ABSTRACT
Objective
To evaluate the survival outcomes of fetuses with severe left congenital diaphragmatic hernia (CDH) treated with fetal endoscopic tracheal occlusion (FETO) in Latin American centers.
Method
A retrospective cohort including fetuses with isolated left CDH and severe pulmonary hypoplasia (observed/expected lung area to head ratio (O/E‐LHR) < 35% with liver herniation) treated with FETO in five Latin‐American countries was compared to a contemporary control group with similar lung size but managed expectantly during pregnancy. Propensity score matching and multivariate logistic regression were used to compare survival outcomes between cases with and without FETO.
Results
360 fetuses with severe left CDH were included, 180 treated with FETO were compared with 180 contemporaneous cases managed expectantly during pregnancy with similar O/E‐LHR values (25.2 vs. 25.7, p = 0.50). FETO was performed at a mean GA of 28.4 (ranges, 24.0–32.0) weeks. Balloon removal was performed at a mean GA of 33.8 (ranges, 28.4–38.0) weeks. The mean duration of tracheal occlusion was 37.5 (ranges, 2.0–84.0) days. The FETO group showed significantly lower GA at delivery (35.2 vs. 37.0 weeks, respectively, p < 0.001), and higher incidence of preterm prelabor rupture of membranes (47.8% vs. 20.0%, p = < 0.001). The neonatal survival rate was significantly higher in the FETO group compared with the expectant care group (39.4% vs. 8.9%, respectively, p < 0.001) (odds ratio: 14.8; 95% confidence interval [CI]: 7.1–30.9; p < 0.001).
Conclusions
In Latin American centers, FETO was associated with a significant increase in survival among fetuses with left CDH and severe lung hypoplasia.
Keywords: fetal endotracheal occlusion, fetal surgery, Latin American, left congenital diaphragmatic hernia, survival
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What's already known about this topic?
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Left congenital diaphragmatic hernia (CDH) carries a high risk of neonatal death due to pulmonary hypoplasia and/or pulmonary hypertension. This risk is even greater in Latin American (LA) countries, where neonatal management may be suboptimal. Fetal endoscopic tracheal occlusion (FETO) has been shown to improve survival in cases of left CDH with severe lung hypoplasia in European and North American centers.
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What does this study add?
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This multicenter study describes neonatal survival of fetuses with severe left‐sided CDH treated with and without FETO across seven Latin American centers and demonstrates that fetoscopic intervention improves overall survival, justifying this fetal intervention in countries with suboptimal neonatal management.
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1. Introduction
Congenital diaphragmatic hernia (CDH) is characterized by a defect in the diaphragm that allows protrusion of the abdominal viscera into the thoracic cavity, leading to severe lung hypoplasia and/or pulmonary hypertension. These complications result in high rates of neonatal morbidity and mortality [1, 2, 3].
Fetal Endoscopic Tracheal Occlusion (FETO) has been shown to accelerate lung growth and reduce pulmonary hypertension in fetuses with CDH [4, 5]. A randomized controlled trial (the “TOTAL trial”) demonstrated that FETO significantly improves survival outcomes in severe left‐sided CDH [6, 7]. Following its publication, the number of centers offering this fetal intervention has grown worldwide, and a recent meta‐analysis that included international randomized trials and cohorts confirmed the benefit of FETO in improving survival rates fivefold [8].
A prior multicenter study published by our Latin American (LA) CDH Study Group revealed that survival rates for conservatively managed left‐sided CDH during pregnancy were lower than those reported in North America (NA) and Europe [9]. This disparity may stem from inadequate postnatal care and limited access to extracorporeal membrane oxygenation (ECMO) therapy, both of which are critical factors for survival in babies with severe CDH [10]. In keeping with this argument, survival rates for severe left‐sided CDH treated with FETO have also been shown to be lower in countries with suboptimal neonatal management [11]. Therefore, the true impact of FETO in LA countries warrants further investigation, as findings from the TOTAL trial cannot be fully extrapolated to settings with suboptimal neonatal management. In this study, we aimed to evaluate survival in fetuses with severe left‐sided CDH treated with FETO at LA centers.
