanical dilation with a double-balloon catheter for cervical ripening was used. In the control group, only OM was administered. The primary outcome measure was the rate of failure to induce labour, defined as no vaginal delivery within 48h. RESULTS In the study group, the rate of failure to induce labour was significantly lower in comparison with the control group (9.3% vs. 21.2%; P=0.007). The median times for inducing labour were 15.3h in the study group and 20.8h in the control group (P=0.158). There were no significant differences between the two groups with regard to other outcome parameters. As there were no failures of induced labour among women with premature rupture of membranes, the study results were also evaluated after excluding these cases. Among those women without rupture of membranes, the median times for induction were 15.8h in the study group and 32.6h in the control group (P=0.024). The rates of failure to induce labour were 10.8% vs. 28.2% (P=0.002). CONCLUSION A combination of OM and a double-balloon catheter improves the efficacy of labour induction in term pregnancies, particularly in women without premature rupture of the membranes.

Assessment of Lung Volume by 3-Dimensional Sonography and Magnetic Resonance Imaging in Fetuses With Congenital Diaphragmatic Hernias

The purpose of this study was to evaluate the influence of different rotation angles in assessment of the contralateral lung volume by 3‐dimensional (3D) sonography in comparison to magnetic resonance imaging (MRI) in fetuses with congenital diaphragmatic hernias.

Prediction of Mortality and the Need for Neonatal Extracorporeal Membrane Oxygenation Therapy by 3-Dimensional Sonography and Magnetic Resonance Imaging in Fetuses With Congenital Diaphragmatic Hernias

To compare different rotation angles for assessment of fetal lung volume by 3‐dimensional (3D) sonography with magnetic resonance imaging (MRI) regarding prediction of mortality and the need for neonatal extracorporeal membrane oxygenation (ECMO) therapy in fetuses with congenital diaphragmatic hernias.

Prediction of Postnatal Outcomes in Fetuses With Isolated Congenital Diaphragmatic Hernias Using Different Lung-to-Head Ratio Measurements

The purpose of this study was to compare different methods for measuring the fetal lung area‐to‐head circumference ratio and to investigate their prediction of postpartum survival and the need for neonatal extracorporeal membrane oxygenation (ECMO) therapy in fetuses with isolated congenital diaphragmatic hernias.

Finding the most accurate method to measure head circumference for fetal weight estimation.

OBJECTIVE Accurate measurement of fetal head biometry is important for fetal weight estimation (FWE) and is therefore an important prognostic parameter for neonatal morbidity and mortality and a valuable tool for determining the further obstetric management. Measurement of the head circumference (HC) in particular is employed in many commonly used weight equations. The aim of the present study was to find the most accurate method to measure head circumference for fetal weight estimation. STUDY DESIGN This prospective study included 481 term pregnancies. Inclusion criteria were a singleton pregnancy and ultrasound examination with complete fetal biometric parameters within 3 days of delivery, and an absence of structural or chromosomal malformations. Different methods were used for ultrasound measurement of the HC (ellipse-traced, ellipse-calculated, and circle-calculated). As a reference method, HC was also determined using a measuring tape immediately after birth. FWE was carried out with Hadlock formulas, including either HC or biparietal diameter (BPD), and differences were compared using percentage error (PE), absolute percentage error (APE), limits of agreement (LOA), and cumulative distribution. RESULTS The ellipse-traced method showed the best results for FWE among all of the ultrasound methods assessed. It had the lowest median APE and the narrowest LOA. With regard to the cumulative distribution, it included the largest number of cases at a discrepancy level of ±10%. The accuracy of BPD was similar to that of the ellipse-traced method when it was used instead of HC for weight estimation. CONCLUSION Differences between the three techniques for calculating HC were small but significant. For clinical use, the ellipse-traced method should be recommended. However, when BPD is used instead of HC for FWE, the accuracy is similar to that of the ellipse-traced method. The BPD might therefore be a good alternative to head measurements in estimating fetal weight.

Influence of Different Rotation Angles in Assessment of Lung Volumes by 3-Dimensional Sonography in Comparison to Magnetic Resonance Imaging in Healthy Fetuses

Three‐dimensional (3D) sonographic volumetry is established in gynecology and obstetrics. Assessment of the fetal lung volume by magnetic resonance imaging (MRI) in congenital diaphragmatic hernias has become a routine examination. In vitro studies have shown a good correlation between 3D sonographic measurements and MRI. The aim of this study was to compare the lung volumes of healthy fetuses assessed by 3D sonography to MRI measurements and to investigate the impact of different rotation angles.

Welche Erwartungen stellen Schwangere an eine ideale Entbindungsklinik

PURPOSE The aim of this study was to evaluate expectations of pregnant women on an ideal maternity hospital. MATERIAL AND METHODS We prospectively performed a survey among 566 pregnant women with regard to their expectations on a perfect hospital for obstetrics. Data collection was accomplished in 3 obstetrical departments in Mannheim, Germany. The questionnaire contained 23 general questions about sociodemographic characteristics and 34 specific questions about the anticipated childbirth. Women who were less than 20 weeks pregnant and women who did not speak German fluently were excluded from this study. RESULTS In our survey the possibility to get to know midwifes and doctors at information evenings and a guided delivery room tour were defined as very important factors by the interviewed women. Of particular importance was a continuous care by a single midwife and the physical attendance of a family member during childbirth. Furthermore, friendliness of the staff and medical care by paediatricians after childbirth were identified to be important. To some extent, a modern appearance of the ward was also a matter of importance. CONCLUSIONS The medical treatment of mother and the newborn child and the friendliness of the staff have been identified as the most important factors with regard to the expectations of women on an ideal maternity hospital. In addition, a pleasant ambiance of the ward and regular visits by a lactation specialist were named as important.