DOI: 10.1148/radiol.2481070934
(Radiology 2008;248:233-239.)
© RSNA, 2008
MR Lung Volume in Fetal Congenital Diaphragmatic Hernia: Logistic Regression Analysis—Mortality and Extracorporeal Membrane Oxygenation1
Karen A. Büsing, MD,
A. Kristina Kilian, MD,
Thomas Schaible, MD,
Dietmar J. Dinter, MD, and
K. Wolfgang Neff, MD, PhD
1 From the Departments of Clinical Radiology (K.A.B., A.K.K., D.J.D., K.W.N.) and Pediatrics (T.S.), University Hospital Mannheim, University of Heidelberg, Theodor Kutzer Ufer 1-3, 68167 Mannheim, Germany. Received June 1, 2007; revision requested August 3; revision received October 22; accepted December 21; final version accepted January 28, 2008.
Address correspondence to K.A.B. (e-mail: karen.buesing@rad.ma.uni-heidelberg.de).
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ABSTRACT
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Purpose: To prospectively assess the results of logistic regression analysis that were based on magnetic resonance (MR) image fetal lung volume (FLV) measurements to predict survival and the corresponding need for extracorporeal membrane oxygenation (ECMO) therapy in fetuses with congenital diaphragmatic hernia (CDH) before and after 30 weeks gestation.
Materials and Methods: Written informed consent was obtained and the study was approved by the local research ethics committee. FLV was measured on MR images in 95 fetuses (52 female neonates, 43 male neonates) with CDH between 22 and 39 weeks gestation by using multiplanar T2-weighted half-Fourier acquired single-shot turbo spin-echo MR imaging. On the basis of logistic regression analysis results, mortality and the need for ECMO therapy were calculated for fetuses before and after 30 weeks gestation.
Results: Overall, higher FLV was associated with improved survival (P < .001) and decreasing probability of need for ECMO therapy (P = .008). Survival at discharge was 29.2% in neonates with an FLV of 5 mL, compared with 99.7% in neonates with an FLV of 25 mL. The corresponding need for ECMO therapy was 56.1% in fetuses with an FLV of 5 mL and 8.7% in fetuses with an FLV of 40 mL. Prognostic power was considerably lower before 30 weeks gestation.
Conclusion: Beyond 30 weeks gestation, logistic regression analysis that is based on MR FLV measurements is useful to estimate neonatal survival rates and ECMO requirements. Prior to 30 weeks gestation, the method is not reliable and the FLV measurement should be repeated, particularly in fetuses with small lung volumes, before a decision is made about therapeutic options.
© RSNA, 2008
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INTRODUCTION
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In the past decade, prognosis has improved for children with congenital diaphragmatic hernia (CDH), with neonatal survival rates increasing to more than 90% according to reports from numerous tertiary perinatal centers (1–6). Despite these prognostic advances, data in some studies indicate that pregnancy is electively terminated in up to 49% of women (7,8). This finding can be attributed to improved antenatal detection of major congenital anomalies (7). However, the lack of reliable prognostic parameters to facilitate parental counseling and therapeutic decisions may also contribute to the rate of terminated pregnancies.
Recently, various studies have taken the relative fetal lung volume (FLV) measured on magnetic resonance (MR) images as a potential prognostic indicator. The relative FLV is attained by expressing the observed FLV measured at planimetry as a percentage of the expected lung volume calculated with biometric fetal parameters (9–13). At present, however, there is no method to individually estimate neonatal survival rates for these children with respect to the gestational age at the time of assessment. In addition, as yet, there is no equivalent procedure to calculate the probability of the need for neonatal extracorporeal membrane oxygenation (ECMO) therapy. In neonates who do not respond to conventional therapy, ECMO therapy improves survival (14–18). The multiple-institution Congenital Diaphragmatic Hernia Study Group observed a survival rate of 38.5% in neonates in whom, without ECMO, mortality would have been predicted to be greater than 80% (15).
