High-Risk Pregnancy & Fetal Surgery | Dr. Li Xiaotian (MFM) | CMCS Shanghai

About Dr. Li Xiaotian

Dr. Li Xiaotian is Chief of Maternal-Fetal Medicine at Obstetrics & Gynecology Hospital, Fudan University — one of China's foremost obstetric institutions and a national reference centre for high-risk pregnancy management, fetal anomaly diagnosis, and prenatal intervention. She is a leading expert in complex obstetric care, recognised for her expertise in fetal structural anomaly assessment, multidisciplinary high-risk pregnancy management, fetal intervention evaluation, and the coordination of delivery planning and neonatal surgical care for fetuses with life-threatening congenital anomalies. Dr. Li's practice is defined by the philosophy that a fetal diagnosis is not the end of a conversation — it is the beginning of a care plan that must simultaneously protect the mother, optimise the fetal environment, plan the delivery, and prepare the neonatal surgical team, because the outcome of a baby with congenital diaphragmatic hernia is determined not by the surgery alone but by every decision made from the moment of diagnosis to the moment of discharge. Her department at Obstetrics & Gynecology Hospital, Fudan University has established one of China's most comprehensive maternal-fetal medicine programmes, integrating high-resolution fetal ultrasound, fetal MRI, invasive prenatal diagnosis, fetal intervention evaluation, multidisciplinary delivery planning, and structured neonatal surgical coordination into a unified care pathway for families facing complex fetal diagnoses.

Case Overview

Mrs. Sarah Callahan (pseudonym), a 32-year-old Australian teacher based in Shanghai, G2P0 with one prior spontaneous miscarriage, was referred at 22 weeks gestation after routine anomaly ultrasound identified left intrathoracic bowel loops, rightward cardiac displacement, and left diaphragmatic discontinuity — consistent with left-sided congenital diaphragmatic hernia (CDH). Fetal MRI at 23 weeks confirmed left diaphragmatic defect with herniation of the stomach and small bowel into the left thorax, significant cardiac and mediastinal rightward shift, and left pulmonary hypoplasia. Amniocentesis at 24 weeks confirmed a normal fetal karyotype. A multidisciplinary team led by Dr. Li Xiaotian — including maternal-fetal medicine, paediatric surgery, neonatology, and anaesthesiology — determined that the fetal condition did not meet criteria for in-utero intervention (fetoscopic tracheal occlusion, FETO) and recommended intensive antenatal surveillance, planned delivery at a centre with neonatal surgical capability, and elective caesarean section at 39 weeks to minimise delivery-related visceral injury. At 39 weeks and 2 days, a male neonate weighing 3,200 g was delivered by caesarean section with Apgar scores of 8 at 1 minute and 10 at 5 minutes. Left CDH repair was performed at 6 hours of life — a 3.0 cm × 2.5 cm left diaphragmatic defect with herniated stomach and small bowel was reduced and repaired. The neonate was successfully extubated on post-operative day 3, discharged on day 15, and at 6-month follow-up demonstrated normal chest radiograph, normal cardiac position, and normal pulmonary function.

Patient Background

• Name / Nationality: Mrs. Sarah Callahan (pseudonym) — Australian; 32-year-old teacher based in Shanghai
• Age / Obstetric history: 32-year-old female; G2P0 — one prior spontaneous miscarriage; no prior live births
• Chief Complaint: Fetal anomaly identified on routine 22-week anomaly ultrasound — left intrathoracic bowel loops and rightward cardiac displacement
• Antenatal history: Regular menstrual cycles; no significant first-trimester symptoms; 12-week nuchal translucency scan normal; no prior fetal anomaly identified
• No relevant maternal medical history: No hypertension, diabetes, or cardiac disease; no infectious disease history; no prior surgery or trauma; no smoking or alcohol
• No family history of fetal anomaly or congenital malformation
• Examination at presentation: Stable vital signs; cardiac and pulmonary auscultation normal; uterine fundal height 20 cm, consistent with gestational age; fetal position LOA; fetal heart rate 145 bpm, regular; no uterine contractions; no vaginal bleeding or fluid loss; cervical length normal; cervical os closed

Diagnostic Workup

Detailed Fetal Ultrasound (22 weeks + 3 days)

• Thoracic findings: Left intrathoracic echogenic bowel loops and dilated stomach bubble; cardiac rightward displacement; mediastinal rightward shift
• Diaphragm: Left diaphragmatic continuity interrupted; defect size approximately 2.0 cm
• Biometry: BPD 5.4 cm, HC 19.8 cm, AC 17.5 cm, FL 3.8 cm — all consistent with gestational age; no fetal growth restriction
• Amniotic fluid: Amniotic fluid index normal — no polyhydramnios

Fetal MRI (23 weeks)

