Antenatal diagnosis of congenital diaphragmatic hernia

The Impact of Comprehensive Fetal Care on Mortality of Children With Congenital Diaphragmatic Hernia when Delivery is Co-located in a Pediatric Hospital

BACKGROUND

We evaluated the impact of delivery at a comprehensive fetal care center co-located in a pediatric hospital on extracorporeal membrane oxygenation (ECMO) exposure and survivorship of children with CDH.

METHODS

This retrospective study includes maternal-fetal dyads with a prenatal diagnosis of isolated CDH who received any prenatal care at a single fetal center between February 2006 and March 2021. The principal variables included: (1) delivery setting (children born in the pediatric hospital ["inborn"] vs. children who were delivered elsewhere ["outborn"]), (2) exposure to ECMO (yes vs. no), and (3) survival-at-discharge from birth hospitalization (yes vs. no). Multivariable logistic regression was used to evaluate the association between delivery setting and ECMO cannulation, and whether delivery setting moderates the association between exposure to ECMO and survival-at-discharge.

RESULTS

Among 418 maternal-fetal dyads, 77.0% of children were inborn and 32.0% of children were exposed to ECMO during their index hospitalization. Inborn children had more severe prenatal prognostic indicators but had a 57% lower odds of extracorporeal than outborn children. In multivariable logistic regression, delivery setting moderated the association between exposure to ECMO and survival-at-discharge. Although there was no statistically significant difference in mortality between inborn and outborn children who were not exposed to ECMO, inborn children exposed to ECMO had a 6.86 (1.98, 23.74) increased odds of death and outborn children exposed to ECMO had a 17.71 (4.69, 66.87) increased odds of death when both were compared to non-cannulated outborn children.

CONCLUSIONS

Comprehensive fetal care with delivery co-located in a pediatric hospital was associated with decreased exposure to ECMO and a survivorship advantage among children with CDH who required extracorporeal support.

LEVEL OF EVIDENCE

Level III.

Prenatal MRI assessment of mediastinal shift angle as a feasible and effective risk stratification tool in isolated right-sided congenital diaphragmatic hernia

OBJECTIVES

To develop a mediastinal shift angle (MSA) measurement method applicable to right-sided congenital diaphragmatic hernia (RCDH) in fetal MRI and to validate the predictive value of MSA in RCDH.

METHODS

Twenty-seven fetuses with isolated RCDH and 53 controls were included in our study. MSA was measured on MRI axial image at the level of four-chamber view of the fetal heart. The angle between the sagittal midline landmark line and the left boundary landmark line touching tangentially the lateral wall of the left ventricle was used to quantify MSA for RCDH. Appropriate statistical analyses were performed to determine whether MSA can be regarded as a valid predictive tool for postnatal outcomes. Furthermore, predictive performance of MSA was compared with that of lung area to head circumference ratio (LHR), observed/expected LHR (O/E LHR), total fetal lung volume (TFLV), and observed/expected TFLV (O/E TFLV).

RESULTS

MSA was significantly higher in the RCDH group than in the control group. MSA, LHR, O/E LHR, TFLV, and O/E TFLV were all correlated with postnatal survival, pulmonary hypertension (PH), and extracorporeal membrane oxygenation (ECMO) therapy (p < 0.05). Value of the AUC demonstrated good predictive performance of MSA for postnatal survival (0.901, 95%CI: (0.781-1.000)), PH (0.828, 95%CI: (0.661-0.994)), and ECMO therapy (0.813, 95%CI: (0.645-0.980)), which was similar to O/E TFLV but slightly better than TFLV, O/E LHR, and LHR.

CONCLUSIONS

We developed a measurement method of MSA for RCDH for the first time and demonstrated that MSA could be used to predict postnatal survival, PH, and ECMO therapy in RCDH.

CLINICAL RELEVANCE STATEMENT

Newly developed MRI assessment method of fetal MSA in RCDH offers a simple and effective risk stratification tool for patients with RCDH.

KEY POINTS

• We developed a measurement method of mediastinal shift angle for right-sided congenital diaphragmatic hernia for the first time and demonstrated its feasibility and reproducibility. • Mediastinal shift angle can predict more prognostic information other than survival in right-sided congenital diaphragmatic hernia with good performance. • Mediastinal shift angle can be used as a simple and effective risk stratification tool in right-sided congenital diaphragmatic hernia to improve planning of postnatal management.

Acute kidney injury in infants diagnosed with congenital diaphragmatic hernia

BACKGROUND

To assess the association and outcomes of acute kidney injury (AKI) in infants diagnosed with congenital diaphragmatic hernia (CDH).

METHODS

We analyzed the National Inpatient Sample dataset for the years 2010 through 2018. We evaluated the prevalence and outcomes associated with AKI in infants diagnosed with CDH. Outcomes were assessed using regression analysis while controlling for variables.

RESULTS

A total of 32,042,481 term infants were identified, of them 10,804 had CDH. Prevalence of AKI in infants with CDH was 6.5% compared to 0.05% in those without CDH (aOR = 14.7, CI: 13.0-16.6). ECMO was utilized at 62% of CDH infants that had AKI compared to 17% in infants without AKI (aOR = 4.22, CI: 3.38-5.27). Mortality was greater in CDH infants who developed AKI when compared to those without AKI (57.3 vs. 16.7%, aOR = 3.65, CI: 2.99-4.46). The trend of mortality in CDH infants who developed AKI decreased overtime, p < 0.001, while the trends for mortality in the overall CDH infants and in CDH infants without AKI did not change during the study period, p = 0.12.

CONCLUSION

AKI is not uncommon in infants diagnosed with CDH. ECMO utilization and mortality are substantially increased in CDH infants when they develop AKI.

IMPACT

Mortality in infants diagnosed with congenital diaphragmatic hernia (CDH) is relatively high despite advances in neonatal care. Infants with CDH are potentially at increased risk of acute kidney injury (AKI). Within CDH population, infants diagnosed with AKI are at increased risk for ECMO use and mortality. This is the largest study to address the association and outcomes of AKI in term infants diagnosed with CDH.

