Learning Curve for Intrapulmonary Artery Doppler in Fetuses with Congenital Diaphragmatic Hernia

Cruz‐Martínez, R.; Cruz‐Lemini, M.; Méndez, Antonio; Illa, M.; García-Baeza, Víctor; Martínez, Josep M.; Gratacós, E.

doi:10.1159/000441026

Cited by 9 publications

(10 citation statements)

References 30 publications

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“…As a potential limitation of this study, it could be acknowledged that intrapulmonary Doppler insonation is technically difficult and it requires not only training to achieve competence but also very strict guidelines for acquisition and measurement. However, we recently demonstrated that even in inexperienced hands, intrapulmonary-artery Doppler in CDH yielded reliability after a substantial number of examinations 33 and it can be performed in virtually all cases with a low degree of disagreement between experienced examiners. 12,34 In conclusion, fetuses with CDH showed on average a constant lung dimension but with gradual increases in mean intrapulmonary-artery Doppler indices during the second half of pregnancy.…”

Section: Figurementioning

confidence: 99%

Longitudinal changes in lung size and intrapulmonary‐artery Doppler during the second half of pregnancy in fetuses with congenital diaphragmatic hernia

et al. 2018

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Objectives The objectives of the study are to evaluate longitudinal changes in lung size and intrapulmonary‐artery (IPa) Doppler in fetuses with congenital diaphragmatic hernia (CDH) and assess their contribution in predicting neonatal survival. Methods The observed/expected lung‐to‐head ratio (O/E‐LHR) and IPa–pulsatility index (PI) and peak early diastolic reversed flow (PEDRF) were evaluated in a cohort of left‐sided CDH fetuses managed expectantly during pregnancy. Longitudinal changes were analyzed by multilevel analysis, and their value to predict survival using the multiple logistic regression and decision‐tree analysis was assessed. Results A total of 232 scans were performed on 69 CDH fetuses. The O/E‐LHR values remained unchanged during fetal monitoring, whereas IPa–PI and PEDRF showed a progressive increase throughout follow‐up, becoming abnormal on average at 30 weeks of gestation. Absent/reversed end‐diastolic velocity (EDV) in the IPa was observed in 20.3%. O/E‐LHR and IPa Doppler indices were significantly associated with probability of survival (O/E‐LHR ≥ 26%, odds ratio [OR] 19.0; IPa–PI <+2.0 z score, OR 3.0; and positive EDV, OR 7.4). All cases with IPa‐reversed EDV died after birth. Conclusion While lung size remains stable during pregnancy, CDH fetuses show progressive deterioration in intrapulmonary blood flow. IPa Doppler evaluation may aid in predicting survival of CDH fetuses managed expectantly during pregnancy.

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Section: Figurementioning

confidence: 99%

Longitudinal changes in lung size and intrapulmonary‐artery Doppler during the second half of pregnancy in fetuses with congenital diaphragmatic hernia

et al. 2018

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“…One potential explanation is the technical complexity of such measurements in the rabbit, due to smaller dimensions and marked displacement of the major pulmonary vessels, typical for CDH. 30 This might be partially responsible for the high variability of measurements within groups.…”

Section: Discussionmentioning

confidence: 99%

Complementary Effect of Maternal Sildenafil and Fetal Tracheal Occlusion Improves Lung Development in the Rabbit Model of Congenital Diaphragmatic Hernia

et al. 2020

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Objective: To evaluate the effect of combining antenatal sildenafil with fetal tracheal occlusion (TO) in fetal rabbits with surgically induced congenital diaphragmatic hernia (CDH). Background: Although antenatal sildenafil administration rescues vascular abnormalities in lungs of fetal rabbits with CDH, it only partially improves airway morphometry. We hypothesized that we could additionally stimulate lung growth by combining this medical treatment with fetal TO. Methods: CDH was created on gestational day (GD)23 (n¼54). Does were randomized to receive either sildenafil 10 mg/kg/d or placebo by subcutaneous injection from GD24 to GD30. On GD28, fetuses were randomly assigned to TO or sham neck dissection. At term (GD30) fetuses were delivered, ventilated, and finally harvested for histological and molecular analyses. Unoperated littermates served as controls.Results: The lung-to-body-weight ratio was significantly reduced in sham-CDH fetuses either (1.2 AE 0.3% vs 2.3 AE 0.3% in controls, P¼0.0003). Sildenafil had no effect on this parameter, while CDH fetuses undergoing TO had a lung-to-bodyweight ratio comparable to that of controls (2.5 AE 0.8%, P<0.0001). Sildenafil alone induced an improvement in the mean terminal bronchiolar density (2.5 AE 0.8 br/mm 2 vs 3.5 AE 0.9 br/mm 2 , P¼0.043) and lung mechanics (static elastance 61 AE 36 cmH 2 O /mL vs 113 AE 40 cmH 2 O/mL, P¼0.008), but both effects were more pronounced in fetuses undergoing additional TO (2.1 AE 0.8 br/mm 2 , P¼0.001 and 31 AE 9 cmH 2 O/mL, P<0.0001 respectively). Both CDH-sham and CDH-TO fetuses treated with placebo had an increased medial wall thickness of peripheral pulmonary vessels (41.9 AE 2.9% and 41.8 AE 3.2%, vs 24.0 AE 2.9% in controls, P<0.0001). CDH fetuses treated with sildenafil, either with or without TO, had a medial thickness in the normal range (29.4% AE 2.6%). Finally, TO reduced gene expression of vascular endothelial growth factor and surfactant protein A and B, but this effect was counteracted by sildenafil. Conclusion:In the rabbit model for CDH, the combination of maternal sildenafil and TO has a complementary effect on vascular and parenchymal lung development.