• Diaphragmatic defect: Left diaphragmatic defect confirmed; stomach and partial small bowel herniated into the left thorax
• Cardiomediastinal shift: Heart and mediastinum significantly displaced to the right
• Pulmonary development: Left lung hypoplastic; right lung relatively enlarged with normal morphology; total fetal lung volume assessed for prognostication
• Clinical significance: MRI provides superior soft tissue delineation for CDH — confirming herniated organs, quantifying lung volumes, and excluding associated anomalies

Amniocentesis and Chromosomal Analysis (24 weeks)

• Fetal karyotype: Normal (46,XY) — excludes trisomy 18 and trisomy 13, which are associated with CDH and carry a poor prognosis independent of the diaphragmatic defect
• Clinical significance: Isolated CDH with normal karyotype has substantially better prognosis — critical for family decision-making and surgical planning

Maternal Investigations

• Full blood count, coagulation, liver and renal function, glucose, lipids: All within normal limits
• Infectious disease screening (hepatitis B, C, syphilis, HIV): All negative
• TORCH serology IgM (toxoplasma, rubella, CMV, HSV): All negative

Dr. Li's diagnostic assessment: The ultrasound at 22 weeks gave us the diagnosis — left CDH with cardiac shift. The MRI at 23 weeks gave us the prognostic information we needed: which organs are herniated, how much lung is left, and whether the right lung is developing normally. In this case, the stomach and small bowel are in the chest, the left lung is hypoplastic, but the right lung looks structurally normal and has compensated with increased volume. The karyotype is normal. This is isolated left CDH — the best-prognosis subtype. The question now is not whether to treat it — we will repair it after birth — but how to manage the pregnancy to give this baby the best possible condition at the moment of delivery, and whether the lung hypoplasia is severe enough to warrant in-utero intervention before then.

Multidisciplinary Team Discussion and Management Strategy

The MDT convened by Dr. Li Xiaotian included maternal-fetal medicine, paediatric surgery, neonatology, and anaesthesiology. Three sequential decisions were addressed: whether to offer fetal intervention (FETO); how to manage the remainder of the pregnancy; and how to plan the delivery and immediate neonatal care.

FETO evaluation: Fetoscopic tracheal occlusion — in which a detachable balloon is placed in the fetal trachea to stimulate lung growth by preventing egress of fetal lung fluid — is indicated for severe CDH with observed-to-expected lung volume ratio below 25% on MRI. In this patient, the lung measurements and compensatory right lung hypertrophy placed the case in the moderate-severity category, below the FETO threshold. The MDT consensus was that the risks of FETO (preterm labour, premature rupture of membranes, fetal loss) outweighed the potential benefit, and that postnatal repair offered an excellent prognosis for isolated moderate CDH with normal karyotype.

Antenatal surveillance: Weekly maternal and fetal assessment; fetal ultrasound every 2–3 weeks to monitor lung development, cardiac function, and herniated visceral volume; maternal blood pressure and glucose monitoring.

Delivery planning: Elective caesarean section at 39 weeks at a centre with on-site NICU and paediatric surgical capability — avoiding vaginal delivery, which risks further visceral herniation during uterine contractions. Neonatal surgical team to be present at delivery.

Neonatal management plan: Immediate intubation at delivery if respiratory distress present; bag-mask ventilation avoided (inflates herniated bowel, worsens thoracic compression); nasogastric decompression; surgical repair within 24–48 hours once haemodynamically stable.

Treatment Course

Antenatal Surveillance (22 to 39 Weeks)

Mrs. Callahan attended weekly antenatal assessments throughout the remainder of the pregnancy. At 30 weeks, fetal ultrasound demonstrated a modest increase in left lung volume — still significantly smaller than the right lung but showing some compensatory growth — and mild improvement in cardiac and mediastinal position. No polyhydramnios developed. Maternal blood pressure and glucose remained within normal limits; no gestational hypertension or gestational diabetes. The family received regular bilingual counselling from Dr. Li's team and the paediatric surgery team regarding the planned postnatal repair, expected NICU course, and long-term prognosis.

Dr. Li's antenatal note: The 30-week scan was reassuring — the left lung has grown a little, which tells us the pulmonary vasculature is not completely arrested. That matters for the post-operative course, because the severity of pulmonary hypertension after CDH repair is the main determinant of how long the baby needs ventilatory support. A lung that has shown some growth during pregnancy is more likely to respond to post-operative pulmonary vasodilator therapy than one that has shown no growth at all. We are not out of the woods — the left lung is still hypoplastic — but the trajectory is better than we feared at 22 weeks.

Delivery — Elective Caesarean Section at 39 Weeks + 2 Days

Anaesthesia: Epidural anaesthesia; maternal vital signs stable throughout. Male neonate delivered; birth weight 3,200 g; Apgar score 8 at 1 minute (2 points deducted for mild respiratory distress) and 10 at 5 minutes. Immediate respiratory distress and cyanosis on delivery — anticipated presentation of CDH at birth.