The aim of our study was to prospectively assess the results of logistic regression analysis that were based on MR image FLV measurements to predict survival and the corresponding need for ECMO therapy in fetuses with CDH before and after 30 weeks gestation.
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MATERIALS AND METHODS
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Patients
Between June 2004 and March 2006, 92 consecutive women with singleton pregnancies with the diagnosis of CDH and three women with twin pregnancies, each with one fetus affected with CDH, were referred to our center for MR imaging and further therapeutic counseling. All mothers underwent additional routine ultrasonography (US). None of the pregnancies was terminated, and all children were delivered at our institution. The exclusion criterion was any associated malformation diagnosed with US or chromosomal abnormality.
Informed consent was obtained from all mothers to perform fetal MR imaging, and separate consent was obtained for ECMO therapy. The study was approved by the research ethics committee of our hospital. Data are from 24 patients who were previously reported (19), and data from 61 patients overlap with data reported in another manuscript in this issue of Radiology (20).
Mean maternal age was 30.9 years ± 5.7 (standard deviation) and the range was 19–43 years, and the mean gestational age of fetuses at MR imaging was 31 weeks ± 4.2 (range, 22–39 weeks). Among all 95 fetuses (52 female neonates, 43 male neonates) included in our study, CDH was found to be left sided in 82 (86%) fetuses, right sided in 12 (13%) fetuses, and bilateral in one (1%) fetus.
The overall survival rate at discharge in 95 neonates was 83% (n = 79), and ECMO therapy was required in 35% (n = 33) of the neonates. Five (5%) neonates died before ECMO could be commenced. Of all neonates with a poor clinical outcome, 12 died of respiratory insufficiency, two had intracranial hemorrhage while they were undergoing ECMO therapy, one died of persistent pulmonary hypertension after preterm delivery at 28 weeks gestation, and one died of pneumonia.
Study Groups
To determine the effect of gestational age at the time of FLV analysis on prognosis, we subdivided the study population into two groups, with fetal MR imaging being performed prior to 30 weeks gestation (early diagnostic [ED] group) and after 30 weeks gestation (late diagnostic [LD] group).
ECMO Therapy
All neonates were intubated immediately after birth and were given gentle conventional ventilation. ECMO therapy was prescribed in neonates if the postductal Pao2 did not increase above 40 mm Hg and preductal saturation remained at less than 90% for more than 2 hours postnatally or if the postductal Pao2 did not increase above 50 mm Hg and preductal saturation remained at less than 95% for more than 4 hours.
These inclusion and exclusion criteria correspond to classic objective criteria for the need for institution of ECMO therapy (14,21,22). Pediatricians who were responsible for the care of newborns were not aware of the FLV measured at antenatal MR imaging, but they were informed about findings at routine US.
MR Imaging and Volumetry
MR imaging was performed in each fetus on the day of referral to our center by using a 1.5-T supraconducting MR system (Magnetom Sonata or Avanto; Siemens Medical Solutions, Erlangen, Germany). We applied a T2-weighted half-Fourier acquired single-shot turbo spin-echo sequence, with echo time of 166 msec, flip angle of 150°, 4-mm section thickness, no intersection gap, and a 512 x 512 matrix. Sections were adjusted to the orthogonal planes relative to the fetal lungs. Sequences that were degraded by fetal motion artifacts were repeated to obtain images that covered the whole thorax in a single acquisition and allowed a clear identification of parietal and mediastinal boundaries (Fig 1). No sedative was administered to reduce fetal movements.
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Figure 1: Multiplanar T2-weighted half-Fourier acquired single-shot turbo spin-echo MR images (echo time, 166 msec; section thickness, 4 mm; and matrix, 512 x 512) show FLV assessment. Top: Coronal view. Bottom: Transverse view. Region of interest followed lung boundaries and did not include main vessels of pulmonary hila.
