Fetal Endotracheal Occlusion (FETO) in the Resolution of Pulmonary Hypertension in Fetuses With Severe CDH

Description

Enrollment

Women carrying a fetus with severe CDH and a normal karyotype will undergo routine clinical evaluation. The fetus will be 28+0/7 to 31+6/7 weeks of gestational age and have severe CDH. These patients will have ultrasound and/or MRI evaluation to rule out other anomalies, calculation of the LHR from ultrasound measurements, calculation of observed/expected total lung volume and percentage of liver herniation from fetal MRI studies, echocardiography, and detailed obstetric/perinatal consultation. Patients who meet the eligibility criteria will be extensively counseled, and those who wish to participate will provide written, informed consent for the study.

Procedure

The procedure will be performed under spinal anesthesia or local anesthesia with intravenous sedation. The technique of fetal endoscopic tracheal occlusion has been described. Using standard technique, a cannula will be inserted into the amniotic cavity and a fetoscope or flexible operating endoscope will be passed through the cannula into the amniotic fluid. If, upon evaluation, the fetal trachea cannot be entered as described above, the uterus will be accessed through an incision in the belly (called a laparotomy). A laparotomy is a surgical technique tin which an incision is made in the abdomen. After the incision has been made, the uterus will be temporarily repositioned externally. The baby will then be accessed using the fetoscope and ultrasound, as described above. The laparotomy will only be performed if the baby cannot be reached and repositioned to a more favorable one by doing external maneuvers (called external version) for the FETO procedure.

The scope will be guided into the fetal larynx, and then through the fetal vocal cords with the aid of both direct vision through the scope and cross-sectional ultrasonographic visualization. A detachable latex balloon will be placed in the fetal trachea midway between the carina and the vocal cords. The balloon will be inflated with isosmotic contrast material so that it fills the fetal trachea.

Postoperative

The mothers will be discharged once stable. Serial measurements of sonographic lung volume and LHR will begin within 24-48 hours following surgery and continue weekly by targeted ultrasound evaluation. Amniotic fluid level and membrane status will also be monitored at weekly intervals. Comprehensive ultrasonography for fetal growth will be performed every four weeks (+/- 1 wk). All discharged patients will stay within 30 minutes of TCH to permit standardized postoperative management and emergent retrieval of the balloon in the event of preterm labor or premature rupture of membranes prior to the scheduled removal.

After the FETO surgery, prior to leaving the hospital, the mother will be given a medical alert bracelet identifying her as a patient with a baby with blocked airways. She will be encouraged to wear the bracelet at all times so that in case of emergency, she and others will know who to contact. She will also be given a pamphlet with instructions for medical personnel describing how to remove the balloon in case of an emergency. She should carry it with her at all times.

Balloon retrieval will be planned for no later than 36+6/7 weeks, at the discretion of the FETO center. The patient will need to commit to remaining in 30 minutes of Texas Children’s Hospital Pavilion for Women until the balloon is retrieved. In the event of a patient relocating after having the balloon placed, despite having committed to remain in the area during consent process, she will be asked to return for the removal. Every effort to make arrangements for her to be managed by the nearest center capable of an EXIT procedure or balloon retrieval will be made.

After removal of the balloon, patients will have the choice of delivering at Texas Children’s Hospital – Women’s Pavilion with the CDH managed and repaired at TCH, or returning to their obstetrician for delivery with subsequent repair of the CDH by the pediatric surgeons at their referring facility. Given the severity of the CDH, the baby will need to be delivered in a facility that has the capability of immediate pediatric surgery services.

The investigators will need to monitor the baby at regular intervals (at 6 weeks, 3 months, 6 months, 1 year, and 2 years) after delivery to see how well the baby is breathing and how well the baby is developing. These check – ups may be at Texas Children’s Hospital – Pavilion for Women or can be coordinated with doctors from the hospital of the participant’s choosing.

If the child continues care at another institution, the investigators will attempt to follow up with a review of the child’s medical records.