Could the stomach site help predict outcome in babies with left sided congenital diaphragmatic hernia diagnosed antenatally?

Risk Stratification by Percent Liver Herniation in Congenital Diaphragmatic Hernia

INTRODUCTION

Congenital diaphragmatic hernia is associated with pulmonary hypoplasia, pulmonary hypertension, and significant neonatal morbidity. Although intrathoracic liver herniation (LH) >20% is associated with adverse outcomes, the relationship between LH <20% and outcomes is poorly characterized.

METHODS

A single-center retrospective cohort study was performed from 2011 to 2020 of 80 fetuses with left-sided congenital diaphragmatic hernia that were delivered and repaired at our institution. Perinatal, perioperative, and postoperative data were collected. We evaluated the association of %LH with outcomes as a stratified ordinal variable (0%-10% LH, 10%-19% LH, and >20% LH) and as a continuous variable. Data were analyzed by analysis of variance with Bonferroni post hoc analysis, chi-square analyses, and univariate logistic regression.

RESULTS

Extracorporeal membrane oxygenation (ECMO) (P < 0.001), repair on ECMO (P = 0.002), repair with patch (P < 0.001), length of stay (P = 0.002), inhaled nitric oxide use (P < 0.001), and sildenafil use at discharge (P < 0.001), showed significant differences among LH groups. There were no differences among the groups concerning survival (at discharge, 6 mo, and 1 y) and tracheostomy. On further analysis there was no difference between 10% and 19% LH and ≥20% LH patients concerning ECMO (P = 0.55), repair on ECMO (P = 0.54), repair with patch (P = 1.00), length of stay (P = 1.00), and inhaled nitric oxide use (P = 0.33). Logistic regression analysis displayed a significant association with LH and ECMO, repair on ECMO, repair with patch, inhaled nitric oxide use, and sildenafil use.

CONCLUSIONS

Our analysis displays no significant difference in perinatal management between patients with 10%-19% and ≥20% LH. These findings suggest that the historical cutoff of ≥20% LH may not be sufficient alone to guide perinatal counseling and decision-making.

Decreased neonatal morbidity in 'stomach-down' left congenital diaphragmatic hernia: implications of prenatal ultrasound diagnosis for counseling and postnatal management

OBJECTIVE

To evaluate the influence of stomach position on postnatal outcome in cases of left congenital diaphragmatic hernia (CDH) without liver herniation, diagnosed and characterized on prenatal ultrasound (US), by comparing those with ('stomach-up' CDH) to those without ('stomach-down' CDH) intrathoracic stomach herniation.

METHODS

Infants with left CDH who underwent prenatal US and postnatal repair at our institution between January 2008 and March 2017 were eligible for inclusion in this retrospective study. Detailed prenatal US examinations, fetal magnetic resonance imaging (MRI) studies, operative reports and medical records of infants enrolled in the pulmonary hypoplasia program at our institution were reviewed. Cases with liver herniation and those with an additional anomaly were excluded. Cases in which bowel loops were identified within the fetal chest on US while the stomach was intra-abdominal were categorized as having stomach-down CDH. Cases in which bowel loops and the stomach were visualized within the fetal chest on US were categorized as having stomach-up CDH. Prenatal imaging findings and postnatal outcomes were compared between the two groups.

RESULTS

In total, 152 patients with left CDH were initially eligible for inclusion. Seventy-eight patients had surgically confirmed liver herniation and were excluded. Of the 74 included CDH cases without liver herniation, 28 (37.8%) had stomach-down CDH and 46 (62.2%) had stomach-up CDH. Of the 28 stomach-down CDH cases, 10 (35.7%) were referred for a suspected lung lesion. Sixty-eight (91.9%) cases had postnatal outcome data available for analysis. There was no significant difference in median observed-to-expected (o/e) lung-area-to-head-circumference ratio (LHR) between cases with stomach-down CDH and those with stomach-up CDH (41.5% vs 38.4%; P = 0.41). Furthermore, there was no difference in median MRI o/e total lung volume (TLV) between the two groups (49.5% vs 44.0%; P = 0.22). Compared with stomach-up CDH patients, stomach-down CDH patients demonstrated lower median duration of intubation (18 days vs 9.5 days; P < 0.01), median duration of extracorporeal membrane oxygenation (495 h vs 223.5 h; P < 0.05), rate of supplemental oxygen requirement at 30 days of age (20/42 (47.6%) vs 3/26 (11.5%); P < 0.01) and rate of pulmonary hypertension at initial postnatal echocardiography (28/42 (66.7%) vs 9/26 (34.6%); P = 0.01). No neonatal death occurred in stomach-down CDH patients and one neonatal death was seen in a patient with intrathoracic stomach herniation.

CONCLUSIONS

In infants with left CDH without liver herniation, despite similar o/e-LHR and o/e-TLV, those with stomach-down CDH have decreased neonatal morbidity compared to those with stomach herniation. Progressive or variable physiological distension of the stomach over the course of gestation may explain these findings. Stomach-down left CDH is mistaken for a lung mass in a substantial proportion of cases. Accurate prenatal US characterization of CDH is crucial for appropriate prenatal counseling and patient management. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Feasibility and outcomes of fetoscopic endoluminal tracheal occlusion for severe congenital diaphragmatic hernia: A Japanese experience

AIM

To present the feasibility, safety and outcomes of fetoscopic endoluminal tracheal occlusion (FETO) for the treatment of severe congenital diaphragmatic hernia (CDH).

METHODS

This was a single-arm clinical trial of FETO for isolated left-sided CDH with liver herniation and Kitano Grade 3 stomach position (>50% stomach herniation into the right chest). FETO was performed at 27-29 weeks of gestation for cases with observed/expected lung to head ratio (o/e LHR) <25% and at 30-31 weeks for cases with o/e LHR ≥25%.

RESULTS

Eleven cases were enrolled between March 2014 and March 2016, and balloon insertion was successful in all cases. The median o/e LHR at entry was 27% (range, 20-33%). The median gestational age at FETO was 30.9 (range, 27.1-31.7) weeks. There were no severe maternal adverse events. One fetus died unexpectedly at 33 weeks of gestation due to cord strangulation by the detached amniotic membrane. There were 3 cases (27%) of preterm premature rupture of membranes. In all 10 cases, balloon removal at 34-35 weeks of gestation was successful. The median gestational age at delivery was 36.5 (range, 34.2-38.3) weeks. The median duration of occlusion and the median interval between balloon insertion and delivery were 26 days (range: 17-49 days) and 43 days (range, 21-66 days), respectively. Both the survival rate at 90 days of age and the rate of survival to discharge were 45% (5/11).

CONCLUSION

The FETO is feasible without maternal morbidity in Japan and could be offered to women whose fetuses show severe isolated left-sided CDH to accelerate fetal lung growth.

Prediction tools in congenital diaphragmatic hernia

Because congenital diaphragmatic hernia (CDH) is characterized by a spectrum of severity, risk stratification is an essential component of care. In both the prenatal and postnatal periods, accurate prediction of outcomes may inform clinical decision-making, care planning, and resource allocation. This review examines the history and utility of the most well-established risk prediction tools currently available, and provides recommendations for their optimal use in the management of CDH patients.

