Perinatal outcome and prognostic factors in prenatally diagnosed congenital diaphragmatic hernia

Congenital heart disease associated with congenital diaphragmatic hernia: A systematic review on incidence, prenatal diagnosis, management, and outcome

PURPOSE

The purpose of this study was to evaluate the impact of congenital heart disease (CHD) on infants with congenital diaphragmatic hernia (CDH).

METHODS

Using a defined search strategy (PubMed, Cochrane, Embase, Web of Science MeSH headings), we searched studies reporting the incidence, management, and outcome of CDH infants born with associated CHD.

RESULTS

Of 6410 abstracts, 117 met criteria. Overall, out of 28,974 babies with CDH, 4427 (15%) had CHD, of which 42% were critical. CDH repair was performed in a lower proportion of infants with CHD (72%) than in those without (85%; p < 0.0001). Compared to CDH babies without CHD, those born with a cardiac lesion were more likely to have a patch repair (45% vs. 30%; p < 0.01) and less likely to undergo minimally invasive surgery (5% vs. 17%; p < 0.0001). CDH babies with CHD had a lower survival rate than those without CHD (52 vs. 73%; p < 0.001). Survival was even lower (32%) in babies with critical CHD.

CONCLUSION

CHD has a strong impact on the management and outcome of infants with CDH. The combination of CDH and CHD results in lower survival than those without CHD or an isolated cardiac defect. Further studies are needed to address some specific aspects of the management of this fragile CDH cohort.

TYPE OF STUDY

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Level III.

Spleen Behind the Heart Complicates Lung-to-Head Ratio Measurement in Left-Sided Congenital Diaphragmatic Hernia

In fetuses with left-sided congenital diaphragmatic hernia, intrathoracic herniation of the spleen is a common occurrence. The herniated spleen can reside posterior to the left atrium of the heart in the right hemithorax and is increasingly differentiated from the lung with the use of newer sonographic equipment. Estimation of the neonatal prognosis relies on accurate measurement of fetal lung size, particularly with commonly used measurements such as the lung-to-head ratio. Here we describe how herniation of the spleen behind the heart can complicate measurement of the lung-to-head ratio on sonography and lead to overestimation, with implications for perinatal prognostication and management.

Prenatal lung-head ratio: threshold to predict outcome for congenital diaphragmatic hernia

OBJECTIVE

The literature suggests that lung-head ratio (LHR) and liver position may inconsistently predict outcome for congenital diaphragmatic hernia (CDH). We reviewed our inborn neonates with isolated left-sided CDH to determine whether these variables predicted survival and to estimate the optimal LHR threshold.

METHODS

Prenatal LHR and liver position were obtained from 2002 to 2009. The primary endpoint was survival.

RESULTS

LHR was greater in survivors after adjusting for gestational age (median 1.40 versus 0.81; p < 0.001). LHR demonstrated excellent diagnostic discrimination, with area under receiver operating characteristic (ROC) curve 0.93 (95% CI 0.86-0.99). LHR threshold of 1.0 was 83% sensitive and 91% specific in predicting survival. An optimal LHR threshold of 0.85 predicted survival with 95% sensitivity and 64% specificity, reducing false negatives (survivors with low LHR). LHR > 0.85 predicted survival after adjustment for gestational age (OR = 33.6, 95% CI = 5.4-209.5). Liver position did not predict survival.

CONCLUSIONS

Prenatal LHR >0.85 predicts survival for infants with isolated left-sided CDH without compromising discrimination of survivors from non-survivors. The diagnostic utility of LHR may be confounded by gestational age at measurement. Stringent LHR threshold may minimize false-negative attribution and improve utility of this measurement as predictor of survival.

Impact of prenatal evaluation and protocol-based perinatal management on congenital diaphragmatic hernia outcomes

BACKGROUND/PURPOSE

Although intuitive, the benefit of prenatal evaluation and multidisciplinary perinatal management for fetuses with congenital diaphragmatic hernia (CDH) is unproven. We compared the outcome of prenatally diagnosed patients with CDH whose perinatal management was by a predefined protocol with those who were diagnosed postnatally and managed by the same team. We hypothesized that patients with CDH undergoing prenatal evaluation with perinatal planning would demonstrate improved outcome.

METHODS

Retrospective chart review of all patients with Bochdalek-type CDH at a single institution between 2004 and 2009 was performed. Patients were stratified by history of perinatal management, and data were analyzed by Fisher's Exact test and Student's t test.

