目的:评估和比较产前确定的超声检查观察到的预期(O/E)肺面积与头围比(LHR)与MRI检查的O/E胎儿总肺体积(TFLV)的价值,以预测孤立胎儿的产后生存率。预期治疗左侧先天性膈疝(CDH)。
方法:这是一项多中心回顾性研究,包括所有在曼海姆接受预期治疗的分离CDH的连续胎儿,德国,在其他五个欧洲中心,在怀孕期间接受了至少一次超声检查以测量O/E-LHR和一次MRI扫描以测量O/E-TFLV。所有MRI数据集中,和肺容积由两名对产前和产后数据不知情的有经验的操作者测量。进行了多逻辑回归分析,以检查各种围产期变量对出院时生存率的影响,包括管理中心。在左侧CDH伴肝脏胸内疝中,对于来自曼海姆和其他5个欧洲中心的病例,分别构建了受试者-工作特征(ROC)曲线,并将其用于比较O/E-TFLV和O/E-LHR预测出生后生存.
结果:来自曼海姆,在超声检查时,309例患者的中位胎龄(GA)为29.6(范围,19.7-39.1)周,MRI检查的中位GA为31.1(范围,18.0-39.9)周。其他五个欧洲中心,116例患者在超声检查时的中位GA为26.7(范围,20.6-37.6)周,MRI检查的中位数GA为27.7(范围,21.3-37.9)周。回归分析表明,左侧CDH患者出院时的生存率较低(优势比(OR),0.349(95%CI,0.133-0.918),P=0.033)和胸内肝(OR,0.297(95%CI,0.141-0.628),P=0.001),随着O/E-TFLV的增加而升高(或,1.123(95%CI,1.079-1.170),P<0.001),出生时的晚期GA(或,1.294(95%CI,1.055-1.588),P=0.013)和曼海姆出生时(OR,7.560(95%CI,3.368-16.967),P<0.001)。鉴于曼海姆和其他五个欧洲中心之间的生存率差异,两种成像方式之间的ROC曲线比较分别呈现。对于左侧CDH伴肝脏胸内疝的病例,配对比较显示,在预测Mannheim的O/E-TFLV和O/E-LHR出生后生存率的ROC曲线下面积之间没有显着差异(平均差异=0.025,P=0.610,标准误差=0.050),而在其他欧洲研究中心中存在显著差异(平均差=0.056,P=0.033,标准误差=0.056).
结论:在患有左侧CDH和肝胸内疝的胎儿中,在一个中心(Mannheim)中,MRI检查的O/E-TFLV和超声检查的O/E-LHR对出生后生存的预测价值相似,但与其他5个欧洲中心的O/E-LHR相比,O/E-TFLV具有更好的预测价值.因此,在这五个欧洲中心,MRI应包括在左侧CDH的诊断过程中。©2024国际妇产科超声学会。
OBJECTIVE: To assess and compare the value of antenatally determined observed-to-expected (O/E) lung-area-to-head-circumference ratio (LHR) on ultrasound examination vs O/E total fetal lung volume (TFLV) on MRI examination to predict postnatal survival of fetuses with isolated, expectantly managed left-sided congenital diaphragmatic hernia (CDH).
METHODS: This was a multicenter retrospective study including all consecutive fetuses with isolated CDH that were managed expectantly in Mannheim, Germany, and in five other European centers, that underwent at least one ultrasound examination for measurement of O/E-LHR and one MRI scan for measurement of O/E-TFLV during pregnancy. All MRI data were centralized, and lung volumes were measured by two experienced operators blinded to the pre- and postnatal data. Multiple logistic regression analyses were performed to examine the effect on survival at hospital discharge of various perinatal variables, including the center of management. In left-sided CDH with intrathoracic herniation of the liver, receiver-operating-characteristics (ROC) curves were constructed separately for cases from Mannheim and the other five European centers and were used to compare O/E-TFLV and O/E-LHR in the prediction of postnatal survival.
RESULTS: From Mannheim, 309 patients were included with a median gestational age (GA) at ultrasound examination of 29.6 (range, 19.7-39.1) weeks and median GA at MRI examination of 31.1 (range, 18.0-39.9) weeks. From the other five European centers, 116 patients were included with a median GA at ultrasound examination of 26.7 (range, 20.6-37.6) weeks and median GA at MRI examination of 27.7 (range, 21.3-37.9) weeks. Regression analysis demonstrated that the survival rates at discharge were lower in left-sided CDH (odds ratio (OR), 0.349 (95% CI, 0.133-0.918), P = 0.033) and those with intrathoracic liver (OR, 0.297 (95% CI, 0.141-0.628), P = 0.001), and higher with increasing O/E-TFLV (OR, 1.123 (95% CI, 1.079-1.170), P < 0.001), advanced GA at birth (OR, 1.294 (95% CI, 1.055-1.588), P = 0.013) and when birth occurred in Mannheim (OR, 7.560 (95% CI, 3.368-16.967), P < 0.001). Given the difference in survival rate between Mannheim and the five other European centers, ROC curve comparisons between the two imaging modalities were presented separately. For cases of left-sided CDH with intrathoracic herniation of the liver, pairwise comparison showed no significant difference between the area under the ROC curves for the prediction of postnatal survival between O/E-TFLV and O/E-LHR in Mannheim (mean difference = 0.025, P = 0.610, standard error = 0.050), whereas there was a significant difference in the other European centers studied (mean difference = 0.056, P = 0.033, standard error = 0.056).
CONCLUSIONS: In fetuses with left-sided CDH and intrathoracic herniation of the liver, the predictive value for postnatal survival of O/E-TFLV on MRI examination and O/E-LHR on ultrasound examination was similar in one center (Mannheim), but O/E-TFLV had better predictive value compared to O/E-LHR in the five other European centers. Hence, in these five European centers, MRI should be included in the diagnostic process for left-sided CDH. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.