Prenatal Diagnosis of an Intrathoracic Left Kidney Associated with Congenital Diaphragmatic Hernia: Case Report and Systematic Review

INTRODUCTION

A congenital intrathoracic kidney (ITK) is a rare anomaly that is recognized to have four causes: renal ectopia with an intact diaphragm, diaphragmatic eventration, diaphragmatic hernia, and traumatic diaphragmatic rupture. We report a case of a prenatal-diagnosed ITK related to a congenital diaphragmatic hernia (CDH) and conducted a systematic review of all cases of the prenatal diagnosis of this association.

CASE PRESENTATION

A fetal ultrasound scan at 22 gestational weeks showed left CDH and ITK, hyperechoic left lung parenchyma, and mediastinal shift. The fetal echocardiography and karyotype were normal. Magnetic resonance imaging at 30 gestational weeks confirmed the ultrasound suspicion of left CDH in association with bowel and left kidney herniation. The fetal growth, amniotic fluid, and Doppler indices remained within the normal range over time. The woman delivered the newborn via an at-term spontaneous vaginal delivery. The newborn was stabilized and underwent non-urgent surgical correction; the postoperative course was uneventful.

CONCLUSIONS

CDH is the rarest cause of ITK; we found only eleven cases describing this association. The mean gestational age at diagnosis was 29 ± 4 weeks and 4 days. There were seven cases of right and four cases of left CDH. There were associated anomalies in only three fetuses. All women delivered live babies, the herniated kidneys showed no functional damage after their surgical correction, and the prognosis was favorable after surgical repair. The prenatal diagnosis and counseling of this condition are important in planning adequate prenatal and postnatal management in order to improve neonatal outcomes.

Inborn Versus Outborn Delivery in Neonates With Congenital Diaphragmatic Hernia

BACKGROUND

Congenital diaphragmatic hernia (CDH) is a morbid and potentially fatal condition that challenges providers. The aim of this study is to compare outcomes in neonates with prenatally diagnosed CDH that are inborn (delivered in the institution where definitive care for CDH is provided) versus outborn.

METHODS

Prenatally diagnosed CDH cases were identified from the Congenital Diaphragmatic Hernia Study Group (CDHSG) database between 2007 and 2019. Using risk adjustment based on disease severity, we compared inborn versus outborn status using baseline risk and multivariable logistic regression models. The primary endpoint was mortality and the secondary endpoint was need for extracorporeal life support (ECLS).

RESULTS

Of 4195 neonates with prenatally diagnosed CDH, 3087 (73.6%) were inborn and 1108 (26.4%) were outborn. There was no significant difference in birth weight, gestational age, or presence of additional congenital anomalies. There was no difference in mortality between inborn and outborn infants (32.6% versus 33.8%, P = 0.44) or ECLS requirement (30.9% versus 31.5%, P = 0.73). Among neonates requiring ECLS, outborn status was a risk factor for mortality (OR 1.51, 95% CI 1.13-2.01, P = 0.006). After adjusting for post-surgical defect size, which is not known prenatally, outborn status was no longer a risk factor for mortality for infants requiring ECLS.

CONCLUSIONS

Risk of mortality and need for ECLS for inborn CDH patients is not different to outborn infants. Future studies should be directed to establishing whether highest risk infants are at risk for worse outcomes based on center of birth.

Post-herniorrhaphy extubation technique in pediatric patient with congenital diaphragmatic hernia and VACTERL association: A case report

Introduction

and importance: Congenital diaphragmatic hernia (CDH) is a condition characterized by a defect in the diaphragm causing protrusion of abdominal organs into the thoracic cavity. Comprehensive management, definitive surgical procedures and postoperative care are able to significantly reduce morbidity and mortality in post-herniorrhaphy patients. Here, we reported a case of post herniorrhaphy pediatric patient with a challenge in extubation.

Case presentation

A 4-month-old girl with a chief complaint of respiratory distress from was admitted to our Pediatric Intensive Care Unit. The diagnosis of diaphragmatic hernia was confirmed through small bowel follow-through radiological examination. Definitive treatment of laparotomy and herniorrhaphy were then done. The special technique for extubation was applied. Currently, the patient survives without any sequelae awaiting stoma closure.

Clinical discussion

Extubation is the removal of an endotracheal tube when it is no longer needed. In mechanically ventilated patients, extubation can be performed in two ways, either using the tracheal suction catheter (TSC) or positive pressure breath (PPB) techniques. Studies show that the PBB extubation technique has better patient outcomes compared to the TSC technique. However, the TSC technique is more commonly done by medical professionals. We used the PPB technique because there were recurrent atelectases in the left lung.

Conclusion

This case report illustrates extubation technique in a post-herniorrhaphy patient with congenital diaphragmatic hernia and VACTERL association. Moreover, several options of extubation techniques can be used for extubation procedure in pediatric patient with CDH.

•

Most children with congenital diaphragmatic hernia comes with respiratory problems.

•

Comprehensive management, definitive surgical procedures and postoperative care.

•

Good outcome of comprehensive management and appropriate extubation technique.

Cervicothoracic Neurenteric Cyst With Contralateral Diaphragmatic Hernia: An Unusual Combination

We describe a premature male infant who died from complications resulting from two malformations: a large left-sided diaphragmatic hernia and a right-sided cervicothoracic neurenteric cyst. The findings of the first limited prenatal ultrasound led to the incorrect diagnosis of right-sided diaphragmatic hernia. Vertebral anomalies, commonly associated with neurenteric cysts, and an intrathoracic stomach, were not identified until autopsy examination. A literature review describes only one partly similar case relating a neurenteric cyst to the jejunum associated with an ipsilateral diaphragmatic defect identified on prenatal ultrasound. The second report of this combination raises the question of a developmental relationship.

Do Serial Sonographic Assessments of Fetuses with Isolated Congenital Diaphragmatic Hernia Help Us Predict Survival?

OBJECTIVE

The aim of this study was to assess the ability of serial prenatal sonographic measurements, and specifically changes in the observed-to-expected lung-to-head ratio (O/E LHR) throughout gestation and to predict survival in congenital diaphragmatic hernia (CDH).