2. Material and Methods
2.1. Patient Selection
From 2006 to 2025, a retrospective multicenter cohort of fetuses with severe left CDH and severe lung hypoplasia treated with FETO was conducted in eight tertiary LA fetal surgery centers from five LA countries (Hospital de Especialidades del Niño y la Mujer, Querétaro, México; Instituto Medicina Fetal México, Guadalajara, Mexico; Divisao de Obstetricia, Instituto Central, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil; Hospital de San José, Bogota, Colombia; Universidad Pontificia Bolivariana, Medellin, Colombia; Hospital Universitario Austral, Buenos Aires, Argentina; Instituto Peruano de Medicina y Cirugía Fetal, Lima, Perú; and Hospital Italiano, Buenos Aires, Argentina).
To participate, LA centers were required to have successfully performed at least four FETO procedures, to have experience with the standardized assessment of fetuses with CDH and to be members of the “Latin American CDH Study Group” and the Fetal Surgery Committee by the Latin‐American Federation of Obstetrics and Gynecology (FLASOG).
All cases were assessed for eligibility at the FETO centers using similar inclusion and exclusion criteria. Inclusion criteria for FETO were singleton pregnancies before 32 weeks of gestation with confirmed isolated left CDH and severe pulmonary hypoplasia, defined as an observed‐to‐expected lung‐to‐head ratio (O/E‐LHR) below 35% of the contralateral (right) lung and liver herniation into the thorax (liver up) according to the LA severity classification, with expected neonatal survival less than 10% without prenatal intervention [9]. Exclusion criteria were associated malformations, chromosomal abnormalities, right or bilateral CDH, and short cervical length (< 25 mm). Cases treated with FETO that had missing perinatal outcomes were also excluded.
Before FETO, a detailed fetal anatomical scan, advanced fetal echocardiography, and karyotyping or microarray analysis were performed in all cases. The size of the right lung was estimated by ultrasound in a transverse plane of the fetal chest at the level of the four‐chamber view of the fetal heart using the two longest perpendicular diameters [12], and the O/E‐LHR was calculated [13]. All ultrasound examinations were performed by an experienced examiner (one in each center), who had previously completed a formal training in O/E‐LHR measurement in fetuses with CDH [14].
Eligible women were thoroughly counseled by a multidisciplinary team regarding the prognosis and management options, including expectant management during pregnancy with standardized postnatal care, and the potential benefits and risks of minimally invasive intrauterine surgery using FETO.
Survival at discharge from the neonatal intensive care unit (NICU) and survival at 6 months of age were compared with a contemporary control arm that comprised a sample of isolated left CDH with severe lung hypoplasia (O/E‐LHR < 35% and liver up) and normal cervical length, who refused FETO or were not eligible for fetoscopy because their diagnosis or referral occurred beyond 32 weeks of gestation but were managed and delivered in the same participants‐centers.
Through a customized data transfer protocol, anonymized clinical information from each case was submitted and stored in a database accessible only to the main clinical investigator (RCM), who confirmed the eligibility criteria and the absence of exclusion criteria. Approval for the protocol was obtained from the research ethics committees of each country. All patients provided written informed consent for the use of fetal and neonatal data.
