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Prenatal prediction of the postnatal prognosis in Congenital Diaphragmatic Hernia patients Based on ultrasound and additional MRI

Kool, Danien (2021) Prenatal prediction of the postnatal prognosis in Congenital Diaphragmatic Hernia patients Based on ultrasound and additional MRI.

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Embargo date:19 October 2026
Abstract:Introduction – Approximately 40 neonates are born with Congenital Diaphragmatic Hernia (CDH) per year in the Netherlands. When CDH patients are treated with optimal tertiary neonatal care the mortality rate is up to 30%. An example of tertiary neonatal care that can be life-saving is Extracorporeal Membrane Oxygenation (ECMO) therapy. Therefore, it is important to prenatally diagnose and refer CDH patients to an expertise center. One of the two expertise centra is Radboud University Medical Center (Radboudumc) in the Netherlands. In Radboudumc, an extensive workup is performed to prenatally predict the postnatal prognosis and to determine prenatal management. The prognosis is mainly based on the ultrasound findings. Though, the predictive value of the ultrasound has never been evaluated in Radboudumc and is limited according to the expert’s opinion. Therefore, the predictive value of the ultrasound was evaluated for the prenatal prediction of postnatal survival and the need for ECMO therapy in isolated CDH patients. Since the ultrasound is considered to be limited, it is desirable to predict the prognosis more accurately. Magnetic Resonance Imaging (MRI) could help with improving the predictive value if, among other things, the ultrasound and MRI findings could be related to each other. Therefore, it was also investigated what the additional value of MRI is adjunct to ultrasound in the prenatal prediction of postnatal survival and the need for ECMO therapy in isolated CDH patients. Methods – For the analyses of the predictive value of the ultrasound and additional value of the MRI, respectively 39 and 19 isolated CDH patients were retrospectively included. Firstly, the predictive value of the ultrasound was assessed. Receiver Operating Characteristics (ROC) curves were constructed for the prediction of survival and the need for ECMO therapy by the observed versus expected Lung-to-Head Ratio (o/e LHR) at a gestational age of 26 weeks. Subsequently, the additional value of MRI was investigated. The observed versus expected Total Fetal Lung Volume (o/e TFLV) was retrospectively obtained and implemented in the MRI protocol. Then the predictive value of the MRI was determined through constructing ROC curves for the prediction of survival and the need for ECMO therapy by the o/e TFLV. Also, the classification of the severity of pulmonary hypoplasia based on the ultrasound and MRI were compared to determine the discordancy rate. Finally, the additional value of MRI adjunct to ultrasound was planned to be assessed with logistical regression analysis. Results – The predictive value of the ultrasound showed to be more accurate for the need for ECMO therapy (AUC = 0.759) than for postnatal survival (AUC = 0.621). However, the prediction of the need for ECMO therapy is sensitive to bias because the neonatologist is aware of the prenatal prediction of the postnatal prognosis. These findings confirmed the expert’s opinion that the ultrasound is limited in predicting the postnatal survival of CDH patients. The additional value of MRI adjunct to ultrasound in predicting the postnatal prognosis could not be obtained through the fact that the study population was too small. The study population consisted of 19 CDH patients of whom 11 survived while at least 20 survivors were needed for the logistic regression analysis. However, it was found that the MRI-based o/e TFLV cannot accurately predict postnatal survival. Moreover, the o/e TFLV predicted less accurate postnatal survival than the sonographic o/e LHR. The prediction of the need for ECMO therapy was similar for MRI and ultrasound. Lastly, the discordance rate between the classifications of the severity of pulmonary hypoplasia was high with approximately 60%. The differences in measurement methods, 2D versus 3D and one lung versus both lungs, could explain the high discordance rate and imply that the modalities are not the same. Conclusion – The o/e TFLV was implemented in the MRI protocol enabling to relate ultrasound and MRI findings to each other. Nevertheless, the main question, whether MRI has an additional value adjunct to ultrasound, could not be answered through the small study population. However, the findings of this thesis have shown that the prediction of postnatal survival is limited based on both the ultrasound as the MRI. Moreover, the need for ECMO therapy seems to be possible to predict, though, this prediction is sensitive to bias. Finally, the results of this thesis have helped to gain insight into the current status of prenatal management in CDH patients and that is the first step in improving the quality of care for CDH patients in Radboudumc.
Item Type:Essay (Master)
Faculty:TNW: Science and Technology
Subject:44 medicine, 50 technical science in general
Programme:Technical Medicine MSc (60033)
Link to this item:http://purl.utwente.nl/essays/88709
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