METHODS

Retrospective study of CDH fetuses evaluated prenatally and treated postnatally in a single tertiary center, 2008-2020. Sonographic evaluations included side of herniation, liver involvement, and O/E LHR. All data were calculated to assess ability to predict survival.

RESULTS

Overall, 94 fetuses were evaluated prenatally and delivered in our medical center. Among them, 75 had isolated CDH and 19 nonisolated. CDH was categorized as left (n = 76; 80.8%), right (n = 16; 17.0%), or bilateral (n = 2; 2.2%). Overall perinatal survival rate was 57% for all live-born infants, 68% in isolated CDH, and 40% in nonisolated (excluding 2 cases that underwent fetoscopic endoluminal tracheal occlusion and did not survive). The O/E LHR was lower in cases with perinatal death compared to survivors. In cases with multiple evaluations, the minimal O/E LHR was the most accurate predictor of survival and need for perinatal extracorporeal membrane oxygenation (ECMO) support. This remained significant when excluding twin pregnancies or when evaluating only isolated left CDH. In addition to disease severity, the side of herniation and liver position was associated with preoperative mortality.

CONCLUSION

O/E LHR is associated with perinatal survival. In cases with multiple evaluations, the minimal O/E LHR is the most accurate and significant predictor of perinatal mortality and need for ECMO support.

Management of Congenital Diaphragmatic Hernia (CDH): Role of Molecular Genetics

Congenital diaphragmatic hernia (CDH) is a relatively common major life-threatening birth defect that results in significant mortality and morbidity depending primarily on lung hypoplasia, persistent pulmonary hypertension, and cardiac dysfunction. Despite its clinical relevance, CDH multifactorial etiology is still not completely understood. We reviewed current knowledge on normal diaphragm development and summarized genetic mutations and related pathways as well as cellular mechanisms involved in CDH. Our literature analysis showed that the discovery of harmful de novo variants in the fetus could constitute an important tool for the medical team during pregnancy, counselling, and childbirth. A better insight into the mechanisms regulating diaphragm development and genetic causes leading to CDH appeared essential to the development of new therapeutic strategies and evidence-based genetic counselling to parents. Integrated sequencing, development, and bioinformatics strategies could direct future functional studies on CDH; could be applied to cohorts and consortia for CDH and other birth defects; and could pave the way for potential therapies by providing molecular targets for drug discovery.

Diaphragmatic Hernia as a Prenatal Feature of Glycosylphosphatidylinositol Biosynthesis Defects and the Overlap With Fryns Syndrome - Literature Review

Fryns syndrome is an autosomal recessive multiple congenital anomaly syndrome, with diaphragmatic defects and secondary lung hypoplasia as cardinal features. Despite it was reported first in 1979, its exact etiology has not been established to date. With this review, we would like to draw attention to the prenatal presentation of multiple congenital anomalies syndromes, resulting from defects in the synthesis of glycosylphosphatidylinositol anchors, to be considered in a prenatal assessment of fetuses with DH and Fryns-like phenotype.

[Understanding and guidelines for the management of antenatal diagnosis of diaphragmatic hernia: prognostic factors]

Nous avons mené une étude portée sur cinq cas d´hernie de la coupole diaphragmatique fœtale (HCD) sur deux ans au sein de notre unité de diagnostic anténatal afin de faire un rappel sur les repères généraux concernant cette pathologie et sa prise en charge toute en soulignant les actualités en matière d'évaluation prénatale du pronostic néonatale à l´aide du calcul du Lung over Head Ratio (LHR): échographie versus imagerie par résonance magnétique (IRM) dans les pays du tiers-monde. Le but de notre travail est de clarifier le devenir de ces nouveau-nés et d'assurer un accompagnement au couple d'un fœtus portant une hernie de la coupole diaphragmatique.

Unraveling the Genetics of Congenital Diaphragmatic Hernia: An Ongoing Challenge

Congenital diaphragmatic hernia (CDH) is a congenital structural anomaly in which the diaphragm has not developed properly. It may occur either as an isolated anomaly or with additional anomalies. It is thought to be a multifactorial disease in which genetic factors could either substantially contribute to or directly result in the developmental defect. Patients with aneuploidies, pathogenic variants or de novo Copy Number Variations (CNVs) impacting specific genes and loci develop CDH typically in the form of a monogenetic syndrome. These patients often have other associated anatomical malformations. In patients without a known monogenetic syndrome, an increased genetic burden of de novo coding variants contributes to disease development. In early years, genetic evaluation was based on karyotyping and SNP-array. Today, genomes are commonly analyzed with next generation sequencing (NGS) based approaches. While more potential pathogenic variants are being detected, analysis of the data presents a bottleneck-largely due to the lack of full appreciation of the functional consequence and/or relevance of the detected variant. The exact heritability of CDH is still unknown. Damaging de novo alterations are associated with the more severe and complex phenotypes and worse clinical outcome. Phenotypic, genetic-and likely mechanistic-variability hampers individual patient diagnosis, short and long-term morbidity prediction and subsequent care strategies. Detailed phenotyping, clinical follow-up at regular intervals and detailed registries are needed to find associations between long-term morbidity, genetic alterations, and clinical parameters. Since CDH is a relatively rare disorder with only a few recurrent changes large cohorts of patients are needed to identify genetic associations. Retrospective whole genome sequencing of historical patient cohorts using will yield valuable data from which today's patients and parents will profit Trio whole genome sequencing has an excellent potential for future re-analysis and data-sharing increasing the chance to provide a genetic diagnosis and predict clinical prognosis. In this review, we explore the pitfalls and challenges in the analysis and interpretation of genetic information, present what is currently known and what still needs further study, and propose strategies to reap the benefits of genetic screening.