Comparison of mediastinal shift angles obtained with ultrasound and magnetic resonance imaging in fetuses with isolated left sided congenital diaphragmatic hernia

Objectives: To compare ultrasound (US) and magnetic resonance imaging (MRI) in the assessment of mediastinal shift angles (MSAs) in fetuses affected by isolated left congenital diaphragmatic hernia (CDH). The use of MRI-MSA and US-MSA as prognostic factor for postnatal survival in fetal left CDH was also explored.Methods: This was an observational study of 29 fetuses with prenatally diagnosed isolated left CDH, assessed with both US and MRI examinations between January 2015 and December 2018. The US-MSA measurements performed within 2 weeks from the MRI assessment were considered for the analysis. The primary outcome was the postnatal survival rate.Results: No significant difference between US and MRI MSAs was detected (p = .419). Among the 29 cases, there were 21 alive infants, for an overall postnatal survival rate of 72.41%. After stratifying for postnatal survival, the best cutoffs with the highest discriminatory power in terms of sensibility and specificity were 42.1° for the US-MSA and 39.1° for the MRI-MSA. The performance of MRI-MSA in predicting postnatal survival was close to that of US-MSA in terms of sensitivity (62.5 versus 50.0%), specificity (80.9 versus 90.5%), positive predictive value (55.6 versus 66.7%), negative predictive value (85.0 versus 82.6%) and accuracy (75.9 versus 79.3%). There was no statistically significant difference between the two modalities (p > .05 for all).Conclusions: MRI and US can be interchangeably used for the assessment of MSA in prenatally diagnosed isolated left CDH. Moreover, MSA measured by both US and MRI was confirmed to be correlated with perinatal outcome in terms of survival.

Prenatal Diagnosis of Congenital Diaphragmatic Hernia: Does Laterality Predict Perinatal Outcomes?

OBJECTIVE

The objective of this study was to examine laterality as a predictor of outcomes among fetuses with prenatally diagnosed congenital diaphragmatic hernia (CDH).

METHODS

This is a retrospective cohort study of pregnancies with CDH evaluated at our center from 2008 to 2016 compared cases with right-sided CDH (RCDH) versus left-sided CDH (LCDH). The primary outcome was survival to discharge. Secondary outcomes included ultrasound predictors of poor prognosis (liver herniation, stomach herniation, lung area-to-head circumference ratio [LHR]), concurrent anomalies, hydrops, stillbirth, preterm birth, mode of delivery, small for gestational age, use of extracorporeal membrane oxygenation, and length of stay. Terminations and stillbirths were excluded from analyses of neonatal outcomes.

RESULTS

In this study, 157 (83%) LCDH and 32 (17%) RCDH cases were identified. Survival to discharge was similar (64 vs. 66.4%, p = 0.49) with regard to laterality. RCDH had higher rates of liver herniation (90.6 vs. 72%, p = 0.03), hydrops fetalis (15.6 vs. 1.3%, p < 0.01), and lower LHR (0.87 vs. 0.99, p = 0.04). LCDH had higher rates of stomach herniation (69.4 vs. 12.5%, p < 0.01). Rates of other outcomes were similar in univariate analyses. Adjusting for microarray abnormalities, the odds for survival to discharge for RCDH compared with LCDH was 0.93 (0.38-2.30, p = 0.88).

CONCLUSION

Compared with LCDH, fetuses with RCDH had higher rates of adverse ultrasound predictors, but equivalent survival.

A Clinical Study on Congenital Diaphragmatic Hernia in Neonates: Our Institutional Experience

Background:

Congenital diaphragmatic hernia (CDH) is a complex developmental defect having a multifactorial etiology; i majority of cases (~80%), the cause is not known. Survival rates for patients with CDH have increased over the past decade with early prenatal detection and better postnatal management including surgery. Clinical profile and the outcome of 83 CDH neonates were studied and analyzed over a period of 12 years in our institute.

Aims and Objectives:

The clinical study was to analyze the clinical profile and outcome of CDH among the neonates in a tertiary care referral neonatal and pediatric center in Karnataka, India.

Materials and Methods:

This was a retrospective and prospective observational study conducted from January 2005 to March 2017, over a period of 12 years in a tertiary care referral neonatal and pediatric center in southern India. Clinical characteristics and risk factors of 83 neonates admitted and diagnosed with CDH were compared between survivors and nonsurvivors both preoperatively and postoperatively. Neonates with clinical and intraoperative diagnosis of diaphragmatic eventration were not included in this study. Multivariate logistic regression analysis was performed to determine independent predictors for mortality.

Results:

A total of 83 neonates admitted and diagnosed with CDH were included in this study; 73 of them underwent surgical repair. The total survival rate in neonates with CDH was 70/83 (84.33%) and the overall operative mortality was 3/73 (4.1%). There was a significant difference between CDH neonates who survived 70/83 (84.33%) and those who died 13/83 (15.67%), in the age on admission, 5 min Apgar score, onset of respiratory distress, preoperative ventilation, the presence of persistent pulmonary hypertension of the newborn (PPHN), high-frequency oscillatory ventilation (HFOV), and length of hospital stay with P < 0.05. Using multivariate logistic regression analysis, the following factors independently predicted mortality: onset of respiratory distress in hours (odds ratio: 0.5, 95% confidence interval: 0.37–0.82) and preoperative ventilation (odds ratio: 0.02; 95% confidence interval: 0.0028–0.1558). When we compared CDH neonates who survived after surgery (n = 70) with those who expired (n = 3) postoperatively, there was a significant difference in the gestational age in weeks, side of CDH, PPHN, HFOV and length of hospital stay with P < 0.05.

Conclusion:

CDHs are common on the left side with fairly good prognosis. Though, the right-sided CDH are rare; they do carry a good prognosis, as it was seen in our experience.

Is there a determining factor that predicts mortality in patients with congenital diaphragmatic hernia?

AIM

This study was designed to investigate the factors affecting the prognosis in neonates with congenital diaphragmatic hernia (CDH) who were treated in our clinic. These factors included prenatal lung-head ratio (LHR), prenatal stomach and liver presence in the thorax, blood gases in the first 24 h and the modified ventilation index (MVI).

MATERIAL AND METHODS

The study was carried out retrospectively in 30 neonates with prenatally diagnosed left CDH who were treated in our clinic between January 2007 and 2013. Data were collected, evaluated, and statistically analyzed for gender, birth weight, gestational age, prenatal LHR, prenatal presence of stomach and liver in the thorax, postnatal initial blood gases in the first 24 h and MVI.

RESULTS

The median LHR for non-survivors was 1.49 and for survivors 1.51. No statistically significant difference in LHR was detected between survivors and non-survivors. In 19 neonates, prenatal ultrasonography (USG) revealed intrathoracic stomach, and 9 of these infants died. Intrathoracic liver was seen in 15 neonates, and 9 of these died. A statistically significant difference was not found between survivors and non-survivors in the intrathoracic liver or intrathoracic stomach neonates. A comparison between the non-survivors and survivors showed a median pH value of 7.10 in non-survivors and 7.24 in survivors (p = 0.002). The median PaCO2 value was 69.4 mm Hg in non-survivors and 51.9 mm Hg in survivors (p = 0.01). There were statistically significant differences in pH and PaCO2 values. The median value of MVI was 33 in survivors and 100 in non-survivors. There was a statistically significant difference between overall non-survivors and survivors in the MVI value (p < 0.05).