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MR images were transferred to a workstation (Leonardo; Siemens Medical Solutions), and volumes were assessed by using analysis software (Argus; Siemens Medical Solutions). MR images were reviewed by two radiologists (K.W.N., K.A.B., with 10 and 4 years of experience, respectively, in fetal MR imaging). Segmentation was performed independently by one of the two radiologists by using hand tracing of a free-form region of interest on consecutive sections in all three imaging planes. The mean time required for the FLV measurements in one fetus was approximately 15–20 minutes. The volume of each region of interest obtained per image was automatically calculated and added up to determine the volume of the entire lung. The two observers were unaware of each other's results. For statistical analysis, the mean FLV of sections in all three imaging planes was used.
Statistical Analysis
Logistic regression analysis was applied to correlate the FLV with the risk of ECMO therapy and with survival at discharge in ED and LD groups, as well as in both groups combined.
We applied a simple logistic regression analysis model, in which the dependent variable was restricted to two values (ie, survival designated as x = 1 and nonsurvival designated as x = 0), and compared the observed versus the expected outcome for each responsible parameter x to determine the risk.
Furthermore, the t and 
2 tests were applied to evaluate differences in gestational age and FLV between two study groups, and the Fisher exact test was used to assess differences in ECMO requirement, neonatal survival, and location of the hernia between the study cohorts.
Data were analyzed by using statistical software (SAS, release 8.02; SAS Institute, Cary, NC). A difference with a P value of less than .05 was considered to be significant.
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RESULTS
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Study Groups
The ED group and the LD group comprised 38 and 57 neonates, respectively. There were no relevant differences between the two subgroups in regard to the need for ECMO therapy, but survival (P = .01) and the mean FLV (P < .001) were significantly lower in the ED group (Table 1).
Results of Logistic Regression Analysis of Neonatal Survival
Total: both groups.—Survival was significantly influenced by the FLV. The average FLV in neonates who survived was 19.7 mL ± 9.1, compared with 8.8 mL ± 3.9 for neonates who did not survive (P < .001). We also found a tendency to a better survival for neonates with a left-sided hernia than for neonates with right-sided defects, although this finding did not reach significance (P = .139).
According to logistic regression analysis, the following equation can be applied to calculate a corresponding mortality risk in all neonates (Rmort-all) for a specific FLV:
A higher FLV is associated with improved survival, and we found that mortality decreased from 70.8% for neonates with an FLV of 5 mL to 0.3% for neonates with an FLV of 25 mL (Table 2).
Subgroups.—In the ED group, 71% of the neonates survived, compared with 91% of the neonates in the LD group (P = .01). The t test revealed a strong correlation between the FLV and neonates' survival for both subgroups (ED group, P = .007; LD group, P < .001). The location of the defect was of no consequence for neonatal survival (Table 3).
The association between neonatal survival and FLV in the LD group with fetuses of more than 30 weeks gestation, with risk of mortality in the LD group (Rmort-LD), is expressed as follows:
However, in the ED group, multiple regression analysis revealed that neonatal survival depended primarily on whether ECMO therapy was required (P = .017). Compared with the effect of ECMO requirement in this patient cohort, the influence of FLV on mortality was not significant, but we found a tendency for FLV to influence this factor (P = .109). Logistic regression analysis yielded the following equations.
For risk of mortality in children in the ED group who did not require ECMO (Rmort-ED/no ECMO), the equation was thus:
For risk of mortality in children in the ED group who required ECMO therapy (Rmort-ED/ECMO), the equation was thus:
According to these calculations, mortality for a neonate in whom an FLV of 10 mL was measured prior to 30 weeks gestation can be estimated to be 61% if the neonate requires ECMO therapy, compared with 16% if the neonate does not require ECMO therapy. Differences are more evident for smaller FLVs (Fig 2).
Logistic Regression Analysis of ECMO Therapy
Total: both groups.—The need for ECMO therapy was significantly influenced by the FLV (P = .008), and neonates who required ECMO therapy had a poorer prognosis than did neonates who could cope without it (11 of 33 [33%] vs five of 62 [8%], P = .002). We found that neonates with a left-sided hernia required ECMO treatment less frequently than did neonates with a right-sided defect (P = .182); however, this finding was not significant.
