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8 results

  • Chapter 47 - Congenital Diaphragmatic Hernia: Pathophysiology and Antenatal Assessment

  • from Congenital Diaphragmatic Hernia
  • Edited by Mark D. Kilby, University of Birmingham, Anthony Johnson, Dick Oepkes
  • Book:
    Fetal Therapy
    Published online:
    21 October 2019
    Print publication:
    02 January 2020, pp 494-502

  • Summary

    Congenital diaphragmatic hernia (CDH) is a developmental anomaly with a prevalence ranging between 1 and 4/10 000 births, hence qualifying as a rare disease (ORPHA: 2140). During embryogenesis the diaphragm fails to form [1], most often on the left side (85%), rarely on the right (13%), and sporadically bilaterally (2%). Exceptionally there is true agenesis of the hemidiaphragm, but most often the defect is confined to the posterolateral area (Bochdalek hernia). The anterior (Morgagni hernia; 30%) or central areas (2%) are less frequently involved [2]. Occasionally the diaphragm is intact yet thinned and devoid of muscular fibers, and is then called diaphragmatic eventration [3]. In case of a true defect, abdominal viscera can herniate into the thorax, acting as a space-occupying lesion that competes with the developing lungs. In left CDH (LCDH), this typically includes bowel, spleen, stomach, and less often the left lobe of the liver and rarely kidney. In case of a right-sided CDH (RCDH), the liver is virtually always into the thorax [4]. There can be also bowel and right kidney herniation. These structures compromise lung development, leading to variable degrees of pulmonary hypoplasia. The lung ipsilateral to the defect is most affected, however both lungs are in essence hypoplastic. They have a lower number of airways, fewer and smaller alveoli, thickened alveolar walls, and an increased amount of interstitial tissue [5]. This leaves less alveolar airspace, and hence reduces the gas exchange surface area. Parallel to airway changes, there is a similar reduction in arteries, essentially leaving a hypoplastic vascular bed. Morphologically, the vascular wall is thickened by an increase in the arterial media and adventitia, neo-muscularization of small pulmonary arteries [6, 7] and hypermuscularization of midsize and large vessels [8]. These vessels may have an abnormal response to mechanical and chemical stimuli in the postnatal period.

  • Chapter 26 - Neurological disease and neurological catastrophes

  • from Section 4 - The pregnant patient with coexisting disease
  • Edited by Marc van de Velde, Helen Scholefield, Lauren A. Plante
  • Book:
    Maternal Critical Care
    Published online:
    05 July 2013
    Print publication:
    04 July 2013, pp 285-300

  • Summary

    The problems in the pregnant woman are universal: physiological changes during pregnancy lead to a reduction in time from onset of apnea to oxygen desaturation and to an increased likelihood of regurgitation from a full stomach. An antenatal visit allows the airway to be evaluated and discussion to be held with the parturient about the use of invasive monitors, such as invasive arterial blood pressure monitoring and the use of continuous positive airway pressure devices during and after labor and delivery. A recent development in the management of the airway in the obese patient is the use of the so-called ramped position. Perhaps the main factor responsible for a higher incidence of difficulties in airway management is that general anesthesia is generally reserved for extreme obstetric emergencies. The use of supraglottic airways in the management of the obstetric airway is undergoing evaluation.

  • Chapter 19.2 - Congenital diaphragmatic hernia

  • from Section 2 - Fetal disease
  • Edited by Mark D. Kilby, Anthony Johnson, Baylor College of Medicine, Texas, Dick Oepkes
  • Book:
    Fetal Therapy
    Published online:
    05 February 2013
    Print publication:
    13 December 2012, pp 376-388

