Delivery planning for congenital lung malformations: A CVR based perinatal care algorithm

Purpose: Congenital lung malformation (CLM) volume ratio (CVR) of ≥1.1 has been shown to be highly predictive of the need for urgent, perinatal surgical intervention. The purpose of this study was to utilize this information to propose a delivery planning and clinical management algorithm based on this threshold. Methods: A retrospective cohort study was performed for all fetuses evaluated at our fetal center between 5/2015 and 11/2020. Demographics, ultrasound findings, late gestation CVR (≥27 weeks gestational age), prenatal and postnatal treatment, and outcomes were analyzed with nonparametric univariate analysis based on late gestation CVR of 1.1. Receiver operating characteristic curve analysis was performed to evaluate association between late gestation CVR, hydrops, need for fetal intervention, and need for urgent perinatal surgery. Results: Of the 90 CLMs referred to our fetal center, 65 had late gestation CVR with a majority <1.1 (47/65, 72%). All patients with late gestation CVR ≥ 1.1 were managed with resection (18/18) with most resections requiring fetal intervention or urgent neonatal resection (13/18). Late gestation CVR < 1.1 were managed with elective resection (36/47, 77%) or non-operative observation (11/47, 23%). Late gestation CVR ≥ 1.1 had 100% sensitivity and NPV for hydrops, need for fetal intervention, and need for urgent perinatal surgery. Conclusion: CLM with CVR ≥ 1.1 were associated with urgent perinatal surgical intervention and expectant mothers should plan for delivery at centers equipped to manage neonatal resuscitation and potential urgent neonatal resection. Conversely, CLM with CVR < 1.1 may be safe to deliver at patient hospital of choice.