Ultrasound diagnosis of fetal diaphragmatic hernia and complex congenital heart disease at 12 weeks' gestation--a case report

Prenatal Ultrasonographic Diagnosis of Congenital Diaphragmatic Hernia at 11 Weeks Gestation

Congenital diaphragmatic hernia is a major malformation. Early diagnosis is in itself an important factor for the prediction of the outcome. The authors present a case of left-sided fetal diaphragmatic hernia diagnosed by transvaginal ultrasound examination at 10 weeks, 5 days gestation.

Contemporary outcomes in infants with congenital heart disease and bochdalek diaphragmatic hernia

BACKGROUND

Fifteen percent of infants with congenital diaphragmatic hernia (CDH) are born with a coexisting cardiac anomaly. The purpose of this study was to evaluate contemporary outcomes in this patient population and to identify potential risk factors for in-hospital mortality.

METHODS

Data from all CDH neonates with congenital heart disease managed at a single pediatric tertiary care referral center between 1997 and 2011 were retrospectively analyzed.

RESULTS

Forty (18%) of 216 CDH patients had a cardiac anomaly. This group was associated with a significant decrease in overall survival when compared with patients without cardiac anomaly (55% versus 81%; p = 0.001). There was no association between type of cardiac anomaly and mortality based on risk stratification according to the Risk Adjustment for Congenital Heart Surgery and The Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery scoring systems (p = 0.86 and p = 0.87, respectively). Birth weight was similarly no different between survivors and nonsurvivors (2.8 ± 0.6 kg versus 2.8 ± 0.9 kg, respectively; p = 0.98). There was a trend toward increased extracorporeal membrane oxygenation use among nonsurvivors (p = 0.13). Infants with hemodynamic stability enabling subsequent cardiac repair were associated with lower mortality (p = 0.04). Survivors had a wide spectrum of long-term morbidity, but most had some evidence of neurodevelopmental impairment.

CONCLUSIONS

This large single-institution series suggests that the overall prognosis of infants with concomitant CDH and congenital heart disease can be quite variable, regardless of the type of heart anomaly. Hemodynamic instability and need for extracorporeal membrane oxygenation correlate with higher mortality. Although some long-term survivors have excellent outcomes, most suffer from chronic, long-term morbidities.

Congenital diaphragmatic hernia in a first-trimester ultrasound aneuploidy screening program

OBJECTIVES

To review our experience with the prenatal detection of congenital diaphragmatic hernia (CDH) in fetuses presenting for ultrasound screening of chromosomal abnormalities in the first trimester.

METHODS

As part of our first-trimester ultrasound protocol, fetuses with a crown-rump length between 45 and 84 mm underwent a limited anatomical assessment in conjunction with nuchal translucency thickness measurement and nasal bone assessment. Cases of CDH diagnosed prenatally or after delivery in this population were identified.

RESULTS

Among the six cases of CDH detected (prevalence of 1 in 927), the first-trimester ultrasound findings were abnormal in five fetuses (83%), including three with increased nuchal translucency only; one with increased nuchal translucency, an intrathoracic stomach, dextrocardia and a cephalocele; and one with normal nuchal translucency thickness and a small, complex intrathoracic mass later confirmed as the fetal stomach. The diagnosis of CDH was confidently made in the first trimester in one case, in the second trimester in three cases, and after birth in the remaining two cases.

CONCLUSION

The diagnosis of CDH in the first trimester is difficult, especially in those cases in which the defect is small or late migration of the abdominal viscera occurs. Therefore, screening for CDH in the first trimester is unlikely to be effective.

[Increased nuchal translucency with normal karyotype]

Nuchal translucency (NT) measurement in first trimester screening between 11 and 14 weeks' gestation has now been clearly identified as a marker for aneuploidies and in particular for trisomy 21. Even in the absence of aneuploidy increased fetal nuchal translucency has been shown to be a marker for fetal heart malformations and numerous other fetal defects and genetic syndromes when the measure is>or=95th centile which is around 3,5 mm for each gestational age. Fetuses with NT thickness above the 99th centile and normal karyotype have a high risk of adverse prenatal outcome and this increase in risk is exponential as the nuchal translucency measurement increases. However, among children born alive with normal ultrasound at 22 weeks of gestation, there was no significant association between NT thickness and development at 2 years as assessed by clinical examination and ASQ scores, when with a control population. Counselling should emphasize that when the karyotype is normal and no fetal structural malformation was missed prenatally following resolution of nuchal thickening, the prognosis is not impaired at the age of 2.

Fetal Surgery for Congenital Diaphragmatic Hernia and Pulmonary Sequestration Complicated by Postnatal Diagnosis of Transposition of the Great Arteries

This report describes the case of a neonate who underwent fetal surgery for congenital diaphragmatic hernia (CDH) and pulmonary sequestration. His postnatal management was complicated by the additional diagnosis of transposition of the great arteries (TGA). TGA is particularly difficult to diagnose in the fetus. This triad has not previously been documented in the literature. Clinicians should have a high index of suspicion for associated anomalies, especially cardiac, when evaluating and counseling a pregnancy complicated by CDH.

Congenital diaphragmatic hernia. Two cases with early prenatal diagnosis and increased nuchal translucency

The early ultrasound prenatal diagnosis of congenital diaphragmatic hernia is uncommon and suggests a poor outcome. We report 2 cases diagnosed at 10 and 12 weeks' gestation, with increased fetal nuchal translucency thickness (4 and 11 mm) and associated abnormalities (complex heart defect in one and many malformations in the other, including duodenal atresia and asplenia). In 1 case, the baby was delivered vaginally at 36 weeks, but neonatal death occurred; the pregnancy was terminated at 15 weeks in the second case.