Pilot Trial of Fetoscopic Endoluminal Tracheal Occlusion (FETO) in Severe Left Congenital Diaphragmatic Hernia (CDH)

Inclusion Criteria:

• Pregnant women age 18 years and older
• Singleton pregnancy
• Normal fetal karyotype with confirmation by culture results. Results by fluorescencein situ hybridization (FISH) will be acceptable if the patient is > 26 weeks
• Isolated Left CDH with liver up
• Gestation age at enrollment prior to 29 wks plus 6 days
• SEVERE pulmonary hypoplasia with US LHR O/E < 25% (measured at 180 to 295 weeks) atthe time of surgery
• Gestational age at FETO procedure 27 weeks 0 days to 29 weeks 6 days as determined byclinical information (LMP) and evaluation of first ultrasound
• Family meets psychosocial criteria
• Pre-authorization from third-party payor for fetal intervention OR the ability toself-pay for study treatment. For all patients without insurance or the means to payfor the procedure, an attempt will be made to obtain Medicaid. Insurers that havedenied payment have noted that this remains an experimental procedure. As this is afeasibility study and not being offered as either standard of care or as a prospectiverandomized control trial to determine efficacy, the investigators do not feel thatthere is a breach of ethical standards.
• Informed consent

Exclusion Criteria:

• Failure to meet all inclusion criteria
• Patient < 18 years of age
• Multi-fetal pregnancy
• Rubber latex allergy
• Preterm labor, cervix shortened (< 15 mm at enrollment or within 24 hours of FETOballoon insertion procedure) or uterine anomaly strongly predisposing to pretermlabor, placenta previa
• Family does not meet psychosocial criteria. Reasons for exclusion include:insufficient social support, inability to understand requirements of the study,inability to reside in or near San Francisco.
• Right sided CDH or bilateral CDH, isolated left sided with LHR O/E < 25% (measured at 180 to 295 weeks) as determined by ultrasound
• Additional fetal anomaly by ultrasound, MRI, or echocardiogram at the fetal treatmentcenter. Exclude chromosomal abnormalities, associated anomalies recognized to altersurvival prognosis (ie. CDH and congenital heart disease) or presence of an underlyinggenetic syndrome (ie. Fryns). No cases will be removed post hoc if abnormalities arediscovered in the course of post-operative monitoring
• Maternal contraindication to fetoscopic surgery or severe maternal medical conditionin pregnancy
• History of incompetent cervix with or without cerclage
• Placental abnormalities (previa, abruption, accrete) known at time of enrollment
• Maternal-fetal Rh isoimmunization, Kell sensitization or neonatal alloimmunethrombocytopenia affecting the current pregnancy
• Maternal HIV, Hepatitis-B, Hepatitis-C status positive because of the increased riskof transmission to the fetus during maternal-fetal surgery. If the patient's HIV orHepatitis status is unknown, the patient must be tested and found to have negativeresults before enrollment
• Uterine anomaly such as large or multiple fibroids or mullerian duct abnormality
• There is no safe or technically feasible fetoscopic approach to balloon placement
• Participation in another intervention study that influences maternal and fetalmorbidity and mortality or participation in this trial in a previous pregnancy