CONCLUSIONS

Based on the findings, postnatal pH, and PaCO2 and MVI values are favorable prognostic factors in CDH in our selected group of patients.

Fetal stomach and gallbladder in contact with the bladder wall is a common ultrasound sign of stomach-down left congenital diaphragmatic hernia

PURPOSE

The aim of this study was to identify sonographic (US) findings that can assist in prenatal diagnosis of stomach-down left congenital diaphragmatic hernia (CDH), specifically related to positioning of the abdominal contents including the stomach, bladder, and gallbladder.

METHODS

All US examinations with a postnatally confirmed diagnosis of stomach-down left CDH over a 13-year period were retrospectively reviewed for abnormal position of the abdominal contents, including whether the fetal stomach was in contact with the urinary bladder. Normal fetuses that underwent comprehensive US surveys were similarly evaluated for comparison in a 2:1 ratio.

RESULTS

Twenty-two fetuses with stomach-down left CDH were identified in a cohort of 278 fetuses with left CDH. In 15/22 (68.2%) cases of stomach-down left CDH, the bladder and stomach walls were in contact. Contact of the fetal gallbladder with the fetal bladder wall was also observed and was present even more commonly (17/22 cases [77.3%]). There was no case of either the stomach or gallbladder in contact with the bladder wall in the normal fetal cohort (n = 44).

CONCLUSIONS

Recognition of the fetal stomach and/or gallbladder in contact with the bladder wall can help in the detection of stomach-down left CDH. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:8-13, 2017.

Fetal Stomach Position Predicts Neonatal Outcomes in Isolated Left-Sided Congenital Diaphragmatic Hernia

INTRODUCTION

We sought to determine the relationship between the degree of stomach herniation by antenatal sonography and neonatal outcomes in fetuses with isolated left-sided congenital diaphragmatic hernia (CDH).

MATERIALS AND METHODS

We retrospectively reviewed neonatal medical records and antenatal sonography of fetuses with isolated left CDH cared for at a single institution (2000-2012). Fetal stomach position was classified on sonography as follows: intra-abdominal, anterior left chest, mid-to-posterior left chest, or retrocardiac (right chest).

RESULTS

Ninety fetuses were included with 70% surviving to neonatal discharge. Stomach position was intra-abdominal in 14% (n = 13), anterior left chest in 19% (n = 17), mid-to-posterior left chest in 41% (n = 37), and retrocardiac in 26% (n = 23). Increasingly abnormal stomach position was linearly associated with an increased odds of death (OR 4.8, 95% CI 2.1-10.9), extracorporeal membrane oxygenation (ECMO; OR 5.6, 95% CI 1.9-16.7), nonprimary diaphragmatic repair (OR 2.7, 95% CI 1.4-5.5), prolonged mechanical ventilation (OR 5.9, 95% CI 2.3-15.6), and prolonged respiratory support (OR 4.0, 95% CI 1.6-9.9). All fetuses with intra-abdominal stomach position survived without substantial respiratory morbidity or need for ECMO.

DISCUSSION

Fetal stomach position is strongly associated with neonatal outcomes in isolated left CDH. This objective tool may allow for accurate prognostication in a variety of clinical settings.

Advances in prenatal diagnosis and treatment of congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a common birth anomaly. Absence or presence of liver herniation and determination of lung-to-head ratio are the most accurate predictors of prognosis for fetuses with CDH. Though open fetal CDH repair has been abandoned, fetal endoscopic balloon tracheal occlusion promotes lung growth in fetuses with severe CDH. Although significant improvements in lung function have not yet been shown in humans, reversible or dynamic tracheal occlusion is promising for select fetuses with severe CDH. This article reviews advances in prenatal diagnosis of CDH, the experimental basis for tracheal occlusion, and its translation into human clinical trials.

Current advances in prenatal imaging of congenital diaphragmatic [corrected] hernia

Congenital diaphragmatic hernia, despite advances in therapy, remains a complex condition with significant morbidity and mortality. The etiology of the disorder is still incompletely understood, though the pulmonary hypoplasia and pulmonary hypertension that develop secondarily must be overcome to improve survival. Prenatal US and fetal MRI have helped in the development of a greater understanding of this disease. Also with these modalities, measurement techniques have been developed in an attempt to provide prognosticators for the development of pulmonary hypoplasia and pulmonary hypertension. There is a broad range of approaches for performing these measurements, and variability among imaging centers is noted. Despite inconsistent approaches, these techniques have become the foundation for counseling and prenatal and postnatal therapy. It is hoped that with further research with prenatal US and fetal MRI and the development of innovative medical and surgical therapies that the morbidity and mortality of children with congenital diaphragmatic hernias can be significantly reduced.

Re-evaluation of stomach position as a simple prognostic factor in fetal left congenital diaphragmatic hernia: a multicenter survey in Japan

OBJECTIVES

To document outcome and to explore prognostic factors in fetal left congenital diaphragmatic hernia (CDH).

METHODS

This was a multicenter retrospective study of 109 patients with prenatally diagnosed isolated left CDH born between 2002 and 2007. The primary outcome was intact discharge, defined as discharge from hospital without major morbidities, such as a need for respiratory support including oxygen supplementation, tube feeding, parenteral nutrition or vasodilators. All patients were managed at perinatal centers with immediate resuscitation, gentle ventilation (mostly with high-frequency oscillatory ventilation) and surgery after stabilization. Prenatal data collected included liver and stomach position, lung-to-head ratio, gestational age at diagnosis and presence or absence of polyhydramnios. Stomach position was classified into four grades: Grade 0, abdominal; Grade 1, left thoracic; Grade 2, less than half of the stomach herniated into the right chest; and Grade 3, more than half of the stomach herniated into the right chest.

RESULTS

Overall intact discharge and 90-day survival rates were 65.1% and 79.8%, respectively. Stomach herniation was classified as Grade 0 in 19.3% of cases, Grade 1 in 45.9%, Grade 2 in 13.8% and Grade 3 in 21.1%. Multivariate analysis revealed that liver position was the strongest prognostic variable for intact discharge, followed by stomach position. Based on our results, we divided patients into three groups according to liver (up vs. down) and stomach (Grade 0-2 vs. Grade 3) position. Intact discharge rates declined significantly from liver-down (Group I), to liver-up with stomach Grade 0-2 (Group II), to liver-up with stomach Grade 3 (Group III) (87.0%, 47.4% and 9.5% of cases, respectively).

CONCLUSION

Current status and outcomes of prenatally diagnosed left CDH in Japan were surveyed. Stomach herniation into the right chest was not uncommon and its grade correlated with outcome. The combination of liver and stomach positions was useful to stratify patients into three groups (Group I-III) with different prognoses.