2.2. Fetal Endoscopic Tracheal Occlusion
FETO was carried out between 24 and 32 weeks of gestation. Before the intervention, the fetal position was determined by ultrasound. Accordingly, an external version was performed to adjust the fetus to a longitudinal lie (cephalic or breech) and to avoid interposition of the placenta and/or uterine vessels during uterine entry. After fetal lie was optimized, fetal anesthesia was initiated: fentanyl 0.015 mg/kg, vecuronium 0.2 mg/kg, and atropine 0.02 mg/kg were injected under ultrasound guidance in the fetal thigh or arm using a 22‐gauge needle. Before the procedure, the balloon (GOLDBAL 2; Balt Extrusion, Montmorency, France) was inflated and deflated to test its integrity. The coaxial catheter system (Balt Extrusion, Montmorency, France) was tested for permeability and then a 10 French vascular introducer (Check‐Flo, Cook Medical, Bloomington, IN, USA) was placed into the amniotic cavity using a 10 French trocar; the latter was removed and a semi‐rigid 1.2‐mm fetoscope (Karl Storz, Tüttlingen, Germany) contained within a 3.0‐mm fetoscope sheath (11540 KH, Karl Storz) was inserted. Under direct fetoscopic visualization, the scope was advanced into the fetal mouth and pharynx, beyond the epiglottis, and finally through the vocal cords into the fetal trachea. The balloon was inflated with 0.7 mL of normal saline and detached from the catheter. The fetoscope was carefully removed, and the introducer was withdrawn. Ultrasound was used to confirm the correct placement of the balloon. During the procedure and for the following 24 h, indomethacin, nifedipine, or atosiban was administered to provide prophylactic tocolysis. A course of antenatal steroids (betamethasone) was administered preceding planned balloon removal.
2.3. Maternal and Fetal Follow‐Up
Following the procedure, patients were strongly advised to remain within the geographic area of the FETO center until the tracheal balloon was removed, and a commitment letter was signed. Weekly follow‐up visits were performed to check for balloon dislodgement and to monitor the O/E‐LHR, cervical length, amniotic fluid volume, and fetal growth.
2.4. Balloon Removal
At 34–38 weeks of gestation, balloon removal was scheduled either by percutaneous balloon puncture using a 22‐gauge needle under ultrasound guidance or by fetoscopy using a similar technique used for endotracheal balloon placement [15]. Briefly, under maternal local anesthesia, and intramuscular fetal anesthesia, a 10 French vascular introducer was placed into the amniotic cavity to allow access of the 3.0‐mm fetoscopic sheath (11540 KH, Karl Storz) with a semi‐rigid 1.2‐mm fetoscope (Karl Storz, Tüttlingen, Germany). Under endoscopic view, the endoscope was introduced through the fetal mouth to access the fetal trachea and then the balloon was punctured and removed under direct fetoscopic visualization.
Alternatively, tracheoscopy at the time of delivery by ex utero intrapartum treatment (EXIT) was considered in case of emergency delivery. Biweekly follow‐up was recommended thereafter, and delivery was planned at 39–40 weeks [16].
2.5. Neonatal Management
Delivery and neonatal care were provided by staff obstetricians, neonatologists, and pediatric surgeons, who were aware of the fetal intervention. All cases treated with FETO and those managed expectantly during pregnancy were delivered in the same high‐specialized centers to allow similar standardized neonatal management [9]. Briefly, every neonate was intubated and ventilated immediately after birth and admitted to the neonatal intensive care unit (NICU). Conventional ventilation was initially administered and converted to high‐frequency ventilation in cases of preductal and postductal saturation of < 80% and < 70%, respectively, or hypercapnia > 70 mmHg. Inhaled nitric oxide was administered in cases presenting with suprasystemic pulmonary arterial hypertension. Milrinone (0.33–0.66 μg/kg/min) and dobutamine (5–10 μg/kg/min) were administered for hemodynamic support in cases with suboptimal biventricular function. ECMO was not included in the neonatal management protocol of some centers, since it was not available in most of LA centers. Surgical repair of the diaphragmatic defect was performed once hemodynamic and respiratory stabilization had been achieved. All live newborns were followed until 6 months of age. Each referral center recorded data on maternal baseline characteristics, O/E‐LHR measurement, perinatal data, and postnatal outcomes in a database designed for this study.