  • Summary

    This chapter discusses congenital diaphragmatic hernia (CDH) from a perspective of antenatal management, including fetal intervention. It summarizes actual survival rates when this condition is managed after birth, essentially showing that there is no effective postnatal therapy in a subset of fetuses. Prediction methods are typically based on estimation of lung size by ultrasound and determination of liver herniation into the thorax. Three-dimensional (3D) ultrasound (US) and MRI both allow measurement of absolute lung volumetry. MRI allows better visualization of the ipsilateral lung than 3D US. Preliminary work on the use of diffusion-weighted imaging (DWI)-MRI as a tool to differentiate between normal and pathological lung development has shown a significant relationship between DWI-MRI parameters and gestational age in the normal fetus. The chapter also describes the current clinical experience with fetal surgery, including the design of trials that will have to determine the place of fetal surgery.

  • 17 - Pre-pregnancy bariatric surgery: improved fertility and pregnancy outcome?

  • from Section 4 - Interventions
  • Edited by Matthew W. Gillman, Lucilla Poston, King's College London
  • Book:
    Maternal Obesity
    Published online:
    05 August 2012
    Print publication:
    19 July 2012, pp 209-222

  • Summary

    This chapter summarizes the most commonly performed bariatric operations. It reviews the impact of pre-pregnancy bariatric surgery on the female reproductive functions and the relevant pregnancy outcome parameters. The chapter formulates recommendations for clinical care of these patients for both the postoperative as well as the prenatal period. Mixing the different types of bariatric surgery might lead to unreliable conclusions since a different outcome can be expected after the restrictive type than after the malabsorptive types. Women experiencing pregnancy after bariatric surgery have important reproductive health care needs. The specific needs of these high-risk pregnancies are best addressed by a multidisciplinary team including obstetricians, surgeons, endocrinologists, pediatricians, psychiatrists, and nutritionists. Some aspects of prenatal care in women with a history of bariatric surgery require specific attention. Pregnancy after surgery improves many pregnancy outcomes but adds new risks related to nutritional deficiencies and surgical complications, thus requiring a specialized multidisciplinary approach.

  • THE PRENATAL MANAGEMENT OF NEURAL TUBE DEFECTS: TIME FOR A RE-APPRAISAL

  • MASAYUKI ENDO, TIM VAN MIEGHEM, ELISENDA EIXARCH, PAOLO DE COPPI, GUNNAR NAULAERS, FRANK VAN CALENBERGH, LUC DE CATTE, ROLAND DEVLIEGER, LIESBETH LEWI, ALEX EGGINK, KYPROS NICOLAIDES, EDUARDO GRATACOS, JAN DEPREST
  • Journal:
    Fetal and Maternal Medicine Review / Volume 23 / Issue 3-4 / November 2012
    Published online by Cambridge University Press:
    02 July 2012, pp. 158-186
    Print publication:
    November 2012

  • The prevalence of neural tube defects (NTD) in Europe is around 9 per 10,000 births making it one of the most frequent congential anomalies affecting the central nervous system. NTD encompass all anomalies that are secondary to failure of closure of the neural tube. In this review, we will first summarize the embryology and some epidemiologic aspects related to NTDs. The review focuses on myelomeningocele (MMC), which is the most common distal closure defect. We will describe the secondary pathologic changes in the central and peripheral nervous system that appear later on in pregnancy and contribute to the condition's morbidity. The postnatal impact of MMC mainly depends on the upper level of the lesion. In Europe, the vast majority of parents with a fetus with prenatally diagnosed NTDs, including MMC, opt for termination of pregnancy, as they are apparently perceived as very debilitating conditions. Animal experiments have shown that prenatal surgery can reverse this sequence. This paved the way for clinical fetal surgery resulting in an apparent improvement in outcome. The results of a recent randomized trial confirmed better outcomes after fetal repair compared to postnatal repair; with follow up for 30 months. This should prompt fetal medicine specialists to reconsider their position towards this condition as well as its prenatal repair. The fetal surgery centre in Leuven did not have a clinical programme for fetal NTD repair until the publication of the MOMS trial. In order to offer this procedure safely and effectively, we allied to a high volume centre willing to share its expertise and assist us in the first procedures. Given the maternal side effects of current open fetal surgical techniques, we have intensified our research programmes to explore minimally invasive alternatives. Below we will describe how we are implementing this.