Immediate neonatal stabilisation: Neonatal team present at delivery; immediate orotracheal intubation performed — bag-mask ventilation avoided; nasogastric tube placed for gastric decompression; transferred to NICU for pre-operative stabilisation.

Neonatal Surgery — Left CDH Repair (6 Hours of Life)

Pre-operative stabilisation: Six hours of NICU stabilisation — ventilator settings optimised to achieve pre-ductal oxygen saturation above 85% while avoiding barotrauma; pulmonary hypertension managed with inhaled nitric oxide; haemodynamic stability confirmed before proceeding to surgery.

Operative findings: Left diaphragmatic defect 3.0 cm × 2.5 cm; stomach and partial small bowel herniated into the left thorax; Bochdalek-type defect (no hernial sac).

Reduction and repair: Herniated viscera gently reduced into the abdominal cavity; left lung confirmed hypoplastic but present; diaphragmatic defect repaired primarily with interrupted non-absorbable sutures; chest drain placed in the left pleural space.

Operative data: Total operative time approximately 75 minutes; blood loss minimal; no intraoperative complications; haemodynamic stability maintained throughout.

Dr. Li's post-delivery note: The timing of CDH repair is one of the most important decisions in neonatal surgery. The old approach was to repair immediately after birth — the thinking was that the herniated bowel was compressing the lung and needed to come out as fast as possible. We now know that is wrong. The lung hypoplasia is a fixed anatomical reality that does not change the moment the bowel is reduced — what changes is the pulmonary vascular resistance, and that takes hours to days to stabilise after birth. Operating on a neonate with uncontrolled pulmonary hypertension dramatically increases operative mortality. The six-hour stabilisation period allowed us to bring the pulmonary pressures down to a level where the baby could tolerate the anaesthesia and the surgery. That is why he extubated on day three rather than spending three weeks on the ventilator.

Post-operative Management and Outcomes

NICU Course

• Post-operative days 1–2: Mechanical ventilation continued; inhaled nitric oxide maintained for pulmonary hypertension; chest drain output monitored; nasogastric feeds initiated cautiously
• Post-operative day 3: Successfully extubated to nasal cannula oxygen — earlier than the median extubation time for CDH, reflecting moderate pulmonary hypoplasia severity and effective pre-operative stabilisation
• Post-operative day 7: Chest radiograph showed marked reduction in left pleural effusion; cardiac and mediastinal position restored to normal; left lung expansion improved; chest drain removed
• Post-operative day 15: Neonate discharged — breathing on room air; feeding normally; weight gain established; no respiratory, gastrointestinal, or neurological complications

Follow-up Outcomes

• 6-month follow-up: Chest radiograph and ultrasound normal — no diaphragmatic reherniation, no pleural effusion, normal cardiac position; pulmonary function normal for age; growth and developmental milestones on track
• No complications: No gastro-oesophageal reflux, no recurrent respiratory infections, no neurodevelopmental concerns at 6 months

Expert Commentary — Dr. Li Xiaotian

1. Congenital Diaphragmatic Hernia: Why the Lung, Not the Hole, Determines the Prognosis

The diaphragmatic defect in CDH is surgically repairable — it is not the defect itself that determines survival and long-term outcome, but the degree of pulmonary hypoplasia and pulmonary vascular maldevelopment that results from the herniated viscera compressing the developing lung during the critical period of fetal lung growth. A baby with a small defect and minimal lung compression may have near-normal lung development and an uncomplicated post-operative course. A baby with a large defect and severe bilateral pulmonary hypoplasia may not survive despite technically perfect surgical repair, because the lungs cannot sustain gas exchange regardless of what the surgeon does to the diaphragm. This is why the prenatal prognostic assessment — lung-to-head ratio, observed-to-expected lung volume on MRI, liver position, and stomach position — is more important than the defect size itself. In this patient, moderate lung hypoplasia with compensatory right lung growth and the absence of liver herniation placed him in a favourable prognostic category — confirmed by the early extubation and uncomplicated NICU course.

2. FETO: Selecting the Right Patients for In-Utero Intervention

Fetoscopic tracheal occlusion works by blocking the normal egress of fetal lung fluid through the trachea — the fluid accumulates in the lungs, generating a stretch stimulus that accelerates alveolar and vascular growth in the hypoplastic lung. The TOTAL trial demonstrated that FETO significantly improves survival in severe CDH (observed-to-expected lung volume ratio below 25%) but does not improve outcomes in moderate CDH — and carries a significant risk of iatrogenic preterm birth, which itself worsens CDH outcomes. The critical skill in CDH management is not performing FETO — it is correctly identifying which patients will benefit from it and which will be harmed by it. In this patient, the lung measurements placed the case in the moderate category where FETO offers no survival benefit but carries a real risk of preterm delivery. The decision not to intervene in utero was as important as any intervention — it preserved the pregnancy to 39 weeks, giving the neonate the maximum possible gestational maturity at the time of repair.