Update on Congenital Diaphragmatic Hernia

Congenital diaphragmatic hernia (CDH) is a rare developmental defect of the diaphragm, characterized by herniation of abdominal contents into the chest that results in varying degrees of pulmonary hypoplasia and pulmonary hypertension (PH). Significant advances in the prenatal diagnosis and identification of prognostic factors have resulted in the continued refinement of the approach to fetal therapies for CDH. Postnatally, protocolized approaches to lung-protective ventilation, nutrition, prevention of infection, and early aggressive management of PH have led to improved outcomes in infants with CDH. Advances in our understanding of the associated left ventricular (LV) hypoplasia and myocardial dysfunction in infants with severe CDH have allowed for the optimization of hemodynamics and management of PH. This article provides a comprehensive review of CDH for the anesthesiologist, focusing on the complex pathophysiology, advances in prenatal diagnosis, fetal interventions, and optimal postnatal management of CDH.

Perinatal Outcomes in Fetuses Prenatally Diagnosed with Congenital Diaphragmatic Hernia and Concomitant Lung Lesions: A 10-Year Review

AIM

To describe perinatal outcomes of fetuses with a prenatal diagnosis of a concomitant lung lesion in the setting of congenital diaphragmatic hernia (CDH) and to compare outcomes with an isolated CDH control group without a lung lesion, matched by ultrasound-based prognostic markers including presence of liver herniation and lung measurements.

MATERIAL AND METHODS

This was a retrospective case-control study, wherein all pregnancies diagnosed with CDH and concomitant lung lesions were identified between July 1, 2008, and December 31, 2018. For each case, 2 controls with isolated CDH from the same study period were selected after matching for the presence of liver herniation into the thoracic cavity and ultrasound-based lung measurements either observed over expected lung-to-head ratio (LHR) or absolute LHR with their corresponding gestational age. The outcomes analyzed in the 2 groups included survival to hospital discharge, neonatal intensive care unit (NICU) length of stay (LOS), extracorporeal membrane oxygenation (ECMO) requirement and need for supplemental oxygen (O2) at day 30 of life.

RESULTS

A total of 21 pregnancies were identified with CDH and a concomitant lung lesion in the study period. All the lung lesions were stratified into a "low-risk category" with a congenital cystic adenomatoid malformation volume ratio of less than 1.0 at the time of presentation. None of these fetuses developed hydrops or required in utero intervention. Overall survival in the group was 80.7% (17/21) and rate of ECMO was 38.1%. Causes of mortality included pulmonary insufficiency, sepsis, renal failure, and bowel infarction. Upon comparison between the cases and controls, the 2 groups were similar with respect to pregnancy demographics. There were no fetal demises in either group. Outcomes including survival rate, NICU LOS, ECMO requirements and need for supplemental O2 at day 30 of life, were comparable among the 2 groups.

CONCLUSIONS

In our descriptive series, the presence of a concomitant, low-risk lung lesion in the setting of fetal CDH did not have a significant impact on the natural course of the disease, nor was it associated with a worse prognosis.

Congenital diaphragmatic hernia: current management strategies from antenatal diagnosis to long-term follow-up

Congenital diaphragmatic hernia (CDH) is a developmental birth defect consisting of a diaphragmatic defect and abnormal lung development. CDH complicates 2.3-2.8 per 10,000 live births. Despite efforts to standardize clinical practice, management of CDH remains challenging. Frequent re-evaluation of clinical practices in CDH reveals that management of CDH is evolving from one of postnatal stabilization to prenatal optimization. Translational research reveals promising avenues for in utero therapeutic intervention, including fetoscopic endoluminal tracheal occlusion. These remain highly experimental and demand improved antenatal diagnostics. Timely diagnosis of CDH and identification of severely affected fetuses allow time for delivery planning or in utero therapeutics. Optimal perinatal care and surgical treatment strategies are highly debated. Improved CDH mortality rates have placed increased emphasis on identifying and monitoring the long-term sequelae of disease throughout childhood and into adulthood. We review the current management strategies for CDH, highlighting where progress has been made, and where future developments have the potential to revolutionize care in this vulnerable patient population.

Predictive value of gestational age at diagnosis for outcomes in prenatally diagnosed congenital diaphragmatic hernia

OBJECTIVE

To assess the value and accuracy of gestational age at diagnosis in predicting postnatal outcomes of prenatally diagnosed congenital diaphragmatic hernia (CDH).

STUDY DESIGN

The medical records of 158 prenatally diagnosed neonates with CDH from 2008 to 2018 were retrospectively reviewed. Data were analyzed using parametric and nonparametric tests, appropriately.

RESULTS

Gestational age at diagnosis predicted postnatal survival independently. Survival rate at discharge increased when gestational age at diagnosis increased (p < .001). Area under the receiver operator curve for survival for gestational age at diagnosis was 0.74, observed-to-expected lung to head ratio 0.74, and liver herniation 0.76. Patients diagnosed with CDH before 25 gestational weeks had a larger size of the diaphragmatic defect, more need for patch repair, longer duration of mechanical ventilation and hospital stay than those after 25 gestational weeks.

CONCLUSIONS

Gestational age at diagnosis is an independent predictor of CDH prognosis. It has a similar ability to predict survival compared to observed-to-expected lung to head ratio and liver herniation.

A Rare Finding: Right-Sided Congenital Diaphragmatic Hernia With an Intrathoracic Kidney

Congenital diaphragmatic hernia (CDH) is an opening in the diaphragm in which the abdominal viscera protrudes into the chest as the result of an embryologic defect. CDH can be an isolated anomaly or occur simultaneously with a chromosomal abnormality or genetic syndrome. Prognosis for fetuses with CDH is widely variable and depends on numerous factors including premature birth, the presence of a chromosomal abnormality or genetic disorder, location of the herniation, lung volume, and cardiac involvement. This study presents details of a case of right-sided CDH with an intrathoracic kidney detected sonographically. Fetal echocardiography and magnetic resonance imaging (MRI) were used to further characterize the herniation. Both sonography and MRI aided in accurate diagnosis and postnatal treatment planning.

Congenital diaphragmatic hernia: Impact of contemporary management strategies on perinatal outcomes

OBJECTIVE

This study aims to review temporal changes in perinatal management and 1-year survival outcomes of cases of congenital diaphragmatic hernia (CDH) from 1996 to 2015 in Western Australia (WA).

