Lethal nonpulmonary anomalies associated with congenital diaphragmatic hernia: implications for early intrauterine surgery

Congenital diaphragmatic hernia and associated anomalies: their incidence, identification, and impact on prognosis

The general concept of the association of congenital diaphragmatic hernia (CDH) with other anomalies has been well described. This study is aimed at assessing the distribution of the associated anomalies (AA) by organ system, their influence on prognosis, and the practical signs that should prompt a diagnostic search. One hundred and sixty-six high-risk patients with CDH (symptomatic within the first 6 hours of life) were treated in this institution in the past decade. Sixty-five patients (39.2%) were found to have one or more AA, and 101 had isolated CDH. Of patients with anomalies, cardiac (excluding patent foramen ovale and patent ductus arteriosus) was the most frequent type of AA (63%). Hypoplastic heart syndrome was the most common defect. Many patients had multiple AA. For purposes of analysis, the patients were divided into three groups: isolated CDH, cardiac anomalies, and all other anomalies. The groups were compared with respect to several common clinical and laboratory variables, as well as survival. The frequency and timing of antenatal diagnosis were also noted. The analysis led to the following conclusions. (1) AA are present in more than one third of high-risk patients with CDH; in this group, cardiac lesions predominate. (2) High-risk CDH infants with AA have significantly lower APGAR scores and a lower BPDPO2 (best postductal PO2 before ECMO or surgery) than those with isolated CDH. This is even more evident in the group with cardiac AA. In such patients, a careful search for an undetected AA, especially cardiac, is warranted.(ABSTRACT TRUNCATED AT 250 WORDS)

Extracorporeal membrane oxygenation in infants with congenital diaphragmatic hernia and cardiac malformations

Since the introduction of neonatal extracorporeal membrane oxygenation (ECMO) in Canada, the authors have treated three infants with congenital diaphragmatic hernia (CDH) who had serious congenital cardiac anomalies (among 26 infants with CDH treated with ECMO). To determine the incidence of and outcome for infants with combined lesions who received ECMO, 19 years' data (April 1973 to October 1992) from the Extracorporeal Life Support Organization (ELSO) registry were reviewed. Seventeen infants with combined cardiac and diaphragmatic lesions were registered as receiving ECMO in the United States or Canada. Thus, the incidence of combined cardiac and diaphragmatic lesions was 2.5 per thousand neonates (17 of 6,295) receiving ECMO and 13 per thousand neonates (17 of 1,318) receiving ECMO for CDH. Five (29.4%) of the 17 infants survived. A congenital cardiac lesion may not be an absolute contraindication to ECMO in infants with CDH. Decisions to cannulate for ECMO should be based on the potential outcome of the underlying cardiac defect.

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.

Congenital diaphragmatic hernia in the Brachmann-de Lange syndrome

We present 12 children with typical Brachmann-de Lange syndrome and congenital diaphragmatic hernia. Affected children were more likely to be of low birth weight and to have major upper limb malformations. Hernia repair was attempted in 4 of these children, and only one survived past 12 months. Newborn infants with congenital diaphragmatic hernia should be examined carefully for evidence of the Brachmann-de Lange syndrome because diagnosis of this condition may influence their clinical management and prognosis.

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%.

Congenital diaphragmatic hernia: influence of associated malformations on survival

The medical records of 116 consecutive cases of congenital diaphragmatic hernia (CHD) among 368,772 live births at the three maternity hospitals in Dublin were examined and the incidence of associated malformations and their impact on survival analysed. The patients were divided into two groups: group I included 64 (55%) patients who died during resuscitation and stabilisation before surgery at a mean age of 11.2 hours and group II included 52 (45%) patients who were operated upon. All patients in group I underwent detailed postmortem examination as did the 45% patients who died in group II. The mean (SD) gestational age for group I patients (36.1 (4.5) weeks) was significantly lower than the mean gestational age of group II patients (39.0 (2.4) weeks). Similarly, the mean birth weight of group I patients (2415 (906) g) was significantly lower than that of group II patients (3140 (563) g). Of the newborns who died before surgery, 40 (62.5%) patients had 79 associated malformations. The major associated anomalies were: cardiac (n = 16), neural tube defects (n = 15), skeletal (n = 8), chromosomal (n = 5), urinary tract (n = 6), gastrointestinal (n = 3), omphalocele (n = 4), craniofacial (n = 5), pulmonary (n = 2), and syndromes (n = 2). Sixteen (40%) of these patients were found to have multiple anomalies. Of the 52 patients who were operated upon, only four (7.7%) had associated malformations. Our data shows that associated malformations in neonates with CDH is a major factor influencing outcome in this congenital malformation.