RESULTS

Of 116 patients, 71 fetuses presented in the prenatal period and delivered at our facility (PRE), whereas 45 infants were either outborn or postnatally diagnosed (POST). There were more high-risk patients in the PRE group compared with the POST group as indicated by higher rates of liver herniation (63% vs 36%, P = .03), need for patch repair (57% vs 27%, P = .004), and extracorporeal membrane oxygenation use (35% vs 18%, P = .05). Despite differences in risk, there was no difference in 6-month survival between groups (73% vs 73%).

CONCLUSIONS

Patients with CDH diagnosed prenatally are a higher risk group. Prenatal evaluation and multidisciplinary perinatal management allows for improved outcome in these patients.

Prediction of postnatal outcomes in congenital diaphragmatic hernia using MRI signal intensity of the fetal lung

OBJECTIVE

Prognostic prediction in prenatally diagnosed congenital diaphragmatic hernia (CDH) is needed. The aim of the study was to evaluate magnetic resonance imaging (MRI) signal intensity of the fetal lung as a predictor of prognosis in CDH.

STUDY DESIGN

The subjects consisted of 12 fetuses with prenatally diagnosed CDH, who were treated soon after the birth in our institution. They all underwent MRI at 29 to 37 weeks of gestation. The ratio of the lung signal intensity to the spinal fluid signal intensity (L/SF) was calculated using region-of-interest analysis of T2-weighted images. The relationship between L/SF and clinical data was then examined.

RESULT

L/SF were significantly larger in survivors compared with deaths (0.815 vs 0.614, P<0.05). In survivors, L/SF significantly correlated with duration of tracheal intubation (rs=-0.938, P<0.01).

CONCLUSION

L/SF is a unique factor to predict the survival prognosis and likely to quantify the degree of pulmonary hypoplasia in CDH.

MR lung volume in fetal congenital diaphragmatic hernia: logistic regression analysis--mortality and extracorporeal membrane oxygenation

PURPOSE

To prospectively assess the results of logistic regression analysis that were based on magnetic resonance (MR) image fetal lung volume (FLV) measurements to predict survival and the corresponding need for extracorporeal membrane oxygenation (ECMO) therapy in fetuses with congenital diaphragmatic hernia (CDH) before and after 30 weeks gestation.

MATERIALS AND METHODS

Written informed consent was obtained and the study was approved by the local research ethics committee. FLV was measured on MR images in 95 fetuses (52 female neonates, 43 male neonates) with CDH between 22 and 39 weeks gestation by using multiplanar T2-weighted half-Fourier acquired single-shot turbo spin-echo MR imaging. On the basis of logistic regression analysis results, mortality and the need for ECMO therapy were calculated for fetuses before and after 30 weeks gestation.

RESULTS

Overall, higher FLV was associated with improved survival (P < .001) and decreasing probability of need for ECMO therapy (P = .008). Survival at discharge was 29.2% in neonates with an FLV of 5 mL, compared with 99.7% in neonates with an FLV of 25 mL. The corresponding need for ECMO therapy was 56.1% in fetuses with an FLV of 5 mL and 8.7% in fetuses with an FLV of 40 mL. Prognostic power was considerably lower before 30 weeks gestation.

CONCLUSION

Beyond 30 weeks gestation, logistic regression analysis that is based on MR FLV measurements is useful to estimate neonatal survival rates and ECMO requirements. Prior to 30 weeks gestation, the method is not reliable and the FLV measurement should be repeated, particularly in fetuses with small lung volumes, before a decision is made about therapeutic options.

Congenital diaphragmatic hernia: improved surgical results should influence abortion decision making

AIMS

To compare surgical results for congenital diaphragmatic hernia (CDH) in two Scandinavian university hospitals and to evaluate the effects of abortions on the clinical profile of CDH in Iceland.

METHODS

A retrospective study including all CDH-cases in Iceland 1983-2002 and children referred to Lund University Hospital 1993-2002. Aborted fetuses with CDH from a nation-wide Icelandic abort-registry were also included.

RESULTS

In Iceland, 19 out of 23 children with CDH were diagnosed < 24 hours from delivery, one with associated anomalies. Eight fetuses were diagnosed prenatally and seven of them aborted, three having isolated CDH at autopsy. In Iceland, 15 of 18 children operated on survived surgery (83% operative survival). In Lund 28 children were treated with surgery, 23 of them diagnosed early after birth or prenatally. Four children did not survive surgery (86% operative survival) and 9 (31%) had associated anomalies. All the discharged children treated in Iceland and Lund are alive, 3-22 years postoperatively.