METHOD

This research is a retrospective study of all cases of CDH in WA from 1996 to 2015 identified from five independent databases within the WA health network. Detailed information pertaining to pregnancy and survival outcomes were obtained from review of maternal and infant medical records.

RESULTS

There were 215 cases of CDH with 164 diagnosed prenatally. Between 1996 and 2010, a decline in live birth rates for CDH-affected pregnancies was observed, reaching a nadir of 5.3 per 10 000 births before increasing to a peak of 9.73 per 10 000 births in 2011-2015. A corresponding decline was seen in the number of pregnancies terminated in the same period from 8.3 to 4.6 per 10 000 births (P = 0.14) and an increase in survival of live births from 38.9% to 81.3% (P = 0.01).

CONCLUSION

The improved overall survival rate in infants with CDH over the last 20 years may have resulted in an increased tendency for women to continue their pregnancy with a concomitant decline in termination rates. Information from this study will help in the counselling of women following prenatal detection of CDH.

The fetal lung-to-liver signal intensity ratio on magnetic resonance imaging as a predictor of outcomes from isolated congenital diaphragmatic hernia

PURPOSE

We investigated the developmental changes in the unaffected contralateral lungs of patients with isolated left-sided congenital diaphragmatic hernia (CDH) using signal intensity ratios on prenatal magnetic resonance imaging (MRI) and determined whether these changes correlated with clinical outcomes.

METHODS

We performed 47 fetal MRI screens on 30 patients with isolated left-sided CDH. A cohort of 88 fetuses was selected as the control. We calculated the lung-to-liver signal intensity ratio (LLSIR) using region of interest analysis and compared LLSIR between the groups and between those in the CDH group with good and poor prognoses.

RESULTS

In the control group, LLSIR increased as pregnancy progressed [regression line = 2.232 + 0.135 × (GW-23), r = 0.669]. In the CDH group, especially in the poor prognosis group, LLSIR did not significantly increase as pregnancy progressed [regression line for good prognosis = 1.827 + 0.092 × (gestational week-23), r = 0.733; regression line for poor prognosis = 1.731 + 0.025 × (gestational week-23), r = 0.634].

CONCLUSION

Fetal LLSIR on T2-weighted MRI is an accurate marker of fetal lung maturity that correlates with postnatal survival and can potentially be used as a prognostic parameter in CDH management.

Spontaneous prematurity in fetuses with congenital diaphragmatic hernia: a retrospective cohort study about prenatal predictive factors

Background

To evaluate possible predictive factors of spontaneous prematurity in fetuses with congenital diaphragmatic hernia (CDH).

Methods

A retrospective cohort study was performed. Inclusion criteria were presence of CDH; absence of fetoscopy; absence of karyotype abnormality; maximum of one major malformation associated with diaphragmatic hernia; ultrasound monitoring at the Obstetrics Clinic of Clinicas Hospital at the University of São Paulo School of Medicine, from January 2001 to October 2014. The data were obtained through the electronic records and ultrasound system of our fetal medicine service. The following variables were analyzed: maternal age, primiparity, associated maternal diseases, smoking, previous spontaneous preterm birth, fetal malformation associated with hernia, polyhydramnios, fetal growth restriction, presence of intrathoracic liver, invasive procedures performed, side of hernia and observed-to- expected lung to head ratio (o/e LHR). On individual analysis, variables were assessed using the Chi-square test and the Mann-Whitney test. A multiple logistic regression model was applied to select variables independently influencing the prediction of preterm delivery. A ROC curve was constructed with the significant variable, identifying the values with best sensitivity and specificity to be suggested for use in clinical practice.

Results

Eighty fetuses were evaluated, of which, 21 (26.25%) were premature. O/e LHR was the only factor associated with prematurity (p = 0.020). The ROC curve showed 93% sensitivity with 48.4% specificity for the cutoff of 40%.

Conclusion

O/e LHR was the only predictor of prematurity in this sample.

Congenital Diaphragmatic hernia - a review

Congenital Diaphragmatic hernia (CDH) is a condition characterized by a defect in the diaphragm leading to protrusion of abdominal contents into the thoracic cavity interfering with normal development of the lungs. The defect may range from a small aperture in the posterior muscle rim to complete absence of diaphragm.

The pathophysiology of CDH is a combination of lung hypoplasia and immaturity associated with persistent pulmonary hypertension of newborn (PPHN) and cardiac dysfunction. Prenatal assessment of lung to head ratio (LHR) and position of the liver by ultrasound are used to diagnose and predict outcomes. Delivery of infants with CDH is recommended close to term gestation. Immediate management at birth includes bowel decompression, avoidance of mask ventilation and endotracheal tube placement if required. The main focus of management includes gentle ventilation, hemodynamic monitoring and treatment of pulmonary hypertension followed by surgery. Although inhaled nitric oxide is not approved by FDA for the treatment of PPHN induced by CDH, it is commonly used.

Extracorporeal membrane oxygenation (ECMO) is typically considered after failure of conventional medical management for infants ≥ 34 weeks’ gestation or with weight >2 kg with CDH and no associated major lethal anomalies. Multiple factors such as prematurity, associated abnormalities, severity of PPHN, type of repair and need for ECMO can affect the survival of an infant with CDH. With advances in the management of CDH, the overall survival has improved and has been reported to be 70-90% in non-ECMO infants and up to 50% in infants who undergo ECMO.

A review of congenital diaphragmatic hernia

Background: Congenital diaphragmatic hernia (CDH) is a simple diaphragmatic defect that is seen frequently in antenatal scans. Though the surgical repair is relatively easy in the neonate, the mortality is high due to pulmonary hypoplasia and pulmonary vascular changes.

Materials and Methods: The goals of prenatal imaging are to establish the diagnosis. Assessment in a tertiary scanning center would identify prognostic factors which assist in counselling and planning antenatal management. However, the pulmonary hypoplasia associated with the CDH in moderate and severe cases makes the prognosis poor.

Conclusions: Fetal intervention such as, fetal tracheal occlusion, is being trialled and may change the outcomes in the future.