Contemporary management of congenital diaphragmatic hernia

Despite advances in infant transport and intensive care, congenital diaphragmatic hernia (CDH) still poses a serious threat to life during the neonatal period. Only with the introduction of extracorporeal membrane oxygenation (ECMO) has mortality declined significantly. Understanding the pathophysiology of CDH and its devastating effect on the lungs' bronchial and vascular development assists the clinician in rational management during the perioperative period. Successful treatment demands prompt diagnosis, informed preoperative assessment and preparation, carefully timed surgical repair, and aggressive postoperative intensive care with a thorough understanding of the role of ECMO. Improvements in ventilatory support and pharmacologic management of pulmonary hypertension have allowed surgeons to delay repair until circulatory hemodynamics, electrolytes, and oxygenation can be optimized, even resorting to preoperative ECMO in selected cases if needed. Patients with severe bilateral pulmonary hypoplasia pose serious dilemmas in terms of selection for ECMO, as well as for surgical repair. Long-term follow-up of patients after CDH repair reveals persistent hypoperfusion of the involved lung but no debilitating pulmonary disease. Future therapies may include early fetal intervention or lung transplantation, although these areas remain controversial and experimental, and clinical experience is limited.

Vasopressin in cerebrospinal fluid of newborns with hypoxic-ischemic encephalopathy. Preliminary report

Vasopressin in cerebrospinal fluid has been measured in 27 fullterm newborns with hypoxic-ischemic encephalopathy. These newborns were divided into three groups according to the degree of neurological involvement, and they have been compared with a control group of 10 newborns. Determinations of vasopressin in cerebrospinal fluid and plasma were done by RIA. The cerebrospinal fluid vasopressin in asphyxiated newborns was higher than in the control group (p < 0.001); the mean concentration in the group of newborns classified as moderate or severe hypoxic-ischemic encephalopathy was higher than in the control group (18.7 pg/ml vs 4.66 pg/ml), and also higher than in the group classified as mild (14.2 pg/ml). Cerebrospinal fluid vasopressin values have a direct relationship to the plasmatic values at 12 hours of life (r = 0.76; p < 0.001). We concluded that vasopressin values in cerebrospinal fluid at 12 hours increase according to the clinical severity of the neonatal hypoxic-ischemic encephalopathy and that they have a strong relationship with plasmatic vasopressin.

The kidney in the fetal rat model of congenital diaphragmatic hernia induced by nitrofen

This paper explores whether there is a correlation between kidney and lung growths in an experimental model of congenital diaphragmatic hernia (CDH) induced by intragastric administration of Nitrofen (115 mg/kg) in olive oil on time-dated pregnant Wistar rats at the 9th day of gestation. For comparison we used pregnant rats treated with olive oil alone. Twenty-nine normal fetuses from 3 control rats and 24 left CDH fetuses from 6 Nitrofen rats were studied. Fetal (3.6 +/- 0.8 v 4.9 +/- 0.4 g, P < .001) and total lung (2% +/- 0.5% v 2.6% +/- 0.3% of body weight, P < .001) weights were significantly decreased in animals with CDH. Kidneys were also smaller in CDH animals although not significantly (0.7% +/- 0.1% v 0.8% +/- 0.1% of body weight, P = .05) and were also histologically immature. Regression of kidney weight on body weight for both groups yielded regression lines that were identical at analysis of covariance and all data points from the CDH group were within the control group 95% confidence limits. After converting raw data into lung/body and kidney/body weight ratios, no inverse correlation suggesting a feedback mechanism of growth regulation between both organs could be found. Since nitrofen acts through modifications of the thyroid hormone status in both dam and fetus, altered maturation of several organs should be expected although some of them, like the lung, are the leading targets. The present CDH rodent model is probably different from the human malformation in spite of the striking anatomic similarities between them.(ABSTRACT TRUNCATED AT 250 WORDS)

Epidemiological study of congenital diaphragmatic defects with special reference to aetiology