The equation used to calculate a specific risk for ECMO therapy in all neonates (RECMO-all) follows:
Overall, the probability of ECMO therapy decreases with increasing FLV from 56.1% for a 5-mL FLV to 8.7% for a 40-mL FLV (Table 2).
Subgroups.—ECMO therapy was used equally in both ED and LD subgroups (37% vs 33%, P = .725). For the LD group, FLV had a significant effect on ECMO requirement, which decreased from 74% for a 5-mL FLV to 1% for a 50-mL FLV (P = .006).
The equation used to calculate a specific risk for ECMO therapy in the LD group (RECMO-LD) follows:
For the ED group, no relevant effect could be measured (Table 4).
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DISCUSSION
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With US, both direct and indirect measurements of FLV have been used for antenatal prediction of pulmonary hypoplasia in CDH (23–27). Indirect measurements include the lung-to-head ratio (LHR), which reflects the ratio of the right lung area to the head circumference of the fetus. Several early investigators showed that postnatal survival improves with increasing LHR measured antenatally (28–30). Laudy et al (30) found that an LHR of more than 1.4 was associated with a 100% survival and an LHR of less than one indicated 100% mortality. An LHR of less than one, combined with liver herniation, also has been associated with a poor outcome at other centers (25,31). In contrast, data in a number of studies could not confirm these findings either for the children's survival or the postnatal clinical course, including the need for ECMO therapy (32–34). Furthermore, LHR and liver herniation as criteria for lethal pulmonary hypoplasia have not been validated for right-sided and bilateral hernias. More recently, three-dimensional US was used to directly measure FLV in patients with CDH (24,35,36), but no prognostic parameter has been defined as yet.
For some years now, lung volume measurement by using fetal MR imaging has been used to predict survival in fetuses with CDH. Several investigators described a substantial increase in mortality with a relative lung volume of 25%–40% or less of the expected lung volume. This factor provides the first prognostic benchmark based on FLV measurement for patients with CDH (9,11,13,37). Recently, FLV measurement also has been demonstrated to be a highly reliable and valid method with very good measurement accuracy (20,38). Both findings support the use of MR image FLV for further assessment of pulmonary hypoplasia in patients with CDH.
Investigating 95 fetuses with CDH, we demonstrated that logistic regression analysis that is based on MR image FLV measurements is suitable to predict mortality in fetuses with CDH beyond 30 weeks gestation. The method may further help in estimating whether the neonates will require ECMO therapy. For both parameters, the prognostic power of FLV measurement was of no significance in early pregnancy. Prediction of survival was particularly reduced in fetuses with small lung volumes before 30 weeks gestation. This result is in line with our own clinical experience that, prior to 30 weeks gestation, it is difficult to predict how small lungs will develop. We therefore recommend that follow-up MR image FLV measurements be performed in these fetuses after 30 weeks gestation and before decisions about delivery location and mode are made.
We found a slightly higher mortality in the ED group, as well as in neonates with right-sided hernias. This observation suggests that these neonates have rather large defects, which are easier to depict at US, and/or that they were transferred to a specialized center at an early time to evaluate therapeutic options. Because we excluded fetuses with antenatally diagnosed associated malformations or chromosomal abnormalities, either of these two factors was of no consequence to our findings.
Limitations of our study included the fact that we only provide data about survival for neonates who had the opportunity to receive ECMO therapy. Because of an increased risk mainly for bleeding and brain damage, ECMO therapy is still a very controversial issue, and some specialists do not advocate this therapy. Therefore, it is essential to collect additional data from children treated in an intensive care unit but without ECMO therapy. Furthermore, the estimated risk for ECMO therapy calculated in our study cannot generally be assigned to other centers. Although the inclusion and exclusion criteria used at our institution correspond to classic objective criteria for the need to institute ECMO therapy (14,21,22), procedures may vary among the different tertiary care centers. Another possible drawback of our study refers to the neonates who died of respiratory failure prior to ECMO therapy. They were enrolled in the cohort in which neonates did not receive ECMO therapy, but they may also be referred to as potential candidates for ECMO therapy. Thus, these neonates could account for a potential bias to the study population. However, a relevant effect on our study results seems very unlikely, as the number of neonates who died prior to ECMO affected only 5% (five of 95) of the total study population.
