SFM Fetal Therapy Practice Guidelines: Fetoscopic Endoluminal Tracheal Occlusion

Introduction

Fetoscopic endoluminal tracheal occlusion (FETO) was started as an experimental therapy in fetuses with congenital diaphragmatic hernia (CDH) who had a bad prognosis. The Tracheal Occlusion To Accelerate Lung growth-trial (TOTAL) has proved its effectiveness. The intervention attempts to correct pulmonary hypoplasia before delivery to reduce perinatal and neonatal mortality and morbidity.

Pulmonary Hypoplasia

• Severe pulmonary hypoplasia is defined as a 25% increase in the lung area to the head circumference (with or without liver herniation).

• Moderate pulmonary hypoplasia is defined as 25 to 34.9% observed to expected lung area to head circumference ratio (LHR; liver location not considered), or observed to expected LHR of 35 to 44.9 with liver in the chest assessed at 32 weeks and 5 days or later.

• Right sided CDH was not included in the TOTAL trial (FETO can, however, be offered).

Criteria for Eligibility

• Fetuses with severe diaphragmatic hernia (LHR <1 and liver herniated into the chest) identified between 22 ^0/7 weeks and 29 ^6/7 weeks of gestation.

• The mother must be at least 18 years old.

• Singleton pregnancy.

• Left sided diaphragmatic hernia.

• A fetal echocardiography confirms that there are no severe cardiac anomalies.

• Normal chromosomes and no related aberrations (microarray exome sequencing recommended).

• A cervix that is longer than 15 mm in length.

• The absence of maternal contraindications to abdominal-fetoscopic surgery or general anesthesia.

• No maternal latex allergy.

• Acceptance of responsibility for attending the FETO center for balloon removal.

Prerequisites

• A detailed anomalies scan and fetal magnetic resonance imaging (MRI).

• Personalized outcome prediction based on measures of the lung size, liver position, and side of defect.

• LHR: The lung contralateral to the lesion is measured in a standard four chamber view plane of the heart and the head circumference is measured in the standard transthalamic plane.

• The most precise method is to trace the contour of the lung.

• Observed to expected LHR.

• MRI: (1) Volumetric measurement of both lungs, (2) quantification of liver herniation, and (3) detailed examination of the stomach position.

Maternal Risks

• Preterm spontaneous rupture of membranes (18.1–27.3%).

• Chorioamnionitis.

• Antepartum hemorrhage (rare).

Publication History

Article published online:
09 September 2024

• References

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