Congenital diaphragmatic defects (CDD) are easily accessible to ultrasonographic diagnosis. In spite of progress in the management of prenatally detected cases, the mortality rate for CDD remains high. The prognosis depends mainly on the severity of fetal lung hypoplasia but is also linked to the associated malformations. We report on 77 cases of CDD ascertained between 1982 and 1988 from 136,161 consecutive births in the Bouches du Rhône area. The spontaneous perinatal mortality rate was 61% with 28 early post-natal deaths and 14 stillbirths. Eight pregnancies were terminated after prenatal diagnosis. The diaphragmatic defect was associated with other congenital anomalies in 33 cases, more often among stillborn (92.8%) than liveborn infants (23.6%). A chromosomal abnormality was present in 9 cases representing 11.6% of all CDD and in 27.2% of cases with other anomalies. A Mendelian disorder was present in 9 cases (eight Fryns syndrome and one Fraser syndrome). This study underlines the necessity of a systematic work up of prenatally diagnosed cases, including fetal karyotyping and analysis of associated malformations in order to adapt the management of the pregnancy and delivery to the prognosis.

The fetus as a patient. Surgical considerations

The diagnosis and treatment of human fetal defects has evolved rapidly over the past decade due to improved fetal imaging techniques and better understanding of fetal pathophysiology derived from animal models. The detection of a fetal anomaly may now lead to a change in the timing of delivery, a change in the mode of delivery, or prenatal treatment. Because most therapeutic maneuvers involve some risk to the fetus and mother, there must be a reasonable expectation that the procedure is feasible, safe, and effective before it can be attempted in humans. This requires reliable information about the pathophysiology and natural history of the disease process, the efficacy of fetal surgical intervention in ameliorating the disease, and the feasibility and safety of the proposed intervention. This paper focuses on the rationale and initial clinical experience with fetal surgery for a variety of life-threatening fetal anatomic defects.

Preoperative stabilisation in congenital diaphragmatic hernia

Between January 1983 and November 1986, 26 newborn infants with congenital diaphragmatic hernia were treated by early operation at a mean of 7 hours of age. A further 23 infants admitted between December 1986 and December 1989 were stabilised for a mean period of 40 hours before operation. There was no significant difference in survival between the two groups. Delayed operation is not detrimental to infants with congenital diaphragmatic hernia.

Patterns of malformation in children with congenital diaphragmatic defects

The medical records of 102 live-born children with a congenital diaphragmatic defect were reviewed to determine the frequency and nature of underlying chromosomal, genetic, and nongenetic patterns of malformation. Overall, 40 children (39%) had a major nonpulmonary malformation, and 14 of these children (14%) had a previously recognized pattern of malformation. A group of 18 children (18%) with cardiac anomalies had an increased mortality rate in comparison with those children without cardiac defects (72% vs 38%). The frequency and severity of nonpulmonary abnormalities in children with congenital diaphragmatic defects suggest that examination of affected children should include cardiac evaluation, a karyotype when the defect is one feature of a broader pattern of altered development, and a careful evaluation for minor anomalies, which may provide clues to an overall diagnosis.

Correction of congenital diaphragmatic hernia in utero, V. Initial clinical experience

Review of our experience with 45 cases of prenatally diagnosed congenital diaphragmatic hernia (CDH) confirms that most fetuses (77%) will not survive despite optimal pre- and postnatal care. Polyhydramnios, associated anomalies, early diagnosis, and a large volume of herniated viscera (including liver) are associated with a particularly dismal prognosis. After extensive experimental work demonstrated the efficacy, feasibility, and safety of repair in utero, we attempted to salvage six highly selected fetuses with severe CDH by open fetal surgery. Five had liver incarcerated in the chest: three died at operation because attempts to reduce the liver compromised umbilical venous return. In one, a Goretex diaphragm was constructed around the liver, but the baby died after birth. The last two fetuses, one with incarcerated liver, were successfully repaired. Both demonstrated rapid growth of the lung in utero, had surprisingly good lung function after birth despite prematurity, had the abdominal patch removed at 2 weeks, and subsequently died of nonpulmonary problems (an unrelated nursery accident in one and intestinal complications in the other). The only maternal complication was amniotic fluid leak and preterm labor. All six women are well and four have had subsequent normal children. From this phase I experience, we conclude that fetal surgery appears safe for the mother and her reproductive potential, that fetal CDH repair is feasible in selected cases, and that the fetal lung responds quickly after decompression. However, fetal repair remains a formidable technical challenge.