In conclusion, logistic regression analysis that is based on MR image FLV measurements is useful to predict neonatal survival and ECMO requirement in fetuses with CDH beyond 30 weeks gestation. Prior to 30 weeks gestation and particularly in fetuses with small lung volumes, the prognostic power of the method was found to be considerably lower. Thus, in these patients, we recommend that a second examination be performed at a later time and before a decision is made about therapeutic options.
Our study was not designed to provide therapeutic recommendations, especially in regard to ECMO therapy, or to determine when a pregnant woman should be referred to a specialized center with or without the option of ECMO therapy. However, our data may help move toward the goals of identifying fetuses at risk for neonatal respiratory failure, compared with those who do not necessarily need to be delivered at a specialized center, and subsequently of facilitating parental guidance. The prognostic and therapeutic importance of our results needs to be assessed in further clinical studies.
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ADVANCES IN KNOWLEDGE
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- Logistic regression analysis that is based on MR image fetal lung volume (FLV) measurements is valuable in predicting mortality and extracorporeal membrane oxygenation (ECMO) requirement in fetuses with congenital diaphragmatic hernia (CDH) beyond 30 weeks gestation.
- A higher FLV is associated with improved survival (P < .001) and decreased probability of the need for ECMO therapy (P = .008).
- Prior to 30 weeks gestation, the prediction of survival is limited, particularly in neonates with small FLVs, and the method cannot be used to estimate the need for neonatal ECMO therapy.
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IMPLICATIONS FOR PATIENT CARE
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- In fetuses with CDH beyond 30 weeks gestation, logistic regression analysis that is based on MR image FLV measurements is useful to predict neonatal survival and ECMO requirement and may facilitate parental guidance and therapeutic decisions, including antenatal transfer to a specialized center.
- Before 30 weeks gestation, we suggest that FLV be repeatedly assessed, especially in fetuses with small FLVs, before a decision is made about therapeutic op-tions.
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FOOTNOTES
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Abbreviations: CDH = congenital diaphragmatic hernia • ECMO = extracorporeal membrane oxygenation • ED = early diagnostic • FLV = fetal lung volume • LD = late diagnostic • LHR = lung-to-head ratio
See also the other article by Büsing et al in this issue.
Author contributions: Guarantors of integrity of entire study, K.A.B., T.S., K.W.N.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; manuscript final version approval, all authors; literature research, K.A.B., D.J.D.; clinical studies, all authors; statistical analysis, K.A.B., T.S., K.W.N.; and manuscript editing, K.A.B., D.J.D., K.W.N.
Authors stated no financial relationship to disclose.
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References
|
|---|
- Langham MR Jr, Kays DW, Beierle EA, et al. Twenty years of progress in congenital diaphragmatic hernia at the University of Florida. Am Surg 2003;69:45–52.[Medline]
- Kays DW, Langham MR Jr, Ledbetter DJ, Talbert JL. Detrimental effects of standard medical therapy in congenital diaphragmatic hernia. Ann Surg 1999;230:340–348.[CrossRef][Medline]