2.6. Statistical Analysis
Data were collected using Microsoft Access 2010 (Microsoft Corp., Redmond, WA, USA). The normality of continuous variables was confirmed by Shapiro‐Wilk test. T‐tests and χ 2 tests were used to compare quantitative and qualitative data, respectively. All tests were two‐tailed, and a probability value of < 0.05 was considered statistically significant. Propensity score matching (PSM) was used to match cases treated with and without FETO with similar characteristics based on maternal age, fetal lung size and GA at diagnosis. A matching algorithm with a predefined caliper width of 0.25 standard deviation was used to perform a 1:1 matching. The impact of fetal surgery on survival outcome was evaluated using multiple logistic regression adjusted by GA at birth in the balanced sample. Statistical calculations were performed using the Statistical Package for the Social Sciences (SPSS, version 31.0; SPSS Inc., Chicago, IL, USA) software.
3. Results
During the 20‐year study period, 360 left‐sided CDH fetuses with severe lung hypoplasia were recruited from eight LA centers, 180 were selected for FETO and were compared with 180 contemporaneous controls managed expectantly during pregnancy. The FETO group included 48 cases previously reported from the fetal surgery center in Mexico [11, 17] and 20 from Brazil [18], and the control group included 59 cases from a previously published historical cohort of severe left CDH expectantly managed during pregnancy in the same LA centers [9]. Table 1 provides details on the patients included in the FETO group by each participating center. A similar protocol for FETO was used among all participants centers except for one Brazilian center who used a different balloon (GOLDBAL 4) inflated with 0.8 mL rather than 0.7 mL and in all cases, an EXIT procedure to remove the balloon was scheduled at 38 weeks rather than 34–35 weeks.
TABLE 1.
Number of cases treated with fetal endoscopic tracheal occlusion from each participant center of the Latin American congenital diaphragmatic hernia study group.
| Country a | Center | Year of first intervention | FETO procedures (n) |
|---|---|---|---|
| Argentina | Hospital Universitario Austral, Buenos Aires | 2015 | 4 (2.2%) |
| Hospital Italiano & Universidad Hospital Italiano, Buenos Aires | 2022 | 7 (3.9%) | |
| Brazil | Instituto de Medicina Materno‐Fetal, San Paulo | 2006 | 44 (24.4%) |
| Universidade de Sao Paulo, Sao Paulo | 2016 | 27 (15.0%) | |
| Colombia | Clínica Universitaria Bolivariana, Medellin | 2012 | 11 (6.1%) |
| Hospital de San José, Fundación Universitaria de Ciencias de la Salud, Bogotá | 2011 | 5 (2.8%) | |
| Mexico | Hospital de Especialidades del Niño y la Mujer, Querétaro & Instituto Medicina Fetal México, Querétaro/Guadalajara. | 2012 | 75 (41.7%) |
| Peru | Instituto de Medicina y Cirugía Fetal, Lima | 2018 | 7 (3.9%) |
| Total | 180 |
By alphabetical order.
Table 2 shows the maternal and fetal characteristics of the study population. No differences were observed in mean O/E‐LHR values between cases with and without FETO (25.2 vs. 25.7, p = 0.50). Endotracheal placement of the balloon was successfully performed at a mean GA of 28.4 (ranges, 24.0–32.0) weeks on the first attempt in all but three cases, which required a second procedure to achieve tracheal occlusion. External version before FETO was required in 58/180 cases (32.2%), and the placenta was situated anteriorly in 103/180 cases (57.2%). The mean duration of the intrauterine procedure was 22.2 (range, 3.0–121) min. No maternal complications such as placental abruption, uterine bleeding requiring maternal blood transfusion, chorioamnionitis, fetal death during fetoscopy were reported. The mean duration of maternal hospitalization was 1.8 (ranges, 0–9) days.
TABLE 2.