CONCLUSION

CDH is a serious anomaly where morbidity and mortality is directly related to other associated anomalies and pulmonary hypoplasia. However, majority of CDH patients do not have other associated anomalies. In spite of improved surgical results (operative mortality < 20%), a large proportion of pregnancies complicated with CDH are terminated. We conclude that the improved survival rate after corrective surgery must be emphasized when giving information to parents regarding abortion of fetuses with a prenatally diagnosed CDH.

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.

Reliability of the lung-to-head ratio as a predictor of outcome in fetuses with isolated left congenital diaphragmatic hernia at gestation outside 24-26 weeks

OBJECTIVE

The purpose of this study was to investigate the relationship between lung-to-head ratio (LHR) and gestational age (GA) in fetuses with isolated left congenital diaphragmatic hernia and to determine the applicability and reliability of LHR to predict postnatal outcome beyond 24-26 weeks of gestation.

STUDY DESIGN

The institutional review board approved this retrospective review of the University of California, San Francisco, Fetal Treatment Center database for cases with left congenital diaphragmatic hernia who were referred between March 1995 and June 2004. LHR was determined at the initial evaluation. One hundred seven live-born fetuses at 20-34 weeks of gestation (excluding cases that were lost to follow-up, with factors that potentially could influence the LHR measurement or postnatal outcome, or that were terminated electively).

RESULTS

The median GA at LHR measurement was 25.6 weeks; the median LHR was 1.01; the median GA at birth was 37.7 weeks; and the overall survival rate was 59% (64/107). The median LHR of nonsurvivors was significantly lower than that of survivors, but neither GA at LHR measurement nor at delivery was significantly different between the groups. Multiple logistic regression analysis confirmed LHR to be an independent predictor of postnatal survival, and receiver-operator characteristic curve analysis demonstrated that an LHR of > or = 0.97 has the highest performance in predicting postnatal survival. When fetuses were grouped by GA at initial LHR measurement to determine reliability of LHR, specifically with respect to GA, in the 26-34 and 24-26 weeks of gestation groups, median LHR of survivors was significantly higher than that of nonsurvivors, and receiver-operator characteristic curve analysis confirmed LHR to be a reliable predictor of postnatal survival. However, for fetuses at 20-24 weeks of gestation, there was a trend toward a higher LHR in survivors, although this did not reach statistical significance.

CONCLUSION

A significant positive linear relationship exists between LHR and GA at the time of measurement, such that LHR reliably predicts postnatal survival in fetuses with left congenital diaphragmatic hernia at 24-34 weeks of gestation and less reliable at 20-24 weeks. However, given the limitations of a retrospective, cross-sectional study, further prospective longitudinal studies that will investigate the change of LHR with GA and its association with fetal outcome are necessary.

Pleural and pericardial effusion: a potential ultrasonographic marker for the prenatal differential diagnosis between congenital diaphragmatic eventration and congenital diaphragmatic hernia

OBJECTIVES

To determine whether or not the presence of pleural and/or pericardial effusion can be used prenatally as an ultrasonographic marker for the differential diagnosis between diaphragmatic eventration and diaphragmatic hernia.

METHODS

We present two case reports of non-isolated diaphragmatic eventration associated with pleural and/or pericardial effusion. Additionally, we reviewed the literature for all cases of congenital diaphragmatic hernia (CDH) and diaphragmatic eventration that met the following criteria: (1) prenatal diagnosis of a diaphragmatic defect and (2) definitive diagnosis by autopsy or surgery. The frequencies of pleural effusion, pericardial effusion and hydrops were compared between the two conditions using Fisher's exact test. A subanalysis was conducted of cases with isolated diaphragmatic defects (i.e. diaphragmatic defects not associated with hydrops and other major structural or chromosomal anomalies).

RESULTS

A higher proportion of fetuses with diaphragmatic eventration had associated pleural and pericardial effusions compared with fetuses with diaphragmatic hernia (58% (7/12) vs. 3.7% (14/382), respectively, P < 0.001). This observation remained true when only cases of diaphragmatic defects not associated with hydrops and other major structural or chromosomal anomalies were compared (29% (2/7) with eventration vs. 2.2% (4/178) with CDH, P < 0.02).

CONCLUSIONS

The presence of pleural and/or pericardial effusion in patients with diaphragmatic defects should raise the possibility of a congenital diaphragmatic eventration. This information is clinically important for management and counseling because the prognosis and treatment for CDH and congenital diaphragmatic eventration are different. Published by John Wiley & Sons, Ltd.