- Bagolan P, Casaccia G, Crescenzi F, Nahom A, Trucchi A, Giorlandino C. Impact of a current treatment protocol on outcome of high-risk congenital diaphragmatic hernia. J Pediatr Surg 2004;39:313–318.[CrossRef][Medline]
- Moya FR, Lally KP. Evidence-based management of infants with congenital diaphragmatic hernia. Semin Perinatol 2005;29:112–117.[CrossRef][Medline]
- Downard CD, Jaksic T, Garza JJ, et al. Analysis of an improved survival rate for congenital diaphragmatic hernia. J Pediatr Surg 2003;38:729–732.[CrossRef][Medline]
- Boloker J, Bateman DA, Wung JT, Stolar CJ. Congenital diaphragmatic hernia in 120 infants treated consecutively with permissive hypercapnea/spontaneous respiration/elective repair. J Pediatr Surg 2002;37:357–366.[CrossRef][Medline]
- Colvin J, Bower C, Dickinson JE, Sokol J. Outcomes of congenital diaphragmatic hernia: a population-based study in Western Australia. Pediatrics 2005;116:e356–e363.[Abstract/Free Full Text]
- Geary MP, Chitty LS, Morrison JJ, Wright V, Pierro A, Rodeck CH. Perinatal outcome and prognostic factors in prenatally diagnosed congenital diaphragmatic hernia. Ultrasound Obstet Gynecol 1998;12:107–111.[CrossRef][Medline]
- Bonfils M, Bonfils M, Emeriaud G, et al. Fetal lung volume in congenital diaphragmatic hernia. Arch Dis Child Fetal Neonatal Ed 2006;91:F363–F364.[Abstract/Free Full Text]
- Coakley FV, Lopoo JB, Lu Y, et al. Normal and hypoplastic fetal lungs: volumetric assessment with prenatal single-shot rapid acquisition with relaxation enhancement MR imaging. Radiology 2000;216:107–111.[Abstract/Free Full Text]
- Mahieu-Caputo D, Sonigo P, Dommergues M, et al. Fetal lung volume measurement by magnetic resonance imaging in congenital diaphragmatic hernia. BJOG 2001;108:863–868.[CrossRef][Medline]
- Williams G, Coakley FV, Qayyum A, Farmer DL, Joe BN, Filly RA. Fetal relative lung volume: quantification by using prenatal MR imaging lung volumetry. Radiology 2004;233:457–462.[Abstract/Free Full Text]
- Gorincour G, Bouvenot J, Mourot MG, et al. Prenatal prognosis of congenital diaphragmatic hernia using magnetic resonance imaging measurement of fetal lung volume. Ultrasound Obstet Gynecol 2005;26:738–744.[CrossRef][Medline]
- The collaborative UK ECMO trial: follow-up to 1 year of age. Pediatrics 1998;101:e1–e10. doi:10.1542/peds.101.4.e1. Published 1998. Accessed February 22, 2006.
- Does extracorporeal membrane oxygenation improve survival in neonates with congenital diaphragmatic hernia? the Congenital Diaphragmatic Hernia Study group. J Pediatr Surg 1999;34:720–724.[CrossRef][Medline]
- Bulas D, Glass P. Neonatal ECMO: neuroimaging and neurodevelopmental outcome. Semin Perinatol 2005;29:58–65.[CrossRef][Medline]
- D'Agostino JA, Bernbaum JC, Gerdes M, et al. Outcome for infants with congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation: the first year. J Pediatr Surg 1995;30:10–15.[CrossRef][Medline]
- McGahren ED, Mallik K, Rodgers BM. Neurological outcome is diminished in survivors of congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation. J Pediatr Surg 1997;32:1216–1220.[CrossRef][Medline]
- Büsing KA, Kilian AK, Schaible T, Debus A, Weiss C, Neff KW. Reliability and validity of MR image lung volume measurement in fetuses with congenital diaphragmatic hernia and in vitro lung models. Radiology 2008;246:553–561.[CrossRef][Medline]
- Büsing KA, Kilian AK, Schaible T, Endler C, Schaffelder R, Neff KW. MR relative fetal lung volume in congenital diaphragmatic hernia: survival and need for extracorporeal membrane oxygenation. Radiology 2008;248:240–246.