Maternal and neonatal clinical characteristics for cases with and without fetal endoscopic tracheal occlusion (FETO). Data are given as mean (standard deviation) or absolute numbers (percentage).
| FETO group, n = 180 | No‐FETO group n = 180 | p | |
|---|---|---|---|
| Maternal age (years) | 29.1 (6.2) | 27.6 (7.0) | 0.06 |
| Primiparity (%) | 56 (31.1) | 76 (42.2) | 0.03 |
| Body mass index (Kg/m2) | 27.0 (5.6) | 28.4 (4.4) | 0.04 |
| Polyhydramnios (%) | 39 (21.7) | 21 (11.7) | 0.01 |
| Anterior placenta (%) | 104 (57.8) | 77 (42.9) | < 0.01 |
| GA at diagnosis (weeks) | 23.9 (4.0) | 26.4 (4.9) | < 0.01 |
| O/E‐LHR at diagnosis (%) | 25.2 (8.0) | 25.7 (6.3) | 0.50 |
| Male/female ratio (n 0/n 1) | 89/91 | 104/76 | 0.11 |
| PPROM (%) | 86 (47.8) | 36 (20.0) | < 0.01 |
| Intrauterine fetal demise (%) | 2 (1.1) | 2 (1.1) | 1.00 |
| GA at birth (weeks) | 35.2 (2.7) | 37.0 (2.8) | < 0.01 |
| Preterm delivery < 37 weeks (%) | 122 (67.8) | 78 (43.3) | < 0.01 |
| Preterm delivery < 32 weeks (%) | 21 (11.7) | 10 (5.6) | 0.04 |
| Cesarean delivery (%) | 154 (85.6) | 152 (84.4) | 0.77 |
| Birthweight (grams) | 2335 (471) | 2518 (623) | < 0.01 |
| Neonatal death (%) | 107 (60.1) | 162 (91.0) | < 0.01 |
Abbreviations: FETO, Fetal Endoscopic Tracheal Occlusion; GA, gestational age; O/E LHR, observed/expected lung to head ratio; PPROM, Premature Prelabor Rupture of Membranes.
The mean duration of tracheal occlusion was 37.5 (ranges, 2.0–84.0) days. There were 2/180 fetuses (1.1%) with intrauterine fetal demise before balloon removal and in 3/180 cases (1.7%), the balloon deflated spontaneously. An emergency balloon removal due to preterm prelabor rupture of membranes or preterm labor was required in 55/175 (31.4%) cases. Four patients refused to stay close to the surgery center after an unsuccessful attempt of emergency balloon removal using an EXIT procedure in the referral center. Thus, the rate of unsuccessful balloon removal was 2.3% (4/175). Thus, in the remaining 171 cases, the balloon was removed at a mean GA of 33.8 (ranges, 28.4–38.0) weeks either by ultrasound guided needle puncture in 85/171 (49.7%), fetoscopy in 51/171 (29.8%), or the EXIT procedure in 35/171 (20.5%).
Following FETO, O/E‐LHR values increased from a mean of 25.0% before FETO to 50.7% before balloon removal (p < 0.001). Women who underwent the FETO procedure had a higher incidence of PPROM (47.8% vs. 20.0%, p < 0.001), preterm delivery before 37 weeks (67.8% vs. 43.3%, p < 0.001), and a lower mean GA at delivery (35.2 vs. 37.0 weeks, p < 0.001) compared with expectantly managed women. Figure 1 illustrates the survival rate between the study groups. Survival at discharge from the NICU was 39.4% (71/180) in the FETO group, as compared to 8.9% (16/180) in the control group without FETO (p < 0.001). Survival at 6 months was significantly higher in the FETO group than in controls (37.2% vs. 8.9%, p < 0.001). PSM selected 176 cases treated with FETO that were matched with 176 controls. Survival at discharge from the NICU was significantly higher in the FETO group (40.3% vs. 6.8%, two‐sided p < 0.001) than in the controls. Logistic regression analysis showed a significant association between FETO and neonatal survival (odds ratio [OR]: 14.8; 95% confidence interval [CI]: 7.1–30.9; p < 0.001). GA at birth was significantly associated with survival probability (OR 1.2; 95% CI: 1.1–1.4, p < 0.001).