Isolated congenital diaphragmatic hernia in the third trimester: a case report and literature review

OBJECTIVE

To report a rare congenital anomaly, a right diaphragmatic hernia, in a near-term baby.

CASE REPORT

A 40-year-old female, gravida 3, para 2, had undergone regular prenatal care in our department since the early second trimester. She underwent amniocentesis at 16 weeks of gestation. The result showed normal 46,XY. Fetal growth was appropriate throughout the pregnancy. A small heart with marked left-side deviation was noted in the third trimester. The heart rate was less than 25% of normal. A homogenous mass with centralized vessels was noted in the fetus's right chest. The baby showed respiratory distress immediately after delivery. Imaging studies after birth proved there was a right diaphragmatic hernia with severe pulmonary hypertension and poor lung function.

CONCLUSION

Right congenital diaphragmatic hernia is rare. A prenatal diagnosis is difficult to make in the second trimester. Prognosis is greatly influenced by the associated abnormalities.

Experiences in the Perinatal Management of Congenital Diaphragmatic Hernia during the Last 15 Years in a Tertiary Referral Institute

OBJECTIVE

Review of cases of perinatally diagnosed congenital diaphragmatic hernias with special regard to time of diagnosis, organs herniated into the thorax, associated malformations, and outcomes.

METHODS

We analyzed the data of 106 cases between July 1, 1990, and June 30, 2005. The observation period was analyzed in two parts.

RESULTS

Prenatal ultrasound was performed in 89.6% (95/106) of the cases. 51.7% (46/89) of the pre- and postnatally verified congenital diaphragmatic hernia cases were diagnosed before the 24th week of gestation. 11% (11/100) of the hernias were identified postnatally. 71% (71/100) of the cases were associated with other malformations. The hernia was on the left side in 86% (86/100) and bilateral in 5% (5/100) of the cases. Between 1990 and 1997, the proportion of right-sided hernias was 4.3% (2/46), while during the second period it was 13% (7/54). 27.5% (14/51) of the newborns survived the perinatal period. The survival rate of the newborns delivered by caesarean section was three times higher than that of infants delivered vaginally. In the latter group, the rate of premature deliveries was considerably higher. The pregnancy was terminated in 45% (40/89) of the cases. 15% (6/40) of the terminated cases were isolated. Intrauterine or intrapartum deaths occurred in 5.6% (5/89) of the prenatally diagnosed cases. Simultaneous thoracic herniation of liver, spleen, or stomach decreased the survival rate. In these cases, the discharge rate was between 6 and 22%.

CONCLUSIONS

According to the analysis of 15-year data, the herniated organs, multiple malformations, as well as the mode of delivery influence the survival in a large number of cases. Early diagnosis predicts a large hernia, a higher malformation rate, and a less favourable prognosis.

A population-based study of congenital diaphragmatic hernia outcome in New South Wales and the Australian Capital Territory, Australia, 1992-2001

PURPOSE

The aim of the study was to describe the incidence and survival of infants born with congenital diaphragmatic hernia (CDH) in the state of New South Wales (NSW) and the Australian Capital Territory (ACT), Australia.

METHODS

A population-based cohort study of all infants inclusive up to 1 month of age diagnosed with CDH in NSW and the ACT between 1992 and 2001 was conducted. Data sources were the NSW and ACT Neonatal Intensive Care Data Collection (Neonatal Intensive Care Units Study), NSW Birth Defects Register, Population Health Research Centre of ACT Health, and NSW Midwives Data Collection. Individual risk factors for mortality were assessed using the chi(2) test with P < .05 being considered statistically significant. Multivariate analysis was performed using logistic regression to adjust for potential confounding variables.

RESULTS

From the databases used, the incidence of CDH in NSW and the ACT was 1 per 3800 births. Of 242 infants identified with CDH, 8% underwent termination of pregnancy, 10% were stillborn after 20 weeks' gestation, and 82% were liveborn. Most liveborn infants (70%) were delivered at term with a 64% survival, whereas 30% were preterm with a 35% survival. For liveborn infants, the overall preoperative mortality was 35% with 56% surviving to discharge. Logistic regression identified a low 5-minute Apgar score, prematurity, and air leak as independent risk factors for mortality.

CONCLUSIONS

This population-based study of CDH provides us with baseline data for our states. Mortality is high in preterm infants and in the preoperative period. Avoiding preterm delivery and improving preoperative stabilization are the measures most likely to improve survival.