- Rothenbach P, Lange P, Powell D. The use of extracorporeal membrane oxygenation in infants with congenital diaphragmatic hernia. Semin Perinatol 2005;29:40–44.[CrossRef][Medline]
- Bahrami KR, Van Meurs KP. ECMO for neonatal respiratory failure. Semin Perinatol 2005;29:15–23.[CrossRef][Medline]
- Ruano R, Benachi A, Joubin L, et al. Three-dimensional ultrasonographic assessment of fetal lung volume as prognostic factor in isolated congenital diaphragmatic hernia. BJOG 2004;111:423–429.[CrossRef][Medline]
- Ruano R, Martinovic J, Dommergues M, Aubry MC, Dumez Y, Benachi A. Accuracy of fetal lung volume assessed by three-dimensional sonography. Ultrasound Obstet Gynecol 2005;26:725–730.[CrossRef][Medline]
- Jani J, Peralta CF, Van Schoubroeck D, Deprest J, Nicolaides KH. Relationship between lung-to-head ratio and lung volume in normal fetuses and fetuses with diaphragmatic hernia. Ultrasound Obstet Gynecol 2006;27:545–550.[CrossRef][Medline]
- Moeglin D, Talmant C, Duyme M, Lopez AC. Fetal lung volumetry using two- and three-dimensional ultrasound. Ultrasound Obstet Gynecol 2005;25:119–127.[CrossRef][Medline]
- Sabogal JC, Becker E, Bega G, et al. Reproducibility of fetal lung volume measurements with 3-dimensional ultrasonography. J Ultrasound Med 2004;23:347–352.[Abstract/Free Full Text]
- Lipshutz GS, Albanese CT, Feldstein VA, et al. Prospective analysis of lung-to-head ratio predicts survival for patients with prenatally diagnosed congenital diaphragmatic hernia. J Pediatr Surg 1997;32:1634–1636.[CrossRef][Medline]
- Harrison MR, Mychaliska GB, Albanese CT, et al. Correction of congenital diaphragmatic hernia in utero. IX. Fetuses with poor prognosis (liver herniation and low lung-to-head ratio) can be saved by fetoscopic temporary tracheal occlusion. J Pediatr Surg 1998;33:1017–1022.
- Laudy JA, Van Gucht M, Van Dooren MF, Wladimiroff JW, Tibboel D. Congenital diaphragmatic hernia: an evaluation of the prognostic value of the lung-to-head ratio and other prenatal parameters. Prenat Diagn 2003;23:634–639.[CrossRef][Medline]
- Albanese CT, Lopoo J, Goldstein RB, et al. Fetal liver position and perinatal outcome for congenital diaphragmatic hernia. Prenat Diagn 1998;18:1138–1142.[CrossRef][Medline]
- Arkovitz MS, Russo M, Devine P, Budhorick N, Stolar CJ. Fetal lung-head ratio is not related to outcome for antenatal diagnosed congenital diaphragmatic hernia. J Pediatr Surg 2007;42:107–110.[CrossRef][Medline]
- Heling KS, Wauer RR, Hammer H, Bollmann R, Chaoui R. Reliability of the lung-to-head ratio in predicting outcome and neonatal ventilation parameters in fetuses with congenital diaphragmatic hernia. Ultrasound Obstet Gynecol 2005;25:112–118.[CrossRef][Medline]
- Sbragia L, Paek BW, Filly RA, et al. Congenital diaphragmatic hernia without herniation of the liver: does the lung-to-head ratio predict survival? J Ultrasound Med 2000;19:845–848.
- Kalache KD, Espinoza J, Chaiworapongsa T, et al. Three-dimensional ultrasound fetal lung volume measurement: a systematic study comparing the multiplanar method with the rotational (VOCAL) technique. Ultrasound Obstet Gynecol 2003;21:111–118.[CrossRef][Medline]
- Ruano R, Joubin L, Sonigo P, et al. Fetal lung volume estimated by 3-dimensional ultrasonography and magnetic resonance imaging in cases with isolated congenital diaphragmatic hernia. J Ultrasound Med 2004;23:353–358.[Abstract/Free Full Text]
- Paek BW, Coakley FV, Lu Y, et al. Congenital diaphragmatic hernia: prenatal evaluation with MR lung volumetry—preliminary experience. Radiology 2001;220:63–67.[Abstract/Free Full Text]
- Ward VL, Nishino M, Hatabu H, et al. Fetal lung volume measurements: determination with MR imaging—effect of various factors. Radiology 2006;240:187–193.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