Tracheal occlusion for fetal congenital diaphragmatic hernia: the US experience

Congenital diaphragmatic hernia (CDH) is characterized by a defect in the diaphragm that permits abdominal viscera to herniate into the chest. These herniated viscera are thought to compress the growing lung and cause lung parenchymal and vascular hypoplasia. The genetic defects that cause the diaphragmatic defect may also contribute primarily to lung hypoplasia. Postnatal reduction of the herniated abdominal viscera and correction of the diaphragmatic defect are easily achievable, but the lung hypoplasia persists, often leading to persistent fetal circulation and respiratory failure. This article reviews the experimental basis of fetal therapy for CDH and the US clinical experience with tracheal occlusion.

Fetal preload index of the inferior vena cava and neonatal outcome of congenital diaphragmatic hernia

PURPOSE

The purpose of this study was to assess prognostic factors in patients with congenital diaphragmatic hernia (CDH).

METHODS

Thirteen patients with CDH diagnosed antenatally and delivered in our hospital between 1995 and 2006 were retrospectively studied. Assessments of sonographic examinations included gestational age at time of diagnosis; the ultrasonographic parameters [amniotic fluid index, cardiothoracic area ratio, and the lung-thoracic transverse area ratio (LTR)]; and the incidence of polyhydramnios, intrauterine growth retardation, and hydrops. Doppler velocimetry measurements comprised the resistance index of the umbilical artery, the resistance index of the midcerebral artery, the maximal velocity of the descending aorta, and the preload index of the inferior vena cava (IVCPLI). Results were expressed as the mean ± standard deviation. The features of survivors and nonsurvivors were compared.

RESULTS

Six fetuses were survivors and seven were nonsurvivors. The mean LTR value tended to be markedly low in both groups (23.8 ± 16.4 vs 12.1 ± 1.1). In Doppler analysis, the mean IVCPLI value in survivors was significantly lower than that in nonsurvivors (0.34 ± 0.08 vs 0.52 ± 0.14, P = 0.01).

CONCLUSION

We concluded that fetal IVCPLI might be a good predictor of the outcome in patients with CDH.

Experience in the Management of Eighty-Two Newborns With Congenital Diaphragmatic Hernia Treated With High-Frequency Oscillatory Ventilation and Delayed Surgery Without the Use of Extracorporeal Membrane Oxygenation

The aim of this study is to analyze neonatal outcome of isolated congenital diaphragmatic hernia and to identify prenatal and postnatal prognosis-related factors. A retrospective single institution series from January 2000 to November 2005 of isolated congenital diaphragmatic hernia neonates was reviewed. Respiratory-care strategy was early high-frequency oscillatory ventilation, nitric oxide in pulmonary hypertension, and delayed surgery after respiratory and hemodynamic stabilization. Survival rate at 1 month was 65.9%. None of the prenatal factors were predictive of neonatal outcome, except an intra-abdominal stomach in left diaphragmatic hernia. Preoperative pulmonary hypertension was more severe in the nonsurvivor group and was predictive of length of ventilation in the survivors. During the first 48 hours of life, the best oxygenation index above 13 and the best PaCO2 above 45 were predictive of poor outcome. When treating isolated congenital diaphragmatic hernia with early high-frequency ventilation and delayed surgery but excluding extracorporeal membrane oxygenation, survival rates compare favorably with other reported series, and the respiratory morbidity is low.

Prenatal prognosis in isolated congenital diaphragmatic hernia

OBJECTIVE

A monocentric retrospective study of 79 neonates with isolated diaphragmatic hernia antenatally diagnosed was performed to identify prenatal parameters that may characterize the severity of the disease.

STUDY DESIGN

Postnatal treatment protocol included early high frequency ventilation, inhaled nitric oxide, and delayed surgery. Postnatal survival rate was 63.3%.

RESULTS

Age at diagnosis, polyhydramnios, and left ventricle/right ventricle index were not related with survival. None of the 9 left diaphragmatic hernias with intraabdominal stomach died. Neonatal mortality was significantly related with the side of the defect, intrathoracic position of the liver, the ratio of fetal lung area to head circumference value, and fetal lung volume ratio measured by resonance magnetic imaging.

CONCLUSION

No prenatal factor alone firmly predicts neonatal outcome. Clinicians should help stratify the severity of the disease and compare accurately different postnatal therapeutic strategies.

Fetal surgery for congenital diaphragmatic hernia: the North American experience

The role for fetal surgery in treating fetuses with congenital diaphragmatic hernia (CDH) is unclear. Two decades of investigation have improved our understanding of the prenatal natural history, pathophysiology, and outcomes of these patients. During this same period, there have been advances in fetal surgery techniques including improvements in fetal monitoring, maternal-fetal anesthesia, tocolysis, and improved instrumentation to permit increased application of videoscopic approaches. Because of technical challenges, open fetal repair of CDH has been abandoned. Fetal tracheal ligation has shown promise, but a recently published prospective, randomized trial failed to show a benefit of fetoscopic tracheal ligation compared with expert postnatal treatment. Although there is evidence that postnatal outcomes for infants with this disease have improved with the adoption of gentilation ventilator management, high-frequency ventilation, and ECMO, there continues to be a subset of infants with severe CDH that die or suffer serious long-term morbidity despite advanced surgical care. The purpose of this article is to review issues related to prenatal diagnosis, patient selection, and outcomes for fetal surgery; and ultimately to assess whether there is a role for fetal surgery in treating fetuses with CDH.

Antenatal diagnosis of congenital diaphragmatic hernia

Congenital diaphragmatic hernia occurs in approximately 1 of 2200 live births and is associated with a high degree of morbidity and mortality. Poor outcome in these cases is primarily related to the presence of additional anomalies or abnormal karyotype and the development of pulmonary and cardiovascular complications. Prenatal diagnosis occurs in approximately 50% of cases. Multiple ultrasound markers have been identified as being predictive of outcome. Three-dimensional ultrasound, fetal echocardiography, and magnetic resonance imaging have been identified as additional imaging modalities that can assist in making the antenatal diagnosis and accurately assessing perinatal outcome.

Extralobar sequestration with congenital diaphragmatic hernia: a complicated case study

This article presents a case study of an infant (JG) with an antenatal diagnosis of a left diaphragmatic hernia and an extralobar sequestration of his right lung, which was noted postnatally. JG's course was complicated by persistent pulmonary hypertension of the newborn (PPHN) and suspected pulmonary hypoplasia, and he required support with extracorporeal life support (ECLS). JG's case was unusual in his presentation of extreme PPHN that was unresponsive to inhaled nitric oxide and ECLS. His PPHN was nearly intractable, requiring treatment with vasodilators combined with intravenous sildenafil, which had never been tried in our institution before this case. The article concludes with a discussion of the etiology, diagnosis, and management of congenital diaphragmatic hernia and extralobar sequestration, singly and in combination.

Heart rate variability as an indicator of outcome in congenital diaphragmatic hernia with and without ECMO support

OBJECTIVE

To examine differences in the spectral power content in neonates diagnosed with congenital diaphragmatic hernia (CDH) who survive or succumb.

STUDY DESIGN

A case-series study design evaluated four neonates diagnosed with CDH, two of which were supported by extracorporeal membrane oxygenation (ECMO). The electrocardiogram signal was digitized at 1000 Hz and the Lomb periodogram was computed for the series of interbeat intervals.