[Fetal magnetic resonance imaging. Diagnostics in congenital diaphragmatic hernia]

Ultrasonography is the primary imaging modality for the evaluation of fetal or maternal anomalies. This method is safe, relatively inexpensive, easily accessible, and allows real-time imaging. Continuous technical improvements in ultrasonography in the last 10-15 years have led to improved diagnostic accuracy for fetal malformations. In cases of complex anomalies magnetic resonance imaging (MRI) can provide additional information. MRI has evolved as a valuable diagnostic method for evaluating fetal pathology. Particularly with regard to similarity of liver and lung parenchyma in ultrasonography, diagnosis of congenital diaphragmatic hernia (CDH) can be difficult. Beside morphological aspects, e.g., herniation of abdominal contents into the chest, small amounts of compressed lung can be visualized on MRI. The feasibility of using volumetric measurement on MRI may be helpful to predict high-risk fetuses and facilitate decisions to assure adequate prenatal and postnatal management to improve postnatal outcome.

Bilateral congenital diaphragmatic hernia

Bilateral congenital diaphragmatic hernia (CDH) is a rare condition, with the literature suggesting a bleak prognosis. We describe a case of bilateral CDH that, despite confirming the challenges of diagnosis, demonstrates that the condition can have a favourable outcome.

Outcomes of congenital diaphragmatic hernia: a population-based study in Western Australia

OBJECTIVES

There have been many recent reports of improved survival rates for congenital diaphragmatic hernia (CDH), largely derived from institution-based data. These are often flawed by case selection bias. The objectives of this study were to document the true incidence, management, and outcomes of CDH in a geographically defined population over a 12-year period and to determine the changing trends in these over time. We also sought to ascertain the prenatal and postnatal factors associated with morbidity and death among these infants.

METHODS

A retrospective study of all cases of CDH in Western Australia from 1991 to 2002 was conducted. Cases were identified from 5 independent databases within the Western Australian health network, including the Western Australian Birth Defects Registry. All fetuses and neonates diagnosed with CDH in Western Australia during this period were identified, including miscarriages, stillbirths, and terminations of pregnancies in which a diagnosis of fetal CDH had been made, as well as those diagnosed postnatally. Cases not known to involve CDH until diagnosis at autopsy were also included. Infants with diaphragmatic eventration were excluded from the study. Detailed information was obtained from review of maternal and infant medical records.

RESULTS

One hundred sixteen cases of CDH were identified. Of these, 71 (61%) infants were born alive and 37 survived beyond 1 year of age (52% of live-born infants, 32% of all cases of CDH). Pregnancies involving 38 (33%) fetuses were terminated electively, 4 (3%) fetuses were aborted spontaneously, and 3 (3%) fetuses were stillborn. Another major congenital anomaly was present in 54 (47%) cases. Twenty-one (18%) cases had other anomalies that were likely to be fatal. Of all cases with an additional major anomaly, 42 (78%) died. Twenty-seven (71%) of 38 fetuses for whom the pregnancy was terminated had another major anomaly. Twenty-three (32%) live-born infants had another major anomaly (4 of which were considered fatal conditions); however, this did not affect their survival rates. Fifty-three percent of cases were diagnosed prenatally, and 49% of these pregnancies were then terminated. Of live-born infants with prenatally diagnosed CDH, 10 (33%) survived beyond 1 year of age. The gestational age at diagnosis did not affect the survival rate for live-born infants. Postnatal diagnosis occurred in 55 (47%) cases. Of these, 41 (74%) case subjects were born alive and diagnosed on clinical grounds after birth. In the remaining 14 cases, the diagnosis was made in postmortem examinations of fetuses from pregnancies that were terminated for other reasons (8 cases) or after spontaneous abortion or stillbirth (5 cases). Significant differences were found between prenatally and postnatally diagnosed live-born infants. Among live-born infants, prenatal diagnosis was associated with a significantly reduced survival rate (33%, compared with 66% for postnatally diagnosed infants). Prenatally diagnosed live-born infants were of lower birth weight and were born at an earlier gestational age. There was no statistically significant difference between the 2 groups in the onset of labor (spontaneous or induced) or in the rate of elective cesarean sections. Prenatally diagnosed live-born infants were more likely to be delivered in a tertiary perinatal center and were intubated more commonly at delivery. No difference was found in the Apgar scores at either 1 or 5 minutes between the groups. Of 71 live-born infants, 37 (52%) survived to 1 year of age. The majority of deaths occurred within the first 7 days of life (44%). Preoperative air leaks occurred for 16 (22%) infants, of whom 14 (88%) died. Factors found to predict death of live-born infants included prenatal diagnosis, right-sided hernia, major air leak, earlier gestational age at birth, lower birth weight, and lower Apgar scores at 1 and 5 minutes. Over the course of the decade, there were significant increases in the proportion of cases in which the diagnosis of CDH was made with prenatal ultrasonography and in the number of live-born infants born at the tertiary perinatal center. The mortality rate for all cases, the mortality rate for live-born infants, and the proportion of pregnancies involving prenatally diagnosed cases that were terminated electively were all greater in the later epoch but not significantly so.

