Link: http://www.ncbi.nlm.nih.gov/pubmed/27312047

Ultrasound Obstet Gynecol. 2016 Jun 17. doi: 10.1002/uog.16000. [Epub ahead of print]
Lung size and liver herniation predict the need for extra corporeal membrane oxygenation but not pulmonary hypertension in isolated congenital diaphragmatic hernia: a systematic review and meta-analysis.
Russo FM1,2, Eastwood MP1, Keijzer R3, Al-Maary J3, Toelen J1,4, Mieghem TV1,2, Deprest JA1,2,5.
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Abstract
OBJECTIVES:
To identify antenatal predictors of persistent pulmonary hypertension (PPH) and need for extracorporeal membrane oxygenation (ECMO) in fetuses with congenital diaphragmatic hernia (CDH).
MATERIAL AND METHODS:
We performed a systematic literature review of antenatal diagnostic tests in fetuses with isolated CDH. The target conditions were PPH within 28 days of life and the need for ECMO. Quality of studies was assessed with the QUADAS-2 tool. Meta-analysis was performed when at least three studies reported on the same test. Sensitivity analysis was performed according to prenatal management of CDH (tracheal occlusion versus expectant management).
RESULTS:
Thirty-eight studies met the inclusion criteria. Fifteen reported on the incidence of PPH only, 19 on the need of ECMO only, and 4 on both outcomes. The general quality of the studies was moderate; most studies were retrospective (61%) and single-centre series (92%). One study included only fetuses undergoing tracheal occlusion, 22 only fetuses expectantly managed in utero, and 15 included both populations. We could not identify antenatal predictors of PPH. The need for ECMO was predicted by parameters indicative of lung size: lung-to-head ratio (LHR, relative risk for LHR<1: 1.65; 95% confidence interval 1.27 to 2.14) and observed-to-expected LHR (standardized mean difference -0.70; 95% confidence interval -0.98 to -0.42) measured by ultrasound and observed-to-expected total lung volume (standardized mean difference -1.00; 95% confidence interval -1.52 to -0.4 by magnetic resonance. Liver herniation was also associated with an increased risk of ECMO (relative risk 3.04; 95% confidence interval 2.23 to 4.14). These results were confirmed in a sensitivity analysis on studies including only expectantly managed cases. The data on vascular assessment for the prediction of PPH could not be pooled, as most of the parameters were evaluated in a single series or by a single investigator.
CONCLUSIONS:
In fetuses with CDH, lung size and liver herniation predict the need for ECMO. A predictor for PPH is still lacking. Further studies aiming at diagnosing impaired vascular development in utero should therefore be developed.
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KEYWORDS:
Congenital diaphragmatic hernia; ECMO; fetal MRI; fetal ultrasound; pulmonary hypertension
PMID: 27312047 DOI: 10.1002/uog.16000
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