Re: Diaphragmatic Hernia
From: art fougner, md (evsono@pipeline.com)
Sat Nov 15 12:29:23 2003
Regarding doppler -
>From The Cochrane Library, Issue 4, 2003. Chichester, UK: John Wiley &
Sons, Ltd. All rights reserved.
Doppler ultrasound for fetal assessment in high risk pregnancies
(Cochrane Review)
Neilson JP, Alfirevic Z
ABSTRACT
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A substantive amendment to this systematic review was last made on 23
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February 1996. Cochrane reviews are regularly checked and updated if
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necessary.
Background: Abnormal waveforms from Doppler ultrasound may indicate poor
fetal prognosis. It is also possible that Doppler ultrasound could
encourage inappropriate early delivery.
Objectives: The objective of this review was to assess the effects of
Doppler ultrasound in high risk pregnancies on obstetric care and fetal
outcomes.
Search strategy: We searched the Cochrane Pregnancy and Childbirth Group
trials register. Date of last search: June 2001.
Selection criteria: Randomised trials of Doppler ultrasound for the
investigation of umbilical artery waveforms in high risk pregnancies
compared to no Doppler ultrasound.
Data collection and analysis: Trial quality was assessed and data were
extracted by both reviewers. Study authors were contacted for
additional information.
Main results: Eleven studies involving nearly 7000 women were included.
The trials were generally of good quality. Compared to no Doppler
ultrasound, Doppler ultrasound in high risk pregnancy (especially those
complicated by hypertension or presumed impaired fetal growth) was
associated with a trend to a reduction in perinatal deaths (odds ratio
0.71, 95% confidence interval 0.50 to 1.01). The use of Doppler
ultrasound was also associated with fewer inductions of labour (odds
ratio 0.83, 95% confidence interval 0.74 to 0.93) and fewer admissions
to hospital (odds ratio 0.56, 95% 0.43 to 0.72), without reports of
adverse effects. No difference was found for fetal distress in labour
(odds ratio 0.81, 95% confidence interval 0.59 to 1.13) or caesarean
delivery (odds ratio 0.94, 95% 0.82 to 1.06).
Reviewers' conclusions: The use of Doppler ultrasound in high risk
pregnancies appears to improve a number of obstetric care outcomes and
appears promising in helping to reducing perinatal deaths.
Citation: Neilson JP, Alfirevic Z. Doppler ultrasound for fetal
assessment in high risk pregnancies (Cochrane Methodology Review). In:
The Cochrane Library, Issue 4, 2003. Chichester, UK: John Wiley & Sons,
Ltd.
Try finding similar evidence for NST or biophysical profile in Cochrane.
art
At Thu, 13 Nov 2003, Dave Berck wrote:
>
>Is anybody shocked by this? Fetal surgery seems to me,
>with rare exception, to be a procedure in search of an
>indication (not unlike doppler, but that's another
>story . . . .)
>
>--- "art fougner, md" <evsono@pipeline.com> wrote:
>> In today's New England Journal of Medicine, Harrison
>> et al reports that
>> In Utero Therapy with Fetal Tracheal Occlusion did
>> NOT improve perinatal
>> outcomes.
>>
>> A Randomized Trial of Fetal Endoscopic Tracheal
>> Occlusion for Severe
>> Fetal Congenital Diaphragmatic Hernia
>>
>> Michael R. Harrison, M.D., Roberta L. Keller,
>> M.D., Samuel B. Hawgood,
>> M.D., Joseph A. Kitterman, M.D., Per L. Sandberg,
>> M.D., Diana L.
>> Farmer, M.D., Hanmin Lee, M.D., Roy A. Filly, M.D.,
>> Jody A. Farrell,
>> M.S.N., P.N.P., and Craig T. Albanese, M.D.
>>
>> ABSTRACT
>>
>> Background Experimental and clinical data suggest
>> that fetal endoscopic
>> tracheal occlusion to induce lung growth may improve
>> the outcome of
>> severe congenital diaphragmatic hernia. We
>> performed a randomized,
>> controlled trial comparing fetal tracheal occlusion
>> with standard
>> postnatal care.
>>
>> Methods Women carrying fetuses that were between 22
>> and 27 weeks of
>> gestation and that had severe, left-sided congenital
>> diaphragmatic
>> hernia (liver herniation and a lung-to-head ratio
>> below 1.4), with no
>> other detectable anomalies, were randomly assigned
>> to fetal endoscopic
>> tracheal occlusion or standard care. The primary
>> outcome was survival
>> at the age of 90 days; the secondary outcomes were
>> measures of maternal
>> and neonatal morbidity.
>>
>> Results Of 28 women who met the entry criteria, 24
>> agreed to
>> randomization. Enrollment was stopped after 24
>> patients had been
>> enrolled because of the unexpectedly high survival
>> rate with standard
>> care and the conclusion of the data safety
>> monitoring board that further
>> recruitment would not result in significant
>> differences between the
>> groups. Eight of 11 fetuses (73 percent) in the
>> tracheal-occlusion
>> group and 10 of 13 (77 percent) in the group that
>> received standard care
>> survived to 90 days of age (P=1.00). The severity
>> of the congenital
>> diaphragmatic hernia at randomization, as measured
>> by the lung-to-head
>> ratio, was inversely related to survival in both
>> groups. Premature
>> rupture of the membranes and preterm delivery were
>> more common in the
>> group receiving the intervention than in the group
>> receiving standard
>> care (mean [±SD] gestational age at delivery,
>> 30.8±2.0 weeks vs.
>> 37.0±1.5 weeks; P<0.001). The rates of neonatal
>> morbidity did not
>> differ between the groups.
>>
>> Conclusions Tracheal occlusion did not improve
>> survival or morbidity
>> rates in this cohort of fetuses with congenital
>> diaphragmatic hernia.
>>
>> Source Information
>>
>> >From the Fetal Treatment Center (M.R.H., S.B.H.,
>> J.A.K., P.L.S., D.L.F.,
>> H.L., R.A.F., J.A.F., C.T.A.), the Departments of
>> Surgery (M.R.H.,
>> D.L.F., H.L., J.A.F., C.T.A.), Pediatrics (M.R.H.,
>> R.L.K., S.B.H.,
>> J.A.K., D.L.F., H.L., C.T.A.), Obstetrics,
>> Gynecology and Reproductive
>> Sciences (M.R.H., P.L.S., D.L.F., H.L., R.A.F.,
>> C.T.A.), and Radiology
>> (R.A.F.), and the Cardiovascular Research Institute
>> (R.L.K., J.A.K.),
>> University of California, San Francisco, San
>> Francisco.
>>
>> art
>>
>> --
>> art fougner, md
>> ich bin ein New Yorker
>
>=====
>David J. Berck, MD, MPH
--
art fougner, md
ich bin ein New Yorker
