Fetal Intervention for Congenital Diaphragmatic Hernia

Abstract

Despite improvements in surgical techniques, the results of open fetal surgery to correct congenital diaphragmatic hernia have been disappointing. Hysterotomy induces preterm labour and, where there is a large volume of liver in the fetal chest, reduction of the liver into the abdomen induces immediate fetal death. Less invasive techniques, using both open surgery and fetoscopy, are being developed in the hope of reducing fetal demise. These techniques include blocking the trachea, the creation of an artificial gastroschisis and induction of graft tolerance for postnatal lung transplantation.

Prognosis of Congenital Diaphragmatic Hernia

“…New techniques such as 'PLUG' (Plug the Lung Until it Grows) involves inducing tracheal obstruction in a fetus with CDH to encourage maturation of residual lung tissue. It has been tried experimentally in fetal lambs and may have applications for CDH therapy in the future (16). Lung transplantation at birth, either cadaveric or living related donor, or creation of an iatrogenic gastroschisis to relieve pressure on the developing lung are also techniques undergoing evaluation (16).…”

“…It has been tried experimentally in fetal lambs and may have applications for CDH therapy in the future (16). Lung transplantation at birth, either cadaveric or living related donor, or creation of an iatrogenic gastroschisis to relieve pressure on the developing lung are also techniques undergoing evaluation (16). Partial liquid ventilation with ECMO support is also under investigation.…”

Effect of immediate versus slow intrauterine reduction of congenital diaphragmatic hernia on lung development in the sheep: A morphometric analysis of term pulmonary structure and maturity

“…[3][4][5][6] Reliable diagnosis of CDH prenatally by ultrasound, [6][7][8] together with a poor prognosis, have led to the development of a variety of intrauterine interventions aimed at inducing lung growth and development sufficient to support postnatal life. 5,6,[9][10][11][12][13][14] The mortality and morbidity of the "cures" need to be considered along with the efficacy of prevention or reversal of pulmonary hypoplasia. Open surgical methods, with uterine incision, are often complicated by preterm labor, 5,14 and this risk is greater the longer and more complex the surgical procedure.…”

“…5,6,[9][10][11][12][13][14] The mortality and morbidity of the "cures" need to be considered along with the efficacy of prevention or reversal of pulmonary hypoplasia. Open surgical methods, with uterine incision, are often complicated by preterm labor, 5,14 and this risk is greater the longer and more complex the surgical procedure. Immediate reduction of the hernia contents at surgery, especially of the left lobe of the liver, can occlude blood flow from the placenta to the fetus by kinking of the ductus venosus.…”

Glycine as a Potential Window for Minimal Access Fetal Surgery

“…Fetal anatomical abnormalities may become lethal be cause of the mechanical pressure that they exert on adja cent organs, or because they obstruct a drainage system [ 1,2], Therefore, attempts have been made to relieve those pressure effects by open fetal surgery and drainage proce-dures in the hope of reducing or reversing those effects before birth [1,3,4], One common [5,6] lethal anomaly (1:2,000 pregnancies), for which antenatal correction has been attempted, is congenital diaphragmatic hernia (CDH). But, open fetal surgery for CDH, where a signifi cant portion of the fetus is exposed, has met with a high incidence of preterm labor [7] and potential injury to the fetus [8].…”