CONCLUSIONS

This was a comprehensive, population-based study of CDH, with full case ascertainment, large sample size, and complete outcome data for all cases. The majority of published studies of CDH examined specific patient populations, such as neonates referred to tertiary pediatric surgical centers. Invariably, those studies failed to detect the demise of cases with CDH before arrival at the referral center, whether through termination of pregnancy, in utero fetal demise, or postnatal death occurring before transfer. Exclusion of these cases from calculations of mortality rates results in significant case selection bias. In our study, 35% of live-born infants died before referral or transport. The population of infants reaching the tertiary surgical center represented only 40% of the total cases of CDH. Wide variations in reported survival rates occur throughout the literature. These differences reflect the influence of this case selection bias, as well as variable referral policies and management practices. For our study population, survival rates differed vastly depending on the subgroup analyzed. Ninety-two percent of postoperative infants survived beyond 1 year of age, as did 80% of infants who reached the surgical referral center. However, only 52% of live-born infants, 32% of all cases, and 16% of all prenatally diagnosed cases survived. Therefore, the overall mortality rate for this condition remains high, despite increased prenatal detection, transfer to tertiary institutions for delivery, and advances in neonatal care, and is influenced significantly by the rate of prenatal termination. In our study, 33% of all cases of CDH and 49% of prenatally diagnosed fetuses underwent elective termination of pregnancy. This large number of fetal terminations confounds the accurate assessment of the true outcomes of this condition.

Reliability of the lung-to-head ratio in predicting outcome and neonatal ventilation parameters in fetuses with congenital diaphragmatic hernia

OBJECTIVES

The ratio of the lung area (on the contralateral side of the hernia) to the head circumference, the lung-to-head ratio (LHR), has been proposed as a reliable tool in the assessment of the prognosis of congenital diaphragmatic hernia (CDH). An LHR < 0.6 has been associated with poor outcome whereas one > 1.4 has been associated with survival. We aimed to analyze the role of LHR in predicting fetal outcome and ventilation parameters in cases of isolated CDH in our center.

METHODS

During the 40-month study period, 22 fetuses with an isolated CDH were delivered alive under optimized conditions at our perinatal center. LHR was measured at the time of diagnosis (median, 27 weeks' gestation). In addition to survival, postnatal ventilation parameters including pCO2, pO2, inspiratory O2 partial pressure, inspiratory pressure and oxygenation index were determined, as was the occurrence of pulmonary hypertension.

RESULTS

The overall survival rate was 59%. The LHR was not able to predict fetal outcome reliably. There was no correlation between the liver herniation, LHR and fetal outcome. The prenatally determined lung size reflected in the LHR did not show any significant association with individual ventilation parameters. Eleven of 17 infants examined had signs of pulmonary hypertension and the LHR did not predict this condition.

CONCLUSION

Our study cannot support the optimistic results reported by other groups on the use of LHR as a reliable predictor of outcome in fetuses with CDH. The LHR, as a reflection of lung size, correlates neither with survival patterns nor with various postnatal ventilation parameters.

Evaluation of fetal pulmonary vasculature by power Doppler imaging in congenital diaphragmatic hernia

OBJECTIVE

To evaluate the feasibility of prenatal power Doppler imaging of pulmonary arteries in congenital diaphragmatic hernia and to study its potential to predict outcome.

METHODS

A prospective observational study was conducted. Forty-two cases of congenital diaphragmatic hernia (32 left and 10 right) without associated anomalies were analyzed. Qualitative evaluation of pulmonary vasculature was based on power Doppler imaging performed at 26 to 38 weeks. The pulmonary arteries were studied in the lung contralateral to the hernia. Pulmonary Doppler angiography was considered satisfactory when 3 levels of bifurcation defining 3 distinct segments of the pulmonary arteries were imaged and was otherwise considered poor. We also recorded the gestational age at diagnosis, side of the hernia, abdominal circumference below the third percentile, amniotic fluid volume, lung/thoracic area ratio, left/right ventricle ratio, and, in left-sided hernias, stomach position, and we carried out a multivariate analysis to determine the contribution of each factor to predict neonatal mortality.