RESULTS

Neonates with CDH who survived had log total power values greater than 2. Those with CDH who did not survive had log total power less than 2, but generally exceeded 3 while they were supported by ECMO.

CONCLUSIONS

Neonates who consistently displayed increasing total spectral energies had a better outcome than those whose spectral energies were low. Subjects who succumbed expressed the lowest values, suggesting that a frequency-based evaluation of HRV may be a sensitive prognosticator of outcome that requires further investigation.

Current therapy of infants with congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a life-threatening anomaly with a significant mortality rate. Despite widespread prenatal diagnosis, few parameters have been well defined to aid in prediction of outcome of these infants. Antenatal maternal steroid administration and foetal surgery are not proven interventions. Postnatal treatment has changed over the last 10 years, with avoidance of hyperventilation and ventilator-induced lung injury resulting in improved survival. Therapies such as inhaled nitric oxide, exogenous surfactant administration and extracorporeal membrane oxygenation (ECMO) have undergone limited study, but show no clear benefit in this population. With improved outcome, principally due to avoidance of barotrauma, greater opportunity exists for long-term evaluation of survivors. To date, continuing problems with pulmonary function, nutrition and growth, effects of right ventricular hypertension and developmental issues have been identified. Through co-ordinated, multidisciplinary evaluation of CDH survivors, improved long-term outcome for these challenging patients can be attained.

Congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a lethal human birth defect. Hypoplastic lung development is the leading contributor to its 30-50% mortality rate. Efforts to improve survival have focused on fetal surgery, advances in intensive care and elective delivery at specialist centres following in utero diagnosis. The impact of abnormal lung development on affected infants has stimulated research into the developmental biology of CDH. Traditionally lung hypoplasia has been viewed as a secondary consequence of in utero compression of the fetal lung. Experimental evidence is emerging for a primary defect in lung development in CDH. Culture systems are providing research tools for the study of lung hypoplasia and the investigation of the role of growth factors and signalling pathways. Similarities between the lungs of premature newborns and infants with CDH may indicate a role for antenatal corticosteroids. Further advances in postnatal therapy including permissive hypercapnia and liquid ventilation hold promise. Improvements in our basic scientific understanding of lung development may hold the key to future developments in CDH care.

Congenital diaphragmatic hernia in Scandinavia from 1995 to 1998: Predictors of mortality

BACKGROUND/PURPOSE

There is a lack of large contemporary studies on the management of congenital diaphragmatic hernia (CDH), and the prediction of mortality remains difficult. The aim of this study was to investigate the influence of perinatal factors on mortality rate in a contemporary multicenter study.

METHODS

The authors conducted a retrospective multicenter cohort study. Twelve of 13 Scandinavian pediatric surgical centers participated in the study. During a 4-year period (1995 through 1998) 195 children with CDH were included. The main endpoints were hospital mortality rate and total mortality rate (before 2001). Bivariate and multivariate survival analyses were performed using Kaplan-Meier plots, Log-rank test, and Cox regression.

RESULTS

Overall hospital mortality rate was 30%. Among 168 neonates with symptoms within 24 hours (early presenters) 35% died before discharge. All 61 deaths occurred in 157 neonates with symptoms within the first 2 hours of life. Among early presenters, 27% had prenatal ultrasound diagnosis, 26% were delivered by cesarean section, and 21% had associated major malformations. Bivariate analysis of early presenters showed increased risk of death in neonates with prenatal diagnosis, associated anomalies, right-sided diaphragmatic hernia (RCDH), low 1-minute and 5-minute Apgar scores, low birth weight, short gestational age, and cesarean delivery. Neonates with prenatal diagnosis were characterized by significantly lower Apgar scores, lower birth weight, and increased frequency of associated anomalies than those diagnosed after birth. Multivariate analysis found that prenatal diagnosis (P =.004), 1-minute Apgar (P =.001), and RCDH (P =.042) were independent predictors of total mortality rate.

CONCLUSIONS

In a series of 195 CDH patients, all 61 deaths occurred in the 157 neonates presenting with symptoms within the first 2 hours of life. Prenatal diagnosis, 1-minute Apgar score, and RCDH were significant independent predictors of total mortality.

Influence of congenital heart disease on survival in children with congenital diaphragmatic hernia

OBJECTIVE

We sought to assess outcome in patients with CDH and HD to determine if LHR is also predictive of outcome in this subset of patients.

STUDY DESIGN

We carried out a retrospective review (April 1996-October 2000) of patients with isolated CDH (n = 143, 82.2%) and patients with HD (n = 31, 17.8%) to determine the incidence of additional anomalies, survival to term, CDH repair, cardiac repair, and survival to discharge. Survival based on LHR was analyzed in a subset of fetuses.

RESULTS

The risk of death from birth to last follow-up was 2.9 times higher for patients with CDH plus HD than for patients with CDH alone (P <.0001). Of 11 patients with CDH plus HD who had CDH repair (5 of whom also had HD repair), 5 survived. All 10 patients with an LHR <1.2 died; 3 of 6 with an LHR >1.2 survived (Fisher exact test, P =.04).

CONCLUSION

Heart disease remains a significant risk factor for death in infants with CDH. The LHR helps predict survival in this high-risk group of patients.

The evolving appearance of a congenital diaphragmatic hernia

OBJECTIVE

The prenatal differentiation of a fetal congenital diaphragmatic hernia from other echogenic chest masses can be difficult. The implications of the leading diagnosis can greatly affect the neonatal prognosis. The cases presented illustrate how the primary diagnosis of a fetal chest mass can change during the course of gestation as the appearance of the chest mass evolves.

METHODS

A descriptive analysis of 2 cases reviewed the importance of considering multiple causes of an echogenic chest mass.

RESULTS

The sonographic features of a congenital diaphragmatic hernia that have been described in the literature were not always present at the time of initial evaluation.

CONCLUSIONS

A congenital diaphragmatic hernia should be part of the differential diagnosis considered during consultation with parents whose fetus has an echogenic chest mass.

Noncardiac thoracic anomalies

FHT is a rare diagnosis that may be an isolated finding or associated with multiple fetal anomalies, congenital infection or isoimmunization. The natural history of the lesion is variable. The effusion may regress spontaneously; remain stable in size; or progress to involve both sides of the chest and produce fetal hydrops, pulmonary hypoplasia, and fetal or neonatal demise. Hydrops is associated with significant fetal mortality. Antenatal decompression of the hydrothorax with pleuroamniotic shunting or thoracocentesis may result in a significant decrease in perinatal morbidity and mortality. Persistent hydrothorax can usually be treated with noninvasive measures in the newborn period.

Congenital diaphragmatic hernia: a meta-analysis of mortality factors

PURPOSE

The aim of this study was to review all available studies reported in the English-language literature from 1975 through 1998, and by meta-analysis assess the importance of prenatal diagnosis, associated malformations, side of hernia, timing of surgery, and study population on mortality rates in patients with congenital diaphragmatic hernia (CDH).

METHODS

One-hundred-two studies were identified, and 51 studies (2,980 patients) fulfilled the prespecified inclusion criteria. Studies were grouped according to study population into: (I) fetuses diagnosed prenatally; (II) neonates admitted to a treatment center; and (III) population-based studies.