FIGURE 1.
Illustrates the neonatal survival rates between the group managed with or without endoscopic tracheal occlusion (FETO) in Latin American (LATAM) centers. *p < 0.01.
4. Discussion
The main finding of our study is that FETO was associated with a significant increase in survival among fetuses with left‐sided CDH and severe lung hypoplasia in LA centers.
In our study, to improve the discrimination of cases that could be beneficial for FETO, severe left‐sided CDH was redefined as those fetuses presenting with an O/E‐LHR < 35% and intrathoracic liver herniation. Such O/E‐LHR values were selected according to the severity classification of left‐sided CDH in Latin‐American countries, which have showed a survival rate < 10%. Thus, to reach a comparable survival rate to the TOTAL trial, the severity category of CDH was balanced by increasing the lung size cut‐off to 35% instead of the 25% used in the TOTAL trial. Although a different classification to define severe CDH was used in the FETO group, cases with a similar lung size were used as a control group to avoid a potential bias.
Thus, in our study, survival at discharge from NICU in the FETO group was 40%, which is similar to that observed in international trials using an O/E‐LHR < 25% as a cut‐off to define severe CDH [6, 7]. When comparing our expectantly managed cohort of severe left‐sided CDH with those of the expectant group of the TOTAL trial for severe CDH, our group showed a 60% lower survival rate (9% vs. 22%). This supports the notion that in Latin American countries, FETO is of great benefit and that the impact on survival is even greater than in other regions due to the lower survival rate observed in our expectant management group.
This finding agrees with the results of the Brazilian randomized controlled trial, which included 20 fetuses with severe CDH who underwent FETO and 21 expectantly managed cases during pregnancy, showing a beneficial effect of FETO but a lower survival rate in the control group than that reported in Europe [18]. Similarly, our previously published LA CDH study [9] demonstrated that the severity of CDH, based on the degree of lung hypoplasia, should be reclassified in our region, since for the same lung size, survival of neonates managed expectantly during pregnancy is lower in LA than in Europe. However, this difference in survival could be mitigated when FETO is offered to patients in LA.
On the contrary, the North American Fetal Therapy Network (NAFTNet) recently reported a less beneficial effect of FETO in improving neonatal survival, mainly due to a higher survival rate in the group managed expectantly during pregnancy than that reported in European countries (58% in NAFTNet vs. 22% in the TOTAL trial) [19]. Interestingly, another recently published European multicenter study also found differences in survival within the same region, demonstrating lower mortality in fetuses with severe left‐sided CDH (defined by O/E‐LHR < 35% and liver‐up, evaluated by magnetic resonance imaging) treated with expectant management in a German center with expertise in the neonatal management of severe CDH compared with three other European centers that treated with FETO and the permissive use of ECMO and standardized postnatal care [10]. Similarly, in a recent retrospective study published by the Fetal Surgery Center of Canada, survival outcomes after FETO were similar to those of the TOTAL trial [20].
The main strengths of this study are the selection of a well‐defined population of isolated left‐sided CDH treated with FETO in five LA countries during a long study period and the inclusion of a contemporary control group with similar degree of lung hypoplasia but managed expectantly during pregnancy. Although the non‐randomized design represents a limitation, the use of PSM reduces selection bias by balancing covariates between the study groups and thus allowing a more accurate estimation of the fetoscopic effect. As a limitation, the lack of data precludes a comparison of neonatal respiratory morbidity between the two groups. Although the neonatal management was standardized in all centers, and in general terms, neonatal management for CDH in our LA centers is comparable to that of NA and Europe regarding ventilation, surgical repair timing, and pulmonary hypertension management; suboptimal neonatal care could be partly explained by the unavailability of ECMO in some LA centers and the lack of specialized referral centers for neonatal CDH treatment. In addition, it can be argued that temporal changes in clinical experience, technology, and management strategies may have neonatal management during the 20‐year study period. However, the control group was comprised of a contemporary group of fetuses with similar characteristics, who were delivered in the same participant centers, which decreased the influence of time‐related effects in our results. Finally, although minor variations in the FETO technique were found among participants centers, the lack of a standardized protocol represents a limitation of the current study and a call to create international guidelines for fetal surgery.
