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Wild KT, Hedrick HL, Ades AM, Fraga MV, Avitabile CM, Gebb JS, Oliver ER, Coletti K, Kesler EM, Van Hoose KT, Panitch HB, Johng S, Ebbert RP, Herkert LM, Hoffman C, Ruble D, Flohr S, Reynolds T, Duran M, Foster A, Isserman RS, Partridge EA, Rintoul NE. Update on Management and Outcomes of Congenital Diaphragmatic Hernia. J Intensive Care Med 2023:8850666231212874. [PMID: 37933125 DOI: 10.1177/08850666231212874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Infants with congenital diaphragmatic hernia (CDH) benefit from comprehensive multidisciplinary teams that have experience in caring for the unique and complex issues associated with CDH. Despite prenatal referral to specialized high-volume centers, advanced ventilation strategies and pulmonary hypertension management, and extracorporeal membrane oxygenation, mortality and morbidity remain high. These infants have unique and complex issues that begin in fetal and infant life, but persist through adulthood. Here we will review the literature and share our clinical care pathway for neonatal care and follow up. While many advances have occurred in the past few decades, our work is just beginning to continue to improve the mortality, but also importantly the morbidity of CDH.
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Affiliation(s)
- K Taylor Wild
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Holly L Hedrick
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Anne M Ades
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Maria V Fraga
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Catherine M Avitabile
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Juliana S Gebb
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Edward R Oliver
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kristen Coletti
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Erin M Kesler
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - K Taylor Van Hoose
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Howard B Panitch
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Sandy Johng
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Renee P Ebbert
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Lisa M Herkert
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Casey Hoffman
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Deanna Ruble
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sabrina Flohr
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tom Reynolds
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Melissa Duran
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Audrey Foster
- Department of Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rebecca S Isserman
- Division of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Emily A Partridge
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Natalie E Rintoul
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
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Didier RA, Oliver ER, Rungsiprakarn P, Debari SE, Adams SE, Hedrick HL, Adzick NS, Khalek N, Howell LJ, Coleman BG. Decreased neonatal morbidity in 'stomach-down' left congenital diaphragmatic hernia: implications of prenatal ultrasound diagnosis for counseling and postnatal management. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:744-749. [PMID: 33724570 DOI: 10.1002/uog.23630] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/15/2021] [Accepted: 03/03/2021] [Indexed: 06/12/2023]
Abstract
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.
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MESH Headings
- Adult
- Cephalometry
- Female
- Fetus/diagnostic imaging
- Fetus/pathology
- Head/diagnostic imaging
- Head/pathology
- Hernias, Diaphragmatic, Congenital/diagnostic imaging
- Hernias, Diaphragmatic, Congenital/embryology
- Hernias, Diaphragmatic, Congenital/pathology
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnostic imaging
- Infant, Newborn, Diseases/embryology
- Infant, Newborn, Diseases/pathology
- Lung/diagnostic imaging
- Lung/embryology
- Lung/pathology
- Magnetic Resonance Imaging
- Male
- Morbidity
- Pregnancy
- Retrospective Studies
- Stomach/diagnostic imaging
- Stomach/embryology
- Stomach/pathology
- Ultrasonography, Prenatal
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Affiliation(s)
- R A Didier
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - E R Oliver
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - P Rungsiprakarn
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - S E Debari
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - S E Adams
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - H L Hedrick
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N S Adzick
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Khalek
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - L J Howell
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - B G Coleman
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Wiggins E, Zecevic M, Hippe DS, Moshiri M, Winter T, Dubinsky TJ. Magnetic Resonance Prediction of Lung Maturity in Fetuses With Congenital Diaphragmatic Hernia. Ultrasound Q 2021; 37:272-277. [PMID: 34478427 DOI: 10.1097/ruq.0000000000000567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT To determine if lung to liver MR T2 signal ratio is predictive of neonatal outcome in fetuses with congenital diaphragmatic hernia (CDH).After Interal Review Board approval, the PACS systems at the University of Washington and University of Utah were searched for cases having an in utero fetal MR examination diagnostic of CDH. Inclusion criteria were at least 1 prior ultrasound demonstrating a CDH and an MR obtained within 1 week of that prior ultrasound.A total of 69 patients from the University of Utah and 13 from the University of Washington satisfied the inclusion criteria for a total of 82. After adjusting for gestational age and contralateral lung volume, there was little apparent association between contralateral lung to liver MR T2 signal and 5-minute Apgar score and neonatal mortality When considering neonatal Apgar and mortality, increasing contralateral lung volume was significantly associated with lower risk (hazard ratio, 0.40 per doubling; 95% confidence interval, 0.24-0.69; P = 0.001) as expected.Our data demonstrate that the lung to liver MR signal ratio was not predictive of outcome. The measurement of contralateral lung area, and gestational age at the time of the examination (time of diagnosis) are still the best predictors of poor neonatal outcome.
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Affiliation(s)
- Eve Wiggins
- Department of Radiology, University of Washington School of Medicine, Seattle WA
| | - Mladen Zecevic
- Department of Radiology, University of Washington School of Medicine, Seattle WA
| | - Dan S Hippe
- Department of Radiology, University of Washington School of Medicine, Seattle WA
| | - Mariam Moshiri
- Department of Radiology, University of Washington School of Medicine, Seattle WA
| | - Tom Winter
- Department of Radiology, University of Utah, Salt Lake City, UT
| | - Theodore J Dubinsky
- Department of Radiology, University of Washington School of Medicine, Seattle WA
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