RESULTS

Pooled total mortality rate was significantly higher in category I than in category III (75.6% v 58.2%, P < .001). Pooled hidden postnatal mortality rate (deaths before admittance to a treatment center) in population-based studies was 34.9%. Prenatally diagnosed patients in both category II and III had significantly higher mortality rates than those diagnosed postnatally. Mortality rates were significantly higher among CDH infants with associated major malformations compared with isolated CDH in all 3 categories. An increased mortality rate in right-sided CDH was found in category II and III.

CONCLUSIONS

Prenatal diagnosis of CDH, presence of associated major malformations, and the study population have a major influence on mortality rate. The very high mortality rate in studies of fetuses with a prenatal diagnosis of CDH should be taken into account in prenatal counselling.

Prediction of outcome by computer-assisted analysis of lung area on the chest radiograph of infants with congenital diaphragmatic hernia

BACKGROUND/PURPOSE

Pulmonary hypoplasia is a major cause of mortality and morbidity in infants with congenital diaphragmatic hernia (CDH). Pulmonary hypoplasia is characterized by low volume lungs, and affected infants are likely to have a low lung area on their chest radiograph. The authors assessed whether, in CDH infants, computer-assisted analysis of the chest radiograph lung area gave an accurate indication of lung volume, and if a low lung area was a better predictor of poor outcome (death or oxygen dependency at 28 days) than other test results.

METHODS

Comparisons were made of the radiographic lung area derived by computer-assisted analysis and lung volume, assessed by measurement of functional residual capacity (FRC) on day 1 before surgical intervention and on the first postoperative day. Compliance was measured, and the maximum and modified ventilation indices and maximum Paco2 also was noted. Twenty-five CDH infants with a median gestational age of 38 weeks were studied; 18 had FRC measurements preoperatively.

RESULTS

Both preoperatively and postoperatively, the lung areas and FRCs correlated significantly (r = 0.51, P<.05; r = 0.76, P<.02, respectively). Eleven infants had a poor outcome (5 infants died without an operation); that group preoperatively differed significantly from those with a good outcome with respect to having a lower compliance (P<.02) and higher maximum ventilation index (P<.01) and maximum modified ventilation index (P<.05). Only postoperatively did infants with a poor outcome versus good outcome have a significantly lower lung area (P<.05); they also had a lower increase in lung area preoperatively to postoperatively (P<.01). Receiver operator characteristic curves were constructed; comparison of the areas under the curves showed that preoperatively, a low compliance and high ventilation index were the best predictors of poor outcome. Postoperatively, a low lung area performed as well as the ventilation indices.

CONCLUSION

Computer-assisted analysis of the lung area on the chest radiograph is useful in predicting outcome in CDH infants postoperatively but not preoperatively.

Is prognostication in congenital diaphragmatic hernia possible without sophisticated investigations?

Congenital diaphragmatic hernia is a complex disorder, in which the anatomical defect is only one part of the spectrum of disease. Hypoplasia of lung complicated by pulmonary hypertension and right to left shunting results in serious hypoxemia. Many factors, based on degree of alterations in respiratory physiology and involving analysis of blood gases and acid base systems, have been used in an attempt to prognosticate the outcome. Majority of these investigations are not available in a modest set up like ours. The case records of all 20 patients admitted and operated for congenital diaphragmatic hernia in pediatric surgery unit of Government Medical College Hospital, Jabalpur from 1978 to 1997 were reviewed retrospectively in an attempt to prognosticate without the sophisticated investigations. It was found that even in a very modestly equipped hospital it is possible to prognosticate--to some extent--the outcome in these cases. Major prognosticators found were APGAR score (if child born in hospital), late age of presentation, location of stomach and identification of hernial sac.

[Congenital diaphragmatic hernia. II. Is pulmonary hypoplasia an indefinable obstacle?]

Despite major insights into the pathogenesis and pathophysiology of congenital diaphragmatic hernia, and despite the availability of an antenatal diagnosis and continuous progress in neonatal intensive care, little improvement has been obtained in the prognosis of this malformation. Thus obstetricians, neonatologists and pediatric surgeons are still facing a several dilemma: dilemma before birth to predict the prognosis, i.e., to evaluate the severity of the associated pulmonary hypoplasia in order to decide whether or not to interrupt pregnancy; dilemma after birth in case of severe respiratory failure to decide how far to go in life support. Based on a review of the literature and their own experience, the authors attempt to recapitulate the perinatal management and outcome of this severe malformation.

Prognosis of congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) contributes significantly to perinatal morbidity and mortality. This retrospective study examines the experience of a major teaching hospital to establish survival rates and factors influencing outcome. Survival rates were found to relate closely to the stage at which the diagnosis was made and the presence of associated anomalies. Ultrasound diagnosis early in pregnancy is associated with a higher mortality rate than diagnosis made late in pregnancy or after delivery. Logistic regression analysis and chi-squared analysis did not establish to a significant degree that any factor, alone or in combination, was a reliable prognostic indicator. It is acknowledged, however, that figures in this series are small. Survival figures are presented to facilitate reliable parental counselling. In particular, the presence of associated major anomalies and the gestational age at which diagnosis is made are of critical importance in accurately counselling parents regarding the prognosis for survival. In this study, excluding terminations, the mortality rate for isolated CDH diagnosis before the 21st week was 45.5%, with a corresponding survival rate of 54.5%. Once the infant was liveborn, however, the survival rate rose to 68.0%, and if the infant survived transfer to a paediatric surgical unit, the survival rate in this study was 73.9 %.

Prospective analysis of lung-to-head ratio predicts survival for patients with prenatally diagnosed congenital diaphragmatic hernia

BACKGROUND

Accurate prenatal prediction of outcome for fetuses who have congenital diaphragmatic hernia (CDH) is very difficult. The authors previously reported a retrospective analysis of risk factors for fetal CDH and proposed a new index of severity: the lung-to-head ratio (LHR). The authors now report a prospective study to test whether this new index predicts neonatal outcome.

METHODS

Fifteen patients who had left-sided CDH were sonographically evaluated at the University of California, San Francisco (UCSF) and followed prenatally and postnatally. LHR was measured at 24 to 26 weeks' gestation. Outcome variables included survival and the need for extracorporeal membrane oxygenation (ECMO).

RESULTS

Overall survival was 47%. LHR ranged from 0.62 to 1.86. No patient with an LHR of less than 1.0 (n = 3) survived despite ECMO, whereas all patients with an LHR greater than 1.4 survived (n = 4), one requiring ECMO. LHR values between 1.0 to 1.4 were associated with 38% survival (n = 8), 75% requiring ECMO. Overall, survivors had a mean LHR of 1.4 +/- 0.33 and nonsurvivors, 1.05 +/- 0.3 (P < .05).

CONCLUSION

The LHR is a useful index to help predict neonatal outcome in patients who have left-sided CDH.

