Department of Gynecology and Obstetrics, Antoine Béclère Hospital, Paris-Sud University, Clamart, France.
Reference Center for Rare Diseases: Congenital Diaphragmatic Hernia, Clamart, France.
Ultrasound Obstet Gynecol. 2021 Jun;57(6):959-967. doi: 10.1002/uog.22086. Epub 2021 May 5.
The long-term morbidity associated with isolated left-sided congenital diaphragmatic hernia (CDH) has been described previously. However, antenatal criteria impacting gastrointestinal morbidity (GIM) are not yet defined. The objective of this study was to evaluate the effect of fetal stomach position on the risk of GIM at 2 years of age in children with left-sided CDH.
This was a retrospective, observational multicenter cohort study of data obtained from January 2010 to January 2014, that included patients whose fetus had isolated left-sided CDH, with or without fetal endoscopic tracheal occlusion (FETO). Prenatal maternal, fetal and pediatric data were collected. Fetal stomach position was evaluated a posteriori by two observers, using ultrasound images at the level of the four-chamber view of the heart that had been obtained to calculate the observed-to-expected lung-area-to-head-circumference ratio (O/E-LHR). Fetal stomach position was graded as follows: Grade 1, stomach not visualized; Grade 2, stomach visualized anteriorly, next to the apex of the heart, with no structure in between the stomach and the sternum; Grade 3, stomach visualized alongside the left ventricle of the heart, and abdominal structures anteriorly; or Grade 4, as Grade 3 but with stomach posterior to the level of the atrioventricular heart valves. The primary outcome was GIM at 2 years of age, assessed in a composite manner, including the occurrence of gastroesophageal reflux disease, need for gastrostomy, duration of parenteral and enteral nutrition and persistence of oral aversion. Regression analysis was performed in order to investigate the effect of O/E-LHR, stomach position and FETO on various GIM outcome variables.
Forty-seven patients with fetal left-sided CDH were included in the analysis. Thirteen (27.7%) infants did not meet the criterion of exclusive oral feeding at 2 years of age. Fetal stomach position grade was associated significantly and independently with the duration of parenteral nutrition (odds ratio (OR), 19.86; P = 0.031) and persistence of oral aversion at 2 years (OR, 3.40; P = 0.006). On multivariate analysis, O/E-LHR was predictive of the need for prosthetic patch repair, but not for GIM. FETO did not seem to affect the risk of GIM at 2 years.
In isolated left-sided CDH, fetal stomach position is the only factor that is predictive of GIM at 2 years of age. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
先前已有研究报道了单纯性左侧先天性膈疝（CDH）相关的长期发病率。然而，目前尚未确定影响胃肠道发病率（GIM）的产前标准。本研究的目的是评估胎儿胃的位置对 2 岁时左侧 CDH 患儿发生 GIM 的风险的影响。
这是一项回顾性、多中心队列研究，纳入了 2010 年 1 月至 2014 年 1 月期间的病例，研究对象为患有单纯性左侧 CDH 且胎儿接受或未接受胎儿内镜气管阻塞术（FETO）的患儿。收集了母亲、胎儿和儿科的产前数据。通过两位观察者对胎儿胃的位置进行了回顾性评估，使用心脏四腔心切面的超声图像进行评估，以计算观察到的与预期的肺面积与头围比（O/E-LHR）。胎儿胃的位置分为以下 4 个等级：1 级，胃不可见；2 级，胃在前室间隔的水平可见，紧邻心脏尖端，胃和胸骨之间没有结构；3 级，胃与左心室并排可见，且腹部结构在前；或 4 级，与 3 级相同，但胃位于房室瓣水平之后。主要结局是 2 岁时的 GIM，以综合方式评估，包括胃食管反流病的发生、需要胃造口术、肠外和肠内营养的持续时间以及对口服食物的持续厌恶。为了研究 O/E-LHR、胃的位置和 FETO 对各种 GIM 结局变量的影响，进行了回归分析。
分析纳入了 47 例患有胎儿左侧 CDH 的患儿。13 例（27.7%）患儿在 2 岁时不能满足单纯经口喂养的标准。胎儿胃的位置分级与肠外营养的持续时间显著相关（优势比（OR），19.86；P=0.031），与 2 岁时持续厌恶口服食物也显著相关（OR，3.40；P=0.006）。多变量分析显示，O/E-LHR 可预测需要修补补片，但不能预测 GIM。FETO 似乎并不影响 2 岁时 GIM 的风险。
在单纯性左侧 CDH 中，胎儿胃的位置是唯一能预测 2 岁时 GIM 的因素。