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“…Indeed, any trained sonographer can perform fetal lung Doppler measurements, which are obtained in the same plane as that used for the measurement of o/e-LHR. In a previous study, CUSUM analysis demonstrated that the learning curve of IPA assessment comprises 53 measurements 30 . This is comparable with the learning curves for other commonly used fetal Doppler or ultrasound assessments, such as evaluation of the ductus venosus (80 examinations) and measurement of o/e-LHR (70 measurements) 31,32 .…”

Section: Principal Findingsmentioning

confidence: 93%

Intrapulmonary artery Doppler to predict mortality and morbidity in fetuses with mild or moderate left‐sided congenital diaphragmatic hernia

Basurto

Fuenzalida

Martínez-Portilla

et al. 2021

Ultrasound in Obstet & Gyne

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Objectives In fetuses with isolated left‐sided congenital diaphragmatic hernia (LCDH), prenatal detection of severe pulmonary hypoplasia is important, as fetal therapy can improve survival. Cases with mild or moderate lung hypoplasia still carry a considerable risk of mortality and morbidity, but there has been less interest in the accurate prediction of outcome in these cases. In this study of fetuses with mild or moderate isolated LCDH, we aimed to investigate: (1) the association between intrapulmonary artery (IPA) Doppler findings and mortality at discharge; (2) whether adding IPA Doppler findings improves the prediction of mortality based on lung size and liver herniation; and (3) the association between IPA Doppler findings and early neonatal morbidity. Methods This was a retrospective study of all consecutive fetuses assessed at the BCNatal and UZ Leuven hospitals between 2008 and 2020 with a prenatal diagnosis of isolated, non‐severe LCDH, defined as observed‐to‐expected lung‐to‐head ratio (o/e‐LHR) > 25%, that were managed expectantly during pregnancy followed by standardized neonatal management. An additional inclusion criterion was the availability of IPA Doppler measurements. The primary outcome was the association between IPA Doppler findings and mortality at discharge. Other predictors included o/e‐LHR, liver herniation and gestational age at birth. Secondary outcomes were the association between IPA Doppler findings and the presence of pulmonary hypertension (PHT), need for supplemental oxygen at discharge and need for extracorporeal membrane oxygenation. IPA pulsatility index (PI) values were converted into Z‐scores. Logistic regression analysis was performed to investigate the associations between predictor variables and outcome, and the best model was chosen based on the Nagelkerke R2. Results Observations for 70 non‐severe LCDH cases were available. Fifty‐four (77%) fetuses survived until discharge. On logistic regression analysis, higher IPA‐PI was associated with an increased risk of mortality (odds ratio (OR), 3.96 (95% CI, 1.62–9.70)), independently of o/e‐LHR (OR, 0.87 (95% CI, 0.79–0.97)). An IPA‐PI Z‐score cut‐off of 1.8 predicted mortality with a detection rate of 69% and specificity of 93%. Adding IPA‐PI to o/e‐LHR improved significantly the model's performance (Nagelkerke R2, 46% for o/e‐LHR + IPA‐PI vs 28% for o/e‐LHR (P < 0.002)), with a detection rate of 81% at a 10% false‐positive rate. IPA‐PI was associated with PHT (OR, 2.20 (95% CI, 1.01–4.59)) and need for oxygen supplementation at discharge (OR, 1.90 (95% CI, 1.10–3.40)), independently of lung size. Conclusions In fetuses with mild or moderate LCDH, IPA‐PI was associated with mortality and morbidity, independently of lung size. A model combining o/e‐LHR with IPA‐PI identified up to four in five cases that eventually died, despite being considered to have non‐severe pulmonary hypoplasia. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

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Learning Curve for Intrapulmonary Artery Doppler in Fetuses with Congenital Diaphragmatic Hernia

Cited by 9 publications

References 30 publications

Longitudinal changes in lung size and intrapulmonary‐artery Doppler during the second half of pregnancy in fetuses with congenital diaphragmatic hernia

Longitudinal changes in lung size and intrapulmonary‐artery Doppler during the second half of pregnancy in fetuses with congenital diaphragmatic hernia

Complementary Effect of Maternal Sildenafil and Fetal Tracheal Occlusion Improves Lung Development in the Rabbit Model of Congenital Diaphragmatic Hernia

Intrapulmonary artery Doppler to predict mortality and morbidity in fetuses with mild or moderate left‐sided congenital diaphragmatic hernia

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