Mortality among infants with high-risk congenital diaphragmatic hernia in Singapore

Several factors suggested to predict mortality in congenital diaphragmatic hernia (CDH) have not always been applicable in different centers. A retrospective review was conducted of 19 consecutive neonates in Singapore in whom CDH was diagnosed within 12 hours of birth to identify factors associated with mortality. Of the 19 cases, 15 (79%) were diagnosed using antenatal ultrasonography. Eight (42%) underwent primary repair at a median age of 23 hours (range, 12 to 50 hours). Of the 19 infants, 15 died (mortality rate, 79%). Survivors until hospital discharge were compared with nonsurvivors. Antenatal diagnosis and stomach position in left-sided defects had no effect on outcome, although polyhydramnios tended to be associated with nonsurvival. Significant postnatal factors associated with mortality included a low arterial pH level, low initial arterial-alveolar oxygen ratio, high initial alveolar-arterial oxygen gradient, as well as high oxygenation and ventilation indices. These results reflect difficulty in oxygenation because of pulmonary hypoplasia despite evidence of adequate ventilation. There was no difference between survivors and nonsurvivors in either their initial or best postductal blood gases. The "Bohn quadrants" did not aid in predicting survival of infants who underwent repair because all eight such infants had best postductal carbon dioxide values of less than 40 mm Hg and ventilation indices of less than 1,000. Yet only four (50%) survived until hospital discharge. Large-scale evaluation of these factors may be required in the future to demonstrate their validity and reliability because of changing management strategies for CDH.

Can blood gas values predict pulmonary hypoplasia in antenatally diagnosed congenital diaphragmatic hernia?

The prognosis of antenatally diagnosed congenital diaphragmatic hernias (CDH) is clearly related to the degree of pulmonary hypoplasia (PH). After birth, controversies remain regarding the implementation of various therapies, especially the use of extracorporeal membrane oxygenation (ECMO). In the literature, the persistence of a Pao2 below 100 mm Hg and of Paco2 above 40 mm Hg despite optimal conventional therapy indicates poor prognosis. Therefore, since 1992, published and personal experiences led the authors to exclude CDH patients from ECMO when conventional therapy (including high-frequency oscillatory ventilation and nitric oxide) did not obtain Pao2 of above 80 mm Hg and Paco2 of below 60 mm Hg. The aim of this retrospective study is to determine whether blood gas results correlate with postmortem findings. Between July 1990 and July 1994, 32 cases of CDH were monitored antenatally and managed postnatally at the authors' institution. Six patients survived; 26 died, including one immediately at birth. Thirteen were treated by ECMO. Seventeen had a best Pao2 of above 80 mm Hg, including the six survivors. Fourteen did not reach this level, and none of them survived. Twenty-three infants underwent postmortem examination. PH was assessed using two criteria: (1) lung weight to body weight ratio (LW/BW) and (2) radial alveolar count (RAC). Two patients did not have hypoplasia (LW/BW > 0.018). Twenty-one patients had PH; 12 of them had an LW/BW ratio of less than .009; for 9, the LW/BW ratio was between .009 and .018, and the RAC (< 3.1) confirmed PH. All infants with a best Pao2 of less than 80 mm Hg had PH. Patients with a best Pao2 of greater than 80 mm Hg included two infants who died from complications without PH, eight infants with demonstrated PH, and the six survivors. In conclusion. (1) No infant with nonhypoplastic lungs has been deprived of ECMO by the authors' criteria. (2) Adequate values of blood gases may not eliminate PH. Therefore, this probably justifies starting ECMO when conventional therapy fails. (3) Conversely, permanent poor values of Pao2 allowed the prediction of PH in all cases. Such patients probably can be excluded from ECMO treatment.

Congenital diaphragmatic hernia: lung compliance after antenatal tracheal obstruction or surgical correction of the defect

Fetal lambs with diaphragmatic herniae (CDH) created surgically at 73 days' gestation were subjected to three different forms of intrauterine correction: silastic patch correction of the diaphragmatic defect plus an abdominal patch at 101 days gestation; an intrathoracic "silo" at 101 days; and a tracheal "plug" obstruction at 101 or 129 days. At 143 days' gestation (term 145-149 days), the lambs were delivered by caesarean section and ventilated for 30 min before undergoing respiratory compliance measurements. These results were compared to those of normal lambs and animals with uncorrected herniae. The total respiratory system compliance values in those groups undergoing corrections were remarkably similar: those with any form of correction had a significant improvement (P < 0.05) compared to those with herniae and no correction (patch = 1.57 = ± 0.182 ml/cm H2O; silo = 1.53 ± 0.179; plug at 101 days = 1.66 ± 0.311; plug at 129 days = 2.00 ± 0,175; without correction = 0.62 ± 0.073). None, however, reached the values of those with normal lungs: 2.72 ± 0.223 (P < 0.05). This improvement in compliance in all corrected groups suggests that fetal tracheal obstruction is as effective as the two more invasive forms of open fetal surgery carried out in this study and, as this procedure lends itself to surgery through a small uterine incision or "minimally invasive" surgery, it may be the procedure of choice to reduce the incidence of preterm labour for those human fetuses undergoing antenatal correction of a CDH.bb.

Congenital diaphragmatic hernia: can prenatal ultrasonography predict outcome?

OBJECTIVE

We wanted to establish whether prenatal ultrasonography predicts postnatal outcome in congenital diaphragmatic hernia.

STUDY DESIGN

We designed a retrospective multicenter cohort study of 135 patients with congenital diaphragmatic hernia (122 left, 10 right, 2 bilateral, 1 anterior). In isolated left congenital diaphragmatic hernia five potential prenatal prognostic factors were studied: diagnosis at < or = 25 weeks' gestation, polyhydramnios, intrathoracic stomach, small abdomen, and major mediastinal shift.

RESULTS

None of the 44 fetuses or infants who had multiple malformations survived. Of the 91 cases of isolated congenital diaphragmatic hernia, there were 82 live births; 76 of these infants had a left congenital diaphragmatic hernia. Of these, 51 (67%) died postnatally. A statistically significant relation was found between mortality and polyhydramnios, intrathoracic stomach, and major mediastinal shift. Mortality increased as a function of the number of these prognostic factors from 20% when none was present to 94% when all three were present.

CONCLUSION

In the majority of cases of isolated left congenital diaphragmatic hernia the prognostic value of fetal ultrasonography is too low to alter perinatal management.

Sonographic predictors of survival in fetal diaphragmatic hernia

The authors studied the predictive value of detailed fetal sonographic parameters on outcome for 55 patients with prenatally diagnosed congenital diaphragmatic hernia managed at an ECMO center. Their sonographic assessment included gestational age at time of diagnosis, polyhydramnios (largest amniotic fluid pocket diameter), presence of liver and/or stomach herniation, and abdominal circumference at the level of the umbilical cord. They measured the right lung two-dimensional area at the level of the atria as an estimate of lung size and mediastinal shift. The ratio of right lung area to head circumference (LHR) was calculated to minimize lung size differences owing to gestational age. The principal outcome variable was survival. The overall survival rate was 65%. If the diagnosis was made after 25 weeks' gestation, the survival rate was 100% (12 of 12); the rate was 56% if the diagnosis was made at or before 25 weeks (P < .005). All five neonates with an LHR of less than 0.6 died; the survival rate was 100% for those whose LHR was greater than 1.35; and those with an LHR between 0.6 and 1.35 had a 61% survival rate (P < .001). The survival rate for those whose liver was not herniated was 100% (10 of 10); herniation of the liver decreased the survival rate to 56% (P < .05). Stomach position, polyhydramos, and abdominal circumference were not found to be useful survival predictors. No prenatal sonographic parameter was absolutely predictive of postnatal death except very small right lung size, which was present in only 5 of the 55 patients. Survival is highly likely if the liver is not herniated into the thorax and/or the right lung is large.