Reversal of mortality for congenital diaphragmatic hernia with ECMO

Extracorporeal Membrane Oxygenation (ECMO) has been available to neonates with respiratory failure at the University of Michigan School of Medicine since June 1981. In order to evaluate the impact of this type of pulmonary support, a retrospective analysis of 50 neonates with posterolateral congenital diaphragmatic hernia (CDH) who were symptomatic during the first hour of life and were treated between June 1974 and December 1987 was carried out. The patients were divided into two groups, those treated before June 1981 (16 patients) and those treated after June 1981 (34 patients). Overall survival improved from 50% (eight of 16 patients) during the pre-ECMO era to 76% (26 of 34 patients) during the post-ECMO period (p = 0.06). During the period after June 1981, 21 neonates were unresponsive to conventional therapy and were therefore considered for ECMO. Failure of conventional therapy was defined as acute clinical deterioration with an expected mortality of greater than 80% based on an objective formula previously reported. Six patients were excluded on the basis of specific contraindications to ECMO. Thirteen of 15 infants (87%) supported with ECMO survived. Three patients treated before 1981 met criteria for ECMO; all three died while receiving treatment using conventional therapy. These survival differences are significant (p less than 0.01). In addition, the survival of 87% for the infants treated with ECMO versus the expected mortality of greater than 80% for these same patients when treated with conventional therapy is highly significant (p less than 0.005). Based on this data, ECMO appears to be a successful, reliable, and safe method of respiratory support for selected, critically ill infants with CDH.

Congenital posterolateral diaphragmatic hernia: associated malformations

Congenital posterolateral diaphragmatic hernia (CDH) is widely regarded as an isolated defect, but this view is incomplete. We reviewed our clinical and autopsy experience and the literature from the past 25 years in order to catalogue the frequency and clinical importance of additional malformations in patients with CDH. The study showed two broad categories of patients. In the larger group of infants (65 of 108, or 60%), CDH was the only severe defect, apart from those normally associated with the presence of abdominal viscera in the thorax. Thirty-six of these patients (55%) survived. A striking finding among infants with isolated CDH, not previously highlighted in the literature, was cryptorchidism which was present in 30% of males. By contrast, 43 patients (40%) had one or more severe extradiaphragmatic malformations; only six of these infants (14%) survived. Defects in morphogenesis were widespread, heterogeneous, and seemingly related to numerous pathogenetic mechanisms. Most often abnormalities involved the heart, brain, genitourinary system, craniofacial region, or limbs. The high incidence of multiple anomalies in some patients with CDH should influence our investigations into causes and mechanisms. Patients with CDH should be evaluated carefully for additional defects--their presence has a significant impact on management and worsens prognosis.

Fetal diaphragmatic hernia: ultrasound diagnosis and clinical outcome in 19 cases

Nineteen cases of congenital diaphragmatic hernia diagnosed in utero are reported with emphasis on sonographic findings, associated congenital and karyotypic abnormalities, the presence or absence of polyhydramnios, and clinical outcome. The survival of these infants was very poor despite accurate prenatal diagnosis, maximal surgical and medical treatment and maximal postnatal care. The overall survival rate was 10.5%, and for fetuses who lived beyond delivery the survival rate was 20%.

Diaphragmatic hernia in the fetus: prenatal diagnosis and outcome in 94 cases

Most babies born with congenital diaphragmatic hernia (CDH) die after birth. The natural course of CDH in the human fetus is not known. We found 94 cases of fetal CDH in the records of surgeons and obstetricians surveyed in the United States and Canada. We found the following: (1) prenatal diagnosis of CDH is accurate and current techniques can detect lethal nonpulmonary anomalies and prevent diagnostic errors; (2) despite optimal conventional therapy, most fetuses with detectable CDH will die in the neonatal period (80% mortality); (3) polyhydramnios is both a common prenatal marker for CDH (present in 76% of fetuses) and a predictor for poor clinical outcome (only 11% survived); (4) fetal CDH is a dynamic process--nonsurvivors have larger defects and may have more viscera displaced into the chest at an earlier stage of development. Surgical intervention before birth may be necessary to improve survival of the fetus with CDH and polyhydramnios.