Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Dr Penikis, Ms Zhou, and Drs Sferra and Kunisaki).
Section of Pediatric Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI (Dr Engwall-Gill).
Am J Obstet Gynecol MFM. 2023 Oct;5(10):101128. doi: 10.1016/j.ajogmf.2023.101128. Epub 2023 Aug 10.
Several studies have shown that the congenital pulmonary airway malformation volume ratio is a useful prognosticator of neonatal outcome in prenatally diagnosed lung lesions. However, there remains a lack of consensus on which congenital pulmonary airway malformation volume ratio values have the best predictive value because of operator dependence, inherent changes in lung lesion size throughout gestation, and the widespread use of maternal steroids.
This study sought to determine the association between serial congenital pulmonary airway malformation volume ratio measurements and neonatal outcomes among fetuses with lung malformations.
This was a retrospective cohort study of fetuses with a prenatally diagnosed lung malformation managed at 2 major fetal centers from January 2010 to December 2021. Prenatal variables, including prospectively measured congenital pulmonary airway malformation volume ratio measurements (initial, maximum, and final), were analyzed. The results were correlated with 3 outcome measures, namely surgical resection before 30 days of life, a need for supplemental O at birth, and endotracheal intubation at birth. Statistical analyses were performed using receiver operating characteristic curve analyses, Welch 2 sample t tests, and multivariable logistic regressions (P<.05).
There were 123 fetuses with isolated lung lesions identified. Eight (6.5%) had hydrops. The mean initial congenital pulmonary airway malformation volume ratio was 0.67±0.61 cm at 22.9±3.9 weeks' gestation. The mean maximum congenital pulmonary airway malformation volume ratio was 1.08 ± 0.94 cm at 27.0 ± 4.0 weeks' gestation. The mean final congenital pulmonary airway malformation volume ratio was 0.58±0.60 cm at 33.2±4.1 weeks' gestation. At a mean gestational age at delivery of 38.3±2.6 weeks, 15 (12.2%) underwent neonatal lung resection for symptomatic disease. In a multivariable regression, all 3 congenital pulmonary airway malformation volume ratio measurements showed a significant correlation with neonatal lung resection (P<.001). Optimal congenital pulmonary airway malformation volume ratio cutoffs were established based on an initial congenital pulmonary airway malformation volume ratio of ≥0.8 cm, maximum congenital pulmonary airway malformation volume ratio of ≥1.5 cm, and a final congenital pulmonary airway malformation volume ratio of ≥1.3 cm with associated areas under the curve of 0.89, 0.97, and 0.93, respectively. The final congenital pulmonary airway malformation volume ratio had the highest specificity for predicting surgical lung resection in the early postnatal period.
Measuring congenital pulmonary airway malformation volume ratios throughout pregnancy in fetuses with pulmonary malformations has clinical value for prenatal counseling and planning care transition after delivery. Fetuses with a final congenital pulmonary airway malformation volume ratio of more than 1.3 cm are likely to require neonatal surgery and therefore should be delivered at tertiary care centers with a neonatal intensive care unit and pediatric surgical expertise.
多项研究表明，先天性肺气道畸形体积比是产前诊断肺病变新生儿结局的有用预测因子。然而，由于操作人员依赖性、整个妊娠期肺病变大小的固有变化以及广泛使用母亲类固醇，哪种先天性肺气道畸形体积比值具有最佳的预测价值，目前仍缺乏共识。
本研究旨在确定先天性肺气道畸形体积比测量值与患有肺畸形的胎儿的新生儿结局之间的关系。
这是一项回顾性队列研究，纳入了 2010 年 1 月至 2021 年 12 月在 2 个主要胎儿中心管理的产前诊断为肺畸形的胎儿。分析了包括前瞻性测量的先天性肺气道畸形体积比测量值（初始值、最大值和最终值）在内的产前变量。将结果与 3 个结局指标相关联，即出生前 30 天内的手术切除、出生时需要补充氧气和出生时气管内插管。使用接收者操作特征曲线分析、Welch 2 样本 t 检验和多变量逻辑回归（P<.05）进行统计分析。
共确定了 123 例孤立性肺病变胎儿。8 例（6.5%）有水肿。初始先天性肺气道畸形体积比的平均值为 0.67±0.61 cm，在 22.9±3.9 周的胎龄。最大先天性肺气道畸形体积比的平均值为 1.08 ± 0.94 cm，在 27.0 ± 4.0 周的胎龄。最终先天性肺气道畸形体积比的平均值为 0.58±0.60 cm，在 33.2±4.1 周的胎龄。在平均分娩胎龄为 38.3±2.6 周时，15 例（12.2%）因症状性疾病进行了新生儿肺切除术。在多变量回归中，所有 3 个先天性肺气道畸形体积比测量值均与新生儿肺切除术显著相关（P<.001）。基于初始先天性肺气道畸形体积比≥0.8 cm、最大先天性肺气道畸形体积比≥1.5 cm 和最终先天性肺气道畸形体积比≥1.3 cm，建立了最佳先天性肺气道畸形体积比截断值，相应的曲线下面积分别为 0.89、0.97 和 0.93。最终先天性肺气道畸形体积比在预测新生儿早期手术后具有最高的特异性。
在患有肺畸形的胎儿中，整个妊娠期测量先天性肺气道畸形体积比对于产前咨询和分娩后护理过渡计划具有临床价值。最终先天性肺气道畸形体积比大于 1.3 cm 的胎儿可能需要新生儿手术，因此应在设有新生儿重症监护病房和儿科外科专业知识的三级护理中心分娩。