RESULTS

More than 3 divisions of the fetal pulmonary arteries were imaged in 20 cases; 1 or 2 divisions or none were imaged in 22. Neonatal mortality was significantly greater when fewer than 3 divisions of the pulmonary arteries were imaged (18 [82%] of 22) than when 3 divisions could be identified on power Doppler imaging (5 [25%] of 20; P = .0005). However, the lung/thoracic area ratio was the only factor that remained significantly associated with mortality in the multivariate analysis.

CONCLUSIONS

An altered pulmonary power Doppler image is associated with neonatal mortality, but estimation of the lung area remains the best predictor of neonatal outcome.

Congenital diaphragmatic hernia: an evaluation of the prognostic value of the lung-to-head ratio and other prenatal parameters

OBJECTIVES

A retrospective analysis of the prognostic significance of the lung-to-head ratio (LHR) and other prenatal parameters on the outcome of fetuses with left-sided congenital diaphragmatic hernia (CDH).

METHODS

A total of 26 fetuses with isolated left CDH without chromosomal abnormalities were included. Twenty-one LHR measurements could retrospectively be calculated from the last available ultrasonographic recordings before birth. The relationship between LHR and fetal outcome and the gestational age dependency of this relation was tested. Cutoff levels as previously published were applied to determine their predictive value in this population. The association between other prenatal predictive variables and fetal outcome was also determined. Survival was defined as discharge from the hospital.

RESULTS

The overall survival rate was 50%. There was a statistically significant difference between the mean LHR of the survivors compared to the mean LHR of the nonsurvivors (1.78 vs 1.02), whereas the mean gestational age of these two groups did not differ. LHR was not gestational age dependent in the prediction of fetal outcome. The cutoff levels LHR <1, 1-1.4, >1.4 showed a good applicability in the prediction of fetal outcome within the present study population with a 100% survival if LHR >1.4 and a 100% mortality if LHR <1. An intrathoracic position of the stomach, mediastinal shift, polyhydramnios as individual variables and early diagnosis (<25 weeks' gestation) revealed to be poor sonographic predictors for fetal outcome.

CONCLUSION

LHR proved to be a good predictor for fetal outcome, independent of gestational age at the time of the measurement. To substantiate our observation, a prospective multicenter study is warranted.

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

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

Perinatal management and outcome of prenatally diagnosed congenital diaphragmatic hernia: a 1995-2000 series in Rennes University Hospital

OBJECTIVES

To assess the prognosis of prenatally diagnosed congenital diaphragmatic hernia (CDH) during the years 1995-2000 in order to improve prenatal counselling.

METHODS

Retrospective study of all 31 cases of women with prenatally diagnosed CDH.

RESULTS

Nine pregnancies (29%) were terminated and two fetuses (6%) were stillborn. Ten fetuses (32%) had associated anomalies (four Fryns' syndrome) and four (13%) had underlying chromosomal anomalies. Twenty pregnancies were continued. Seven babies died before surgery either immediately in the delivery room (five between 1 and 45 min), or during the 'stabilisation period' (two babies, 7 and 21 h). Three babies presented with trisomy 18, Fryns' syndrome or transposition of the great arteries with microdeletion 22q11. Thirteen babies had the defect repaired (median 18 h, range 4-72 h) and 12 survived. Mechanical ventilation was required for a median of 12 days. One survivor has cerebral palsy.

CONCLUSION

Of 31 prenatally diagnosed CDH cases 38% are alive, of 20 ongoing pregnancies 60% are alive, and of 13 babies who underwent surgery 92% are alive. No baby with associated malformations survived. These numbers need to be known by each member of the counselling team in order to give parents adequate information to make their decision.

Fetal therapy: state of the art

OBJECTIVE

To review our experience with the use of sonography in evaluating potential candidates for in utero fetal therapy performed at The Center for Fetal Diagnosis and Treatment at The Children's Hospital of Philadelphia.

METHODS

This review article was designed to discuss open hysterotomy for the 4 fetal surgical procedures that have been performed at our institution. The procedures included surgical repair of myelomeningocele, resection of sacrococcygeal teratoma in fetuses with nonimmune hydrops, resection of an enlarging congenital cystic adenomatoid malformation that is not amenable to thoracoamniotic shunting, and tracheal clip occlusion for severe left congenital diaphragmatic hernia.

RESULTS

For each surgical procedure, the use of sonography in the prenatal diagnosis of the congenital anomaly was detailed, as were indications for surgery and surgical procedures, postoperative monitoring and finally delivery, postnatal treatment, and long-term follow-up. Three of the procedures have been reasonably successful with rather dramatic results in some cases such that these techniques are still being performed. The 1 exception was open hysterotomy for the tracheal clip procedure for congenital diaphragmatic hernia, which has been abandoned.

