Intrapulmonary artery Doppler to predict mortality and morbidity in fetuses with mild or moderate left-sided 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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DOI：
10.1002/uog.23701
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发表时间：
2021-10-01
影响因子：
7.1
通讯作者：
Gomez, O.
中科院分区：
文献类型：
--
作者：
Basurto, D.;Fuenzalida, J.;Gomez, O.
目的对于孤立性左侧先天性腹股沟疝（LCDH）的胎儿，产前检测重度肺发育不全非常重要，因为胎儿治疗可以提高存活率。轻度或中度肺发育不全的病例仍然有相当大的死亡率和发病率风险，但对这些病例的准确预测结果的兴趣较少。本研究对轻度或中度孤立性LCDH的胎儿进行了研究，目的是：（1）肺内动脉（IPA）多普勒结果与出院时死亡率之间的关系;（2）增加IPA多普勒结果是否可以改善基于肺大小和肝疝的死亡率预测;以及（3）IPA多普勒结果与早期新生儿发病率之间的关系。方法这是一项回顾性研究，对在BCNatal和UZ Leuven医院评估的所有连续胎儿进行评估在2008年至2020年期间，产前诊断为孤立的非重度LCDH，定义为预期肺头比（o/e-LHR）> 25%，在妊娠期间进行预期管理，然后进行标准化新生儿管理。另一个入选标准是IPA多普勒测量的可用性。主要结局是IPA多普勒结果与出院时死亡率之间的相关性。其他预测因素包括o/e-LHR、肝疝和出生时胎龄。次要结局是IPA多普勒结果与肺动脉高压（PHT）、出院时补充供氧需求和体外膜肺氧合需求之间的相关性。将IPA脉动指数（PI）值转换为Z评分。采用多因素Logistic回归分析，以Nagelkerke R-2模型为基础，选择最佳模型。结果70例非重度LCDH患者的观察结果可用。54只（77%）胎仔存活至出院。Logistic回归分析显示，IPA-PI升高与死亡风险增加相关（比值比（OR），3.96（95%CI，1.62-9.70）），独立于o/e-LHR（OR，0.87（95%CI，0.79-0.97））。IPA-PI Z评分临界值为1.8预测死亡率，检出率为69%，特异性为93%。在o/e-LHR中加入IPA-PI显著改善了模型的性能（Nagelkerke R-2，o/e-LHR+ IPA-PI为46%，o/e-LHR为28%（P
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 R-2.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 R-2, 46% for o/e-LHR+ IPA-PI vs 28% for o/e-LHR (P