  • Ultrasound Determination of Chorionicity in Twin Pregnancy: Accuracy and Operator Experience

  • Roland G.L. Devlieger, Thomas Demeyere, Jan A. Deprest, Dominique Van Schoubroeck, Ingrid Witters, Dirk Timmerman, Myriam Hanssens
  • Journal:
    Twin Research / Volume 4 / Issue 4 / 01 August 2001
    Published online by Cambridge University Press:
    21 February 2012, pp. 223-226
    • Article
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  • To evaluate the accuracy of ultrasound in early detection of chorionicity and amnionicity in twin pregnancies and evaluate the role of operator-experience, a prospective follow up of 87 consecutive twin pregnancies was performed. Chorionicity and amnionicity were determined by 17 different observers, divided in 2 groups on the basis of their experience, using a composite of US markers at the first US examination confirming a viable intrauterine twin pregnancy. Accuracy of prediction was determined for both groups by comparison with postnatal pathology. From the 87 pregnancies examined at 10.1 (minimum 5.5 weeks, maximum 26.0) weeks of gestation, pathology was available in 82 cases and a correct prediction of chorionicity was made in all but two cases, both being diagnosed as monochorionic while dichorionic by observers belonging the more experienced group. No monochorionic pregnancy was missed and amnionicity was correctly diagnosed in all cases, including two monoamniotic twins. We conclude that use of a composite of ultrasound markers for early detection of chorionicity and amnionicity is reliable in a clinical setting where physicians with a variable degree of experience perform ultrasound examination.

  • The effect of pre-pregnancy BMI on intention, initiation and duration of breast-feeding

  • Isabelle Guelinckx, Roland Devlieger, Annick Bogaerts, Sara Pauwels, Greet Vansant
  • Journal:
    Public Health Nutrition / Volume 15 / Issue 5 / May 2012
    Published online by Cambridge University Press:
    31 October 2011, pp. 840-848
    • Article
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  • Objective

    To determine whether pre-pregnancy BMI influences breast-feeding practice.

    Design

    Retrospective epidemiological study.

    Setting

    University Hospital Leuven, Catholic University Leuven, Belgium.

    Subjects

    Two hundred women (median age 29 years, interquartile range (IQR) 4; 52 % nulliparae) were grouped into four categories according to pre-pregnancy BMI using WHO cut-offs.

    Results

    The incidence of intention and initiation of breast-feeding was significantly lower in underweight (64 %) and obese women (68 %) compared with normal weight (92 %) and overweight women (80 %). Initiation was also related to parity (OR = 0·582; 95 % CI 0·400, 0·846), but not to gestational weight gain, method of delivery or hypertensive disorders. Fifty-two per cent of underweight, 70 % of normal weight and 56 % of overweight women were exclusively breast-feeding their infant during the first month of life. This incidence was significantly lower in the obese group (34 %; P = 0·030). Only 40 % of all infants were exclusively breast-fed at 3 months of age, with the lowest prevalence among women with obesity (P = 0·0 0 1). The median duration of any breast-feeding in the obese group (1·8 months, IQR 3·4) was significantly shorter than in the underweight (3·0 months, IQR 3·1), normal weight (3·0 months, IQR 2·4) and overweight group (3·0 months, IQR 3·5; P = 0·024). Reasons given for ceasing breast-feeding in the obese group were maternal complications (29 %), insufficient milk supply (23 %), sucking problems (21 %) and work resumption (21 %).

    Conclusions

    Breast-feeding practice in the total population, but especially among women with obesity, fell short of global WHO recommended standards. Policy initiatives and local interventions should continue to support breast-feeding, but also prevent maternal obesity.