3. Delivery Planning for CDH: Why Elective Caesarean Section at a Surgical Centre Matters

The mode and location of delivery for a fetus with CDH are not administrative decisions — they are clinical decisions with direct consequences for neonatal outcome. Vaginal delivery subjects the fetus to uterine contractions and birth canal compression that can worsen visceral herniation and cause additional lung compression at the moment of birth. Elective caesarean section eliminates this risk and allows precise timing of delivery to ensure the full neonatal surgical and NICU team is present and prepared. Delivery at a centre without on-site neonatal surgical capability means that a neonate with CDH who requires urgent intervention must be transferred — during which time pulmonary hypertension may worsen and the window for optimal stabilisation may be lost. At Obstetrics & Gynecology Hospital, Fudan University, we plan all CDH deliveries in coordination with the paediatric surgery and neonatology teams — ensuring the surgical team is present at delivery, the NICU bed is prepared, and the inhaled nitric oxide is ready before the baby is born.

4. The Shift from Emergency to Elective CDH Repair: How Delayed Surgery Saves Lives

The historical approach to CDH — emergency surgical repair within hours of birth — was based on the intuitive but incorrect assumption that removing the herniated bowel would immediately improve lung function. The evidence accumulated over three decades shows the opposite: neonates repaired before haemodynamic and pulmonary stabilisation have significantly higher mortality than those repaired after a period of optimisation, because the surgery itself — the anaesthesia, the positive pressure ventilation, the haemodynamic shifts of abdominal closure — is a physiological stress that a neonate with uncontrolled pulmonary hypertension cannot tolerate. The current standard — stabilise first, operate when stable — has transformed CDH survival rates at high-volume centres. In this patient, six hours of pre-operative stabilisation with ventilator optimisation and inhaled nitric oxide reduced the pulmonary vascular resistance to a level where the neonate could tolerate the anaesthesia and the repair without haemodynamic compromise. The early extubation on day three was the direct consequence of that pre-operative investment.

How CMCS Shanghai Coordinated This Case

CMCS Shanghai supported Mrs. Callahan and her husband from the moment of fetal diagnosis through the six-month neonatal follow-up, including: urgent coordination of maternal-fetal medicine consultation with Dr. Li Xiaotian at Obstetrics & Gynecology Hospital, Fudan University with same-week appointment scheduling following the anomaly ultrasound finding; bilingual explanation of the CDH diagnosis, its implications, and the planned diagnostic and management pathway — addressing the family's acute anxiety at the time of diagnosis; coordination of detailed fetal ultrasound and fetal MRI with bilingual radiology report translation and prognostic interpretation; amniocentesis coordination including bilingual consent support, procedure scheduling, and bilingual karyotype result communication; bilingual interpretation throughout all MDT discussions involving maternal-fetal medicine, paediatric surgery, neonatology, and anaesthesiology; FETO evaluation coordination including bilingual explanation of the intervention, the eligibility criteria, and the MDT decision not to proceed — with full explanation of the reasoning to the family; weekly antenatal appointment coordination with bilingual clinical update summaries communicated to the family's obstetrician in Sydney; 30-week reassessment coordination with bilingual ultrasound result interpretation and prognostic update; delivery planning coordination including caesarean section scheduling, anaesthesia consent, and bilingual explanation of the immediate neonatal management plan; neonatal surgical team briefing coordination — ensuring the paediatric surgery team received the complete prenatal record in advance of delivery; real-time updates to the patient's husband and her obstetrician in Australia during the caesarean section and the neonatal surgical repair; NICU daily update coordination — bilingual clinical summaries of the neonate's ventilator status, pulmonary hypertension management, and surgical recovery communicated to the family each day; extubation and discharge coordination with bilingual discharge instructions and follow-up scheduling; and six-month follow-up coordination including chest radiograph, ultrasound, and developmental assessment with results communicated to the family's paediatrician in Australia.

For international families facing a fetal anomaly diagnosis, high-risk pregnancy, or complex neonatal surgical condition in Shanghai, Dr. Li Xiaotian's team at Obstetrics & Gynecology Hospital, Fudan University represents maternal-fetal medicine expertise at the international frontier — combining high-resolution fetal imaging, multidisciplinary delivery planning, and coordinated neonatal surgical care to achieve the best possible outcome for mother and baby from the moment of diagnosis through long-term follow-up. CMCS ensures that expertise is accessible: in the family's language, with overseas obstetricians and paediatricians informed at every step, from the first anomaly scan through six-month neonatal surveillance.

This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.