CONCLUSIONS

Fetal therapy is a rapidly evolving specialty, which is being practiced at several centers in this country. Sonography is an integral part of this specialty practice and has been used extensively in the diagnosis of some congenital anomalies that have debilitating or lethal consequences for the fetus. Technologic improvements in both sonography and magnetic resonance imaging have assisted tremendously in the many advances herein reported in the diagnosis and treatment of the above-described 4 congenital anomalies.

Pediatric thoracic anesthesia

The anesthesiologist caring for infants and children undergoing thoracic surgery faces many challenges. An understanding of the primary underlying lesion as well as associated anomalies that may impact perioperative management is paramount. A working knowledge of respiratory physiology and anatomy in infants and children is required for the planning and execution of appropriate intraoperative care. Familiarity with a variety of techniques for SLV suited to the patient's size will allow maximal surgical exposure while minimizing trauma to the lungs and airways. Finally, use of regional anesthetic techniques, including epidural anesthesia and analgesia, facilitates optimal postoperative pain control and pulmonary function.

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.

Fetal lung volume measurement by magnetic resonance imaging in congenital diaphragmatic hernia

OBJECTIVE

To study the potential for prenatal magnetic resonance imaging to predict pulmonary hypoplasia in congenital diaphragmatic hernia.

DESIGN

Prospective observational study.

SETTING

Tertiary care centre.

PARTICIPANTS

Thirteen cases of congenital diaphragmatic hernia (11 left, 2 right) without associated anomalies and 74 controls.

METHODS

Measurements by magnetic resonance imaging of fetal lung volume were achieved. In the control fetuses, a regression analysis was performed to associate fetal lung volume with gestational age. This yielded a formula allowing calculation of the expected fetal lung volume as a function of gestational age. In the cases with congenital diaphragmatic hernia, the observed/expected fetal lung volume ratio was compared with perinatal outcome.

MAIN OUTCOME MEASURES

Neonatal mortality and pulmonary hypoplasia, which was defined as lung/body weight ratios less than 0.012.

RESULTS

The expected fetal lung volume was derived from the following formula: Fetal lung volume (mL) = exp (1.24722 + 0.08939 x gestational age in weeks). The observed/expected fetal lung volume ratio was significantly lower in congenital diaphragmatic hernia (median: 0.31, range: 0.06-0.63), than in controls (median: 0.99, range: 0.42-1.94). This ratio was significantly less in the infants with congenital diaphragmatic hernia who died (median: 0.26, range: 0.06-0.63) compared with those who survived (median: 0.46, range: 0.35-0.56). The observed: expected fetal lung volume ratio was significantly correlated with the post mortem lung: body weight ratio.

CONCLUSION

In isolated congenital diaphragmatic hernia, fetal lung volume measurement by magnetic resonance imaging is a potential predictor of pulmonary hypoplasia and postnatal outcome. Further studies are required to establish the clinical value of magnetic resonance imaging for the prenatal assessment of fetal lungs.

Prenatal diagnosis of an ectopic intrathoracic kidney in right-sided congenital diaphragmatic hernia using color Doppler ultrasonography

The prenatal sonographic features of a fetus with right-sided congenital diaphragmatic hernia diagnosed at 33 weeks are presented. Color Doppler demonstrated an abnormal course of the right renal artery, arising from the aorta and feeding the intrathoracic right kidney. This case report stresses the role of color Doppler in defining which organs have herniated in fetuses with diaphragmatic hernia.

Deletion 15q24-26 in prenatally detected diaphragmatic hernia: increasing evidence of a candidate region for diaphragmatic development

Survival of children with congenital diaphragmatic hernia (CDH) is mainly dependent on the extent of lung hypoplasia and the presence of additional congenital anomalies or chromosomal aberrations. A chromosomal deletion 15q25-q26.2 in a fetus with prenatally diagnosed CDH and growth retardation is reported. Despite optimal pre- and neonatal management the baby died shortly after birth. There is increasing evidence that the long arm of chromosome 15, and especially the region 15q24 to 15q26, plays a crucial role in the development of the diaphragm. The finding of a deletion within 15q24-26 in a fetus with CDH has to be considered a predictor of poor prognosis. It is of utmost interest for proper parental counselling to search in fetuses with CDH for subtle chromosomal lesions paying special attention to chromosome 15q.

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.