Prenatal management of the fetus with isolated congenital diaphragmatic hernia in the era of the TOTAL trial

Congenital diaphragmatic hernia (CDH) may be isolated or associated with other structural anomalies, the latter with poor prognosis. The defect allows viscera to herniate through the defect into the chest, competing for space with the developing lungs. At birth, pulmonary hypoplasia leads to respiratory insufficiency and persistent pulmonary hypertension that is lethal in up to 30% of patients. When isolated, survival chances can be predicted by antenatal measurement of lung size and liver herniation. Chromosomal microarrays and exome sequencing contribute to understanding genetic factors underlying isolated CDH. Prenatal intervention aims at stimulating lung development, clinically achieved by percutaneous fetal endoscopic tracheal occlusion (FETO) under local anesthesia. The Tracheal Occlusion To Accelerate Lung growth trial (www.totaltrial.eu) is an international randomized trial investigating the role of fetal therapy for severe and moderate pulmonary hypoplasia. Despite an apparent increase in survival following FETO, the search for lesser invasive and more potent prenatal interventions must continue.

Congenital diaphragmatic hernia

Congenital diaphragmatic hernia is an uncommon congenital anomaly of the diaphragm with pulmonary hypoplasia and persistent pulmonary hypertension as serious consequences. Despite recent advances in therapy, congenital diaphragmatic hernia remains a challenging condition. Best treatment strategies are still largely unknown, and practice strategies vary widely among different centres. Additionally, as congenital diaphragmatic hernia is a relatively uncommon condition, it is difficult to recruit sufficient numbers of patients for clinical trials. In recent years, survival rates of congenital diaphragmatic hernia patients appear to have increased. With the progressively improved survival rates, the long-term prognosis and quality of life of patients have become an increasingly important issue. Survivors have been shown to be at risk for many long-term morbidities, which highlights the importance of long-term follow-up of these children. The aim of this review is to give an overview of the current knowledge regarding congenital diaphragmatic hernia.

Intrathoracic intestinal diverticulum in a late presenting congenital bilateral diaphragmatic hernia: a case report

INTRODUCTION

Hernias comprise 3% of all defects of the diaphragm. Bilateral hernias are extremely rare and usually occur in children. Here we present a case report of a bilateral Morgagni-Larrey diaphragmatic hernia with an intrathoracic intestinal diverticulum and late presentation. To the best of our knowledge this is the first report of this type.

CASE PRESENTATION

A 37-year-old Hispanic man was admitted to our emergency department with a 4-day history of obstipation, abdominal pain, distension, nausea, and vomiting. During the initial evaluation, chest and abdominal X-rays were performed, which revealed intestinal displacement into his right and left hemithorax. During laparotomy, a Morgagni-Larrey hernia with a sac was found. His small bowel with a large diverticulum, transverse colon, descending colon, and epiploic fat were herniated into his thorax. Tissues were returned to his abdominal cavity and the hernia defects were corrected with running non-absorbable sutures. He had no postoperative complications.

CONCLUSIONS

Bilateral congenital diaphragmatic hernias remain extremely rare. However, they should be considered in adult patients with intestinal obstruction even when respiratory symptoms are absent. This is the first description of a patient with a prolapsed intestinal diverticulum and bilateral diaphragmatic hernias.

Prediction of mortality and the need for neonatal extracorporeal membrane oxygenation therapy by 3-dimensional sonography and magnetic resonance imaging in fetuses with congenital diaphragmatic hernias

OBJECTIVES

To compare different rotation angles for assessment of fetal lung volume by 3-dimensional (3D) sonography with magnetic resonance imaging (MRI) regarding prediction of mortality and the need for neonatal extracorporeal membrane oxygenation (ECMO) therapy in fetuses with congenital diaphragmatic hernias.

METHODS

One hundred patients with fetal congenital diaphragmatic hernias between 22 and 39 weeks' gestation were examined by 3D sonography and MRI. Sonographic contralateral fetal lung volumes were assessed by the rotational technique (virtual organ computer-aided analysis) at 3 different rotation angles: 6°, 15°, and 30°. The MRI fetal lung volumes were calculated based on multiplanar T2-weighted MRI. To eliminate the influence of gestational age, the observed to expected contralateral fetal lung volume on sonography and the observed to expected fetal lung volume on MRI were calculated. Receiver operating characteristic (ROC) curves were calculated for the statistical prediction of survival and need for ECMO therapy by the observed to expected contralateral fetal lung volume (sonography) and observed to expected fetal lung volume (MRI).

RESULTS

One hundred cases were assessed for survival and 89 for ECMO necessity (11 neonates were not eligible for ECMO). For prediction of postpartum survival and ECMO necessity, the areas under the ROC curves (AUCs) showed very similar results for MRI and 3D sonography: observed to expected fetal lung volume by MRI, 0.819 (95% confidence interval, 0.730-0.909) and 0.835 (0.748-0.922), respectively; 6° sonography, 0.765 (0.647-0.883) and 0.820 (0.734-0.905); 15° sonography, 0.784 (0.672-0.896) and 0.811 (0.719-0.903); and 30° sonography, 0.732 (0.609-0.855) and 0.772 (0.671-0.872). Comparisons between the AUCs revealed no statistical differences.

CONCLUSIONS

We have shown the good prognostic value of 3D sonography in fetuses with congenital diaphragmatic hernias compared with MRI, particularly when using small rotation angles. Therefore, it can be an appropriate diagnostic tool when counseling patients for congenital diaphragmatic hernias.

Fetal umbilical vein deviation in congenital diaphragmatic hernia

OBJECTIVES

Deviation of the intra-abdominal umbilical vein has been described as a marker of congenital diaphragmatic hernia (CDH) and has been shown to help identify liver herniation into the fetal chest. The purpose of this study was to quantify the degree of deviation in affected fetuses and to determine the accuracy of measurements for diagnosing liver herniation.

METHODS

In patients undergoing prenatal sonography for CDH, the midhepatic portion of the umbilical vein was identified, and the distance between the lateral edge of the vein and the inner rib margin was measured. The same was done on the right, and the ratio of the left to right measurement was termed the "umbilical vein ratio." The accuracy of the umbilical vein ratio for predicting the presence and side of the hernia and for diagnosing liver herniation was determined.