Prognostic indicators in congenital diaphragmatic hernia

Congenital diaphragmatic hernia is associated with significant mortality and morbidity. The aim of this study was to compare a series of tests with respect to prediction of outcome. Tidal volume and compliance of the respiratory system (CRS) were measured preoperatively and on the first and second postoperative days. The maximum and modified ventilation indexes and the maximum Paco2 were noted for the first 6 hours of life and the first 6 hours postoperatively. In addition, it was recorded whether the stomach was within the ipsilateral hemithorax preoperatively. Twenty infants were studied (median gestational age, 38 weeks; range, 31 to 40), six of whom had a poor outcome, ie, they died or remained oxygen-dependent after 28 days. A CRS of less than 0.18 mL/cm H2O/kg was the most accurate predictor of poor outcome, with 66% sensitivity and 100% specificity. The authors conclude that lung function measurement are useful in the assessment of infants with congenital diaphragmatic hernia.

Fetal diaphragmatic hernia without visceral herniation

Many cases of congenital diaphragmatic hernia (CDH) are currently detected before birth. The authors hypothesized that there is a subgroup of patients with CDH who have no evidence of visceral herniation in utero and who would be expected to have less pulmonary hypoplasia and a good prognosis. Among 41 neonates with left-sided CDH treated between January 1990 and October 1993, 17 cases were diagnosed after birth. Ten of the 17 had undergone detailed fetal sonographic imaging at or after 20 weeks' gestation. After independent review of the prenatal scans of these 10 patients, one was found to have evidence of a diaphragmatic hernia and was excluded from further analysis. The other nine fetuses survived, and prosthetic repair of the diaphragmatic defect and extracorporeal membrane oxygenation (ECMO) were each required in only one patient. This contrasted with the outcome for 18 control patients with prenatally diagnosed CDH: 4 (22%) died, 13 (72%) required prosthetic repair, 9 (50%) were supported with ECMO and the duration of ventilatory support and hospital stay were significantly longer. There is a spectrum of severity among both pre and postnatally diagnosed cases of CDH. In the neonate with an isolated left-sided diaphragmatic hernia, a good prognosis is to be expected if the condition was not detectable by detailed prenatal sonography in the second half of pregnancy.

Antenatal diagnosis of isolated congenital diaphragmatic hernia is not an indicator of outcome

It has been reported previously that infants diagnosed with congenital diaphragmatic hernia (CDH) antenatally have a much poorer prognosis than those diagnosed postnatally. The authors identified 173 high-risk (symptomatic within the first 6 hours of life) infants with CDH treated in the past decade. Seventy-seven cases were diagnosed antenatally and 96 were diagnosed postnatally. The survival rate was slightly worse for the antenatal group (34% v 48% for the postnatal group; P = .04). However, 59 of the 173 patients (34%) had other life-threatening congenital anomalies. Among the 114 patients with isolated CDH, the survival rate increased to 59% in the antenatal group and 63% in the postnatal group--a difference that was not significant. The timing of antenatal diagnosis (> or < 25 weeks) had no impact on the statistics (P = .08). The only parameter consistently different between all groups and subgroups was the Apgar score at 5 minutes, which was always better in the antenatal group (P < .02), possibly reflecting more efficient resuscitation. Of the 59 patients with other life-threatening anomalies (42 cardiac), there was one survivor among the 34 in the antenatal group and only two among the 25 in the postnatal group, despite the fact that 39 patients had undergone resuscitation, which included ECMO in 25.(ABSTRACT TRUNCATED AT 250 WORDS)

Prenatal diagnosis of congenital diaphragmatic hernia: a retrospective analysis of 28 cases

In a retrospective analysis of 28 cases of fetal diaphragmatic hernia, overall mortality was 86 per cent, but fell to 70 per cent when multiple anomalies were excluded. Congenital heart disease constituted the majority of associated anomalies. The incidence of an abnormal karyotype was 10.5 per cent, but rose to 20 per cent when only fetuses with multiple anomalies were included. Polyhydramnios, which occurred in 75 per cent, was a poor predictor of fetal outcome. The same applied to the intrathoracic position of the fetal stomach. In all four survivors, diaphragmatic hernia was diagnosed beyond 32 weeks of gestation.

Antenatal detection of congenital diaphragmatic hernias: the northern region experience

This study analyses 7 years of data relating to congenital diaphragmatic herniation in the Northern Region. Ninety-nine confirmed cases were notified to the Northern Region Fetal Abnormality Survey between 1985 and 1991, which is an incidence of 0.35 per 1000 births. A specific diagnosis of CDH was made by antenatal ultrasound in 21 fetuses. The rate of detection improved from 6% to 41% but this had no impact on survival; severe pulmonary hypoplasia was found in the majority dying in the first 48 h. Another structural abnormality occurred in 29% and was the primary antenatal scan diagnosis in 11 fetuses. No other reliable indicator of outcome was identified, including the gestation when detected. The incidence of chromosomal abnormality was 5% and Fryns' syndrome 4%.

Familial congenital diaphragmatic hernia: prenatal diagnosis, management, and outcome

Congenital diaphragmatic hernia (CDH) is a developmental defect of as yet unknown aetiology which accounts for 8 per cent of all major congenital anomalies and is associated with up to 80 per cent mortality despite optimal postnatal treatment. The risk of recurrence of CDH for future sibs after one affected infant is about 2 per cent. A multifactorial/threshold inheritance pattern with an observed high male:female sex ratio is currently favoured for the rare occurrence of familial CDH, although other modes of inheritance have also been described. We report three cases of familial CDH, two of whom were brother and sister sibs and the third was a first cousin, born within 18 months of each other. The diagnosis was by ultrasound and there were several factors predicting a poor outcome. The mortality in this group was 100 per cent. The prenatal diagnosis, treatment options, the unusual genetic aspects, outcome, and the pathology involved are discussed.

Estimation of lungs' hypoplasia on postoperative chest x-rays in congenital diaphragmatic hernia

Since we stopped inserting ipsilateral underwater chest drains after surgical reduction of the herniated contents in congenital diaphragmatic hernia, both lungs are allowed to expand at their own pace, making it possible to estimate their degree of hypoplasia on postoperative chest x-rays. Thirty-nine consecutive series of postoperative chest x-rays were examined by an independent reviewer in a blind manner and classified into three groups: none to mild pulmonary hypoplasia (group I, 10 cases); moderate to severe (group II, 20 cases); and very severe hypoplasia (group III, 9 cases). Correlations were done among groups and available anatomical and clinical data. Eight patients out of 9 survived in spite of very severe hypoplasia on postoperative chest x-rays, suggesting that indexes of severity may be misleading when they mistake pulmonary hypoplasia for the cause of death.