The benefits of FETO have been extensively reported in both human and animal models and include an increase in intrabronchial pressure, a decrease in intrapulmonary vascular resistance, and thus, an improvement in fetal lung growth. Our results suggest that endotracheal placement of the balloon by fetoscopy improves fetal lung growth before birth, which facilitates neonatal management, mainly in settings with limited neonatal care, and thus improves survival outcomes.
In conclusion, in LA countries, FETO was associated with an improvement in survival of 30% in the group with severe left‐sided CDH. Further studies are required to assess the potential benefits and risks of FETO in cases of moderate lung hypoplasia (O/E‐LHR > 35%). Therefore, in settings similar to ours, FETO should only be considered for isolated left‐sided CDH fetuses with right lung sizes below 35% and intrathoracic liver herniation.
Funding
The authors have nothing to report.
Ethics Statement
The protocol was approved by the hospital's ethics committee (IRB 080/21062017) of the main organizing center in Mexico. Approval for the clinical protocol of other centers was obtained from the research ethics committees in each country.
Consent
All patients provided written informed consent for the use of fetal and neonatal data.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
The LA CDH Study Group comprises the following collaborators: Rogelio Cruz‐Martínez, Rosa Villalobos‐Gómez, María de la Luz Bermúdez Rojas, Miguel Martínez‐Rodríguez, Adriana Cisneros‐Martínez (Hospital de Especialidades del Niño y la Mujer de Querétaro y Centro de Diagnóstico Prenatal y Cirugía Fetal, Instituto Medicina Fetal México, Guadalajara, Jalisco, México); Savino Gil Pugliese, María Agustina Nobile (Hospital Privado Universitario de Córdoba); Saulo Molina‐Giraldo, José Luis Rojas‐Arias, Martha Lucía Pinto‐Quiñones, Margarita Fadul Valera, Liseth Blanco Fuentes, Condy Bolaños Gnecco (Hospital de San José, Fundación Universitaria de Ciencias de la Salud‐FUCS, Bogotá, Colombia); Adolfo Etchegaray, Rodolfo Keller, Ricardo Daniel Russo, Ángeles Cibert, Fernanda Jousse, María Celeste Berruet, Sabrina Demirdjian, Florencia Contino Stortz, Gabriel Musante, Ernesto Beruti, Rodolfo Fregonese, Sofia Marchionatti, Soledad Heredia (Hospital Universitario Austral, Argentina); Lucas Otaño, César Meller, Horacio Aiello, Juan Otaño, Lucía Vázquez, María Eugenia Carducci, Marcelo Mauricio Urquizo Lino y Gonzalo Mariani (Hospital Italiano de Buenos Aires, Argentina); José Enrique Sanin‐Blair, Raúl García, Jorge Gutierrez Marin, Nazareth Campo (Unidad de Medicina Materno Fetal, Clínica Bolivariana, Medellín, Colombia), Enrique Gil‐Guevara, Oswaldo Gonzáles Carrillo, Jeannette Marchena Arias, Braowell Miranda Frisancho (Instituto Peruano de Medicina y Cirugía Fetal, Lima, Peru); Rodrigo Ruano (Departamento de Medicina Materno‐Fetal, Sao Paulo, Brasil), Amanda Manfroi, Antonio Gomes de Amorim Filho, Mário Henrique Burlacchini de Carvalho, Rossana Pulcineli Vieira de Francisco (Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil). Rogelio Cruz‐Martinez wishes to thank all participants for their invaluable contribution to this work and the Fetal Medicine Foundation of Mexico for supporting the ultrasound evaluation of fetal pathologies and fetal interventions in Guadalajara, Mexico.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.