APSA Paper
Fetal lung-head ratio is not related to outcome for antenatal diagnosed congenital diaphragmatic hernia

https://doi.org/10.1016/j.jpedsurg.2006.09.010Get rights and content

Abstract

We asked if fetal lung-to-head ratio (LHR) of 1.0 or lower or liver herniation had a statistical effect on survival or need for extracorporeal membrane oxygenation (ECMO), compared with LHR above 1.0 in patients with congenital diaphragmatic hernia (CDH).

Methods

Antenatal records of all patients diagnosed with CDH from January of 2002 to June of 2005 were examined. Inclusion criteria were isolated left-sided CDH and absence of significant cardiac or other anomalies/syndromes, treated solely at this institution. Lung-to-head ratio values were compared based on the value currently proposed for fetal intervention: LHR of 1.0 or lower vs LHR above 1.0. Outcome was assessed as survival (discharge to home) or need for ECMO.

Results

Twenty-eight patients met inclusion criteria. Overall survival was 86% (24/28). Postnatal survival in fetuses with LHR of 1.0 or lower (8/11) was not statistically different from LHR above 1.0 (16/17) (73% vs 94%, P = .114). The need for ECMO in the group with LHR of 1.0 or lower (3/11) was not significantly different from those with LHR above 1.0 (1/17) (27% vs 6%, P = .114). Herniation of the fetal liver into the chest did not affect survival or need for ECMO (P = .228).

Conclusion

Neither LHR of 1.0 or lower nor liver herniation identified a risk factor significant enough to warrant fetal intervention. Multicenter studies may be more appropriate to investigate this clinical problem.

Section snippets

Methods

All antenatal patient records with a diagnosis of CDH from January of 2002 to June of 2005 were examined. Inclusion criteria were as follows: all patients who had at least 1 comprehensive antenatal evaluation and LHR measurement at the Center for Prenatal Pediatrics and all patients who were delivered at this institution and managed solely in our neonatal intensive care unit, based on a previously published respiratory care strategy [9]. Only fetuses with an isolated left sided CDH and no

Results

A total of 42 patients were seen in The Center for Prenatal Pediatrics with an antenatal diagnosis of CDH. Twenty-eight met inclusion criteria for this study and constitute the study population. The mean gestational age of our fetuses at the time of LHR measurement in this study was 27 weeks (range, 17-36 weeks). The median gestational age was 26 weeks.

Overall survival in this population was 86% (24/28). Postnatal survival in fetuses with LHR of 1.0 or lower (8/11) was not statistically

Discussion

Lung-to-head ratio, first described in 1996, has been suggested by some centers to be predictive of postnatal survival [3], [6], [11]. This radiologic calculation has been further used to justify fetal or antenatal intervention in hopes of improving survival in high-risk fetuses [4]. Based on previously published data, some centers have assigned an LHR value of 1.0 as an index for very poor prognosis and subsequent fetal intervention, especially in combination with herniation of the fetal liver

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    Chest radiographs are of no value in predicting severity of illness in infants with CDH [27]. Ultrasound and MRI have been used to develop prenatal estimates of pulmonary hypoplasia but these measurements have not been studied in a rigorous, multi-institutional fashion or validated against postnatal anatomic information [28,29]. While many of our centers use potentially useful perinatal markers such as MRI calculated lung volumes, standardized methods to determine volumes have not yet been validated across multiple centers and may not be generalizable [30].

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Presented at the 37th Annual Meeting of the American Pediatric Surgical Association, May 20–24, 2006, Hilton Head, SC.

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