RESULTS

All but 1 of the cases with right-sided hernias had an umbilical vein ratio above the normal range, and all had liver herniation. Of those with a left-sided hernia, only 2 had a ratio within the normal range. Of those with a left-sided hernia, an umbilical vein ratio less than 0.4 was shown by receiver operating characteristic curve analysis to be the best predictor of liver herniation. This cutoff had sensitivity of 89% for predicting herniation, with a false-positive rate of 14%.

CONCLUSIONS

Ninety-three percent of right-sided CDH lesions and 98% of left-sided lesions have an umbilical vein ratio outside the normal range. This finding shows that deviation may a useful indicator of CDH in screening ultrasound examinations. An umbilical vein ratio less than 0.4 is predictive of liver herniation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Prenatally diagnosed 17q12 microdeletion syndrome with a novel association with congenital diaphragmatic hernia

We describe the first reported case of a prenatally diagnosed and recently described 17q12 microdeletion syndrome. The fetus was noted to have a congenital diaphragmatic hernia (CDH), echogenic kidneys and cystic left lung on prenatal ultrasound. The patient underwent amniocentesis which resulted in a normal fluorescence in-situ hybridization and karyotype. An oligonucleotide microarray was then performed which demonstrated a 1.4-Mb deletion within the 17q12 region. The deletion caused haploinsufficiency for 17 genes, including AATF, ACACA, DDX52, DUSP14, GGNBP2, HNF-1B, LHX1, PIGW, SYNRG, TADA2A, and ZNHIT3. The deleted region on 17q12 is similar in size and gene content to previously reported 17q12 microdeletion syndromes, which have a minimal critical region of 1.52 Mb. The newly described 17q12 microdeletion syndrome has been associated with MODY5 (maturity-onset of diabetes of the young type 5), cystic renal disease, pancreatic atrophy, liver abnormalities, cognitive impairment and structural brain abnormalities. CDH has not been previously described with the 17q12 microdeletion syndrome. We hypothesize that CDH is part of the spectrum of this syndrome and likely not detected postnatally due to high prenatal mortality.

Assessment of lung volume by 3-dimensional sonography and magnetic resonance imaging in fetuses with congenital diaphragmatic hernias

OBJECTIVES

The purpose of this study was to evaluate the influence of different rotation angles in assessment of the contralateral lung volume by 3-dimensional (3D) sonography in comparison to magnetic resonance imaging (MRI) in fetuses with congenital diaphragmatic hernias.

METHODS

A total of 126 measurements by 3D sonography and MRI were conducted in 81 patients between 18 and 39 weeks' gestation. The 3D sonographic volumes of the contralateral fetal lung were calculated by the rotational technique (virtual organ computer-aided analysis) with rotation angles of 6°, 15°, and 30°. Transverse multiplanar T2-weighted MRI was performed for the MRI measurements. To compare the accuracy of 3D sonographic volumetry using different rotation angles, MRI assessment was taken as the reference method, and percentage errors and limits of agreement were calculated for each angle.

RESULTS

Three-dimensional sonographic volume measurements showed a high correlation with MRI (6° angle, R(2) = 0.86; 15° angle, R(2) = 0.78; 30° angle, R(2) = 0.68). The mean percentage error showed no systematic error. With regard to random error, the 6° step had significantly lower values than the larger angles 30° step (R = 0.472) and the narrowest limits of agreement.

CONCLUSIONS

Especially when using a small rotation angle, assessment of the contralateral fetal lung volume by 3D sonography in congenital diaphragmatic hernias is a reliable alternative to MRI.

In vitro models of the fetal lung: comparison of lung volume measurements with 3-dimensional sonography and magnetic resonance imaging

OBJECTIVES

Three-dimensional (3D) sonography is an established volumetric method in gynecology and obstetrics. The aim of this study was to investigate the variability of 3D sonographic measurements and their accuracy in comparison with magnetic resonance imaging (MRI) for assessing fetal lung volume using in vitro lung models.

METHODS

Twenty-three in vitro lung models with randomly defined volumes ranging from 1 to 60 mL were made from gelatin with plastic sheaths, manually molded into the shape of fetal lungs. The models were measured using 3D sonography and MRI. The 3D sonographic volumes were calculated using the rotational technique with angles of 6° and 30°. Multiplanar T2-weighted sequences were used for the MRI measurements. The percentage error and absolute percentage error were calculated for each method, and intraobserver and interobserver variability in 3D sonographic measurements was assessed with intraclass correlation coefficients (ICCs). Agreement between calculated and real volumes using the limits of agreement method was also evaluated.

RESULTS

The ICCs for the rotation angles indicated very good intraobserver and interobserver variability (6°, 0.995 and 0.996; 30°, 0.997 and 0.985). No systematic errors were observed in the mean percentage errors for 3D sonographic measurements or MRI volumetry. The lowest median absolute percentage error (1.76) was obtained with MRI volumetry, significantly lower than the values for sonography (6°, 5.00; P < .001; 30°, 5.49; P < .001). There were no significant differences in absolute percentage errors between the rotation angles (P = .82) and no significant differences in limits of agreement between 3D sonography and MRI (6°, P = .76; 30°, P = .39).

CONCLUSIONS

Three-dimensional sonographic volumetry was almost as accurate as MRI in this in vitro model and can be regarded as a good alternative method. Further research is needed to confirm these findings in vivo and to assess the prognostic value in fetuses with lung hypoplasia (eg, congenital diaphragmatic hernias).

Influence of different rotation angles in assessment of lung volumes by 3-dimensional sonography in comparison to magnetic resonance imaging in healthy fetuses

OBJECTIVES

Three-dimensional (3D) sonographic volumetry is established in gynecology and obstetrics. Assessment of the fetal lung volume by magnetic resonance imaging (MRI) in congenital diaphragmatic hernias has become a routine examination. In vitro studies have shown a good correlation between 3D sonographic measurements and MRI. The aim of this study was to compare the lung volumes of healthy fetuses assessed by 3D sonography to MRI measurements and to investigate the impact of different rotation angles.

