Antenatal predictors of outcome in prenatally diagnosed congenital diaphragmatic hernia (CDH)

doi:10.1016/j.jpedsurg.2016.12.008

Journal of Pediatric Surgery

Volume 52, Issue 5, May 2017, Pages 881-888

https://doi.org/10.1016/j.jpedsurg.2016.12.008 Get rights and content

Abstract

Background

Pulmonary hypoplasia is the main cause of mortality in isolated congenital diaphragmatic hernia (CDH) and its prediction is paramount when counseling parents. We sought to identify antenatal parameters that predicted neonatal mortality in CDH.

Method

Search was conducted in MEDLINE, EMBASE, Cochrane Database of