Seminars in perinatology
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Seminars in perinatology · Aug 2005
Multicenter Study Comparative Study Clinical TrialSURUSS in perspective.
Until the publication of the Serum Urine and Ultrasound Screening Study (SURUSS) report, it was difficult to compare the different antenatal screening tests for Down's Syndrome because of variations in study designs. We here present the main results from SURUSS, updated to take account of recent information on nuchal translucency in Down's Syndrome pregnancies, and discuss their implications. ⋯ The Integrated test offers the most effective and safe method of screening for women who attend in the first trimester. The next best test is the Serum integrated test. The Quadruple test is the best test for women who first attend in the second trimester. There is no justification for retaining the Double (alpha-fetoprotein and hCG) or Triple (alpha-fetoprotein, uE3, and hCG) tests, or nuchal translucency alone (with or without maternal age) in antenatal screening for Down's Syndrome.
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Seminars in perinatology · Apr 2005
ReviewFetal intervention for congenital diaphragmatic hernia: the European experience.
Fetuses with CDH presenting with liver herniation and a lung area-to-head circumference ratio of less than 1.0 have a high chance for neonatal death due to pulmonary hypoplasia. Fetal tracheal occlusion (TO) prevents egress of lung liquid, which triggers lung growth. In animal experiments, we were able to develop a minimally invasive technique for Fetoscopic Endoluminal Tracheal Occlusion (FETO) with a detachable balloon. ⋯ Survival in eligible contemporary controls was 1/12 (8%). The presence of liver herniation and a low lung-to-head ratio (LHR <1.0) is a good predictor of poor prognosis at different tertiary centers around the world. Severe CDH may be successfully treated with FETO, which is minimally invasive and may improve postnatal survival.
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Since its beginnings in 1989, the Extracorporeal Life Support Organization (ELSO) Registry has collated and reported data on over 30,000 patients. The majority of patients entered into the Registry have been neonates with respiratory failure from meconium aspiration, persistent pulmonary hypertension, or congenital diaphragmatic hernia. These patients suffer from refractory hypoxemia; thus, this supportive technique came to be called "Extracorporeal Membrane Oxygenation (ECMO)" for its ability to provide excellent gas exchange. ⋯ A novel form of extracorporeal support is "ECPR" or ECMO during cardiac arrest. Bypass circuits and equipment can be set up and instituted within a very short period of time in this circumstance, thus the name "rapid deployment ECMO" has become associated with this form of support. Overall survival in the near-600 patients placed on ECMO during resuscitation is 40%.
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Extracorporeal membrane oxygenation (ECMO) has been offered as a life-saving technology to newborns with respiratory and cardiac failure refractory to maximal medical therapy. ECMO has been used in treatment of neonates with a variety of cardio-respiratory problems, including meconium aspiration syndrome (MAS), persistent pulmonary hypertension of the neonate (PPHN), congenital diaphragmatic hernia (CDH), sepsis/pneumonia, respiratory distress syndrome (RDS), air leak syndrome, and cardiac anomalies. For this group of high-risk neonates with an anticipated mortality rate of 80% to 85%, ECMO has an overall survival rate of 84%, with recent data showing nearly 100% survival in many diagnostic groups. This article reviews the current selection criteria for ECMO and the clinical management of neonates on ECMO, and discusses the long-term outcome of neonates treated with ECMO.
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Seminars in perinatology · Feb 2005
ReviewThe effect of extracorporeal life support on the brain: a focus on ECMO.
Extracorporeal membrane oxygenation (ECMO) therapy has significantly improved outcome in the newborn, pediatric, and adult patient in respiratory and cardiac failure. Despite this therapy providing a life-saving technology, the morbidity in patients treated with ECMO therapy is primarily related to neurologic alterations and not pulmonary findings. For ECMO, this is not unexpected since most patients are being placed on ECMO support because of severe hypoxemia, with ECMO being considered a rescue therapy for respiratory failure in most instances. ⋯ A further understanding of factors associated with morbidity may allow us to alter techniques used in extracorporeal life support (ECLS), hopefully to improve our long-term outcome in this population, while allowing us to expand use of these technologies to other populations such as the premature infant. This article will focus on the effect of ECMO on the brain, with the following chapter by Dr. Richard Jonas outlining the effect of cardiopulmonary bypass on the brain.