METHODS

A total of 126 fetuses between 20 and 40 weeks' gestation were measured by 3D sonography, and 27 of them were also assessed by MRI. The sonographic volumes were calculated by the rotational technique (virtual organ computer-aided analysis) with rotation angles of 6° and 30°. To evaluate the accuracy of 3D sonographic volumetry, percentage error and absolute percentage error values were calculated using MRI volumes as reference points. Formulas to calculate total, right, and left fetal lung volumes according to gestational age and biometric parameters were derived by stepwise regression analysis.

RESULTS

Three-dimensional sonographic volumetry showed a high correlation compared to MRI (6° angle, R(2) = 0.971; 30° angle, R(2) = 0.917) with no systematic error for the 6° angle. Moreover, using the 6° rotation angle, the median absolute percentage error was significantly lower compared to the 30° angle (P < .001). The new formulas to calculate total lung volume in healthy fetuses only included gestational age and no biometric parameters (R(2) = 0.853).

CONCLUSIONS

Three-dimensional sonographic volumetry of lung volumes in healthy fetuses showed a good correlation with MRI. We recommend using an angle of 6° because it assessed the lung volume more accurately. The specifically designed equations help estimate lung volumes in healthy fetuses.

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.

Prenatal detection of pulmonary hypoplasia in fetuses with congenital diaphragmatic hernia: a systematic review and meta-analysis of diagnostic studies

BACKGROUND

Fetuses with congenital diaphragmatic hernia (CDH) are at risk of death from pulmonary hypoplasia at birth.

OBJECTIVE

To determine the value of prenatal imaging parameters for predicting lethal pulmonary hypoplasia in fetuses with CDH.

SEARCH STRATEGY

Relevant papers were identified by searching MEDLINE (1966-2008), EMBASE (1988-2008) and the Cochrane Library (2008 issue 3).

SELECTION CRITERIA

Selected studies examined diagnostic tests for the prenatal prediction of lethal pulmonary hypoplasia in fetuses with CDH. The primary outcome measure was perinatal survival.

RESULTS

Twenty-one studies fulfilled the entry criteria, of which six examined entirely unique heterogeneous parameters and the remaining 15 examined lung-head ratios (LHR) and/or the presence of liver in the fetal thorax. The strongest association was that of LHR > or = 0.6 compared to <0.6 (OR: 17.02; 95% CI: 2.10-137.89), although more clinically relevant was that of LHR >1.0 (OR: 5.07; 95% CI: 2.94-8.74). The finding of liver in the fetal chest was a poor prognostic feature (survival OR: 0.32; 95% CI: 0.21-0.49).

CONCLUSION

In CDH, LHR and the presence of liver in the fetal thorax may be a useful predictive indicator of perinatal survival. Future usage of developing techniques needs careful evaluation prior to usage to guide therapy.

Outcome analysis of neonates with congenital diaphragmatic hernia treated with venovenous vs venoarterial extracorporeal membrane oxygenation

PURPOSE

Venoarterial extracorporeal membrane oxygenation (ECMO) (VA) is used more commonly in neonates with congenital diaphragmatic hernia (CDH) than venovenous ECMO (VV). We hypothesized that VV may result in comparable outcomes in infants with CDH requiring ECMO.

METHODS

We retrospectively analyzed the Extracorporeal Life Support Organization (ELSO) database (1991-2006). Multivariate logistic regression analyses were used to compare VV- and VA-associated mortality.

RESULTS

Four thousand one hundred fifteen neonates required ECMO, with an overall mortality rate of 49.6%. Venoarterial ECMO was used in 82% and VV in 18% of neonates. Pre-ECMO inotrope use and complications were equivalent between VA and VV. The mortality rate for VA and VV was 50% and 46%, respectively. After adjusting for birth weight, gestational age, prenatal diagnosis, ethnicity, Apgar scores, pH less than 7.20, Paco(2) greater than 50, requiring high-frequency ventilation, and year of ECMO, there was no difference in mortality between VV vs VA. Renal complications and on-ECMO inotrope use were more common with VV, whereas neurologic complications were more common with VA. The conversion rate from VV to VA was 18%; conversion was associated with a 56% mortality rate.

CONCLUSION

The short-term outcomes of VV and VA are comparable. Patients with CDH who fail VV may be predisposed to a worse outcome. Nevertheless, VV offers equal benefit to patients with CDH requiring ECMO while preserving the native carotid.

Multivariate model for predicting recurrence in congenital diaphragmatic hernia

PURPOSE

Risk factors that predispose children with congenital diaphragmatic hernia (CDH) to recurrence remain poorly defined. We report a large series of recurrent CDH and ask whether prenatal patient factors or postnatal treatment variables better predict recurrence.

METHODS

Two hundred thirty-eight neonates with unilateral CDH underwent repair from 1990 to 2006. Data were assessed by chi(2) and Mann-Whitney U tests. Multivariate regression identified independent predictors of recurrence. Statistical significance was set at P < .05.

RESULTS

We identified 24 recurrences (10%). Median time from repair to recurrence diagnosis was 4.9 months. Patients with recurrence were older (P = .02) and more often required abdominal wall patches at initial repair (P = .01) compared to nonrecurrence patients. Postoperative length of stay (LOS) after initial repair (P < .01) and morbidity (P = .01) were greater in recurrence patients. Use of diaphragm patch at initial repair was greater in patients with recurrence but only approached statistical significance (P = .05). Only 2 variables independently predicted recurrence by multivariate regression as follows: abdominal (not diaphragm) wall patch during initial repair (odds ratio [OR] 3.50; P = .04) and postoperative LOS (OR, 1.012; P = .01).

CONCLUSION

Neonates at risk for CDH recurrence are better identified by postnatal treatment variables than by prenatal patient factors. Although age at repair and diaphragm patch use are greater in recurrence patients, the only factors to independently predict recurrence were postoperative LOS and abdominal wall patch use. These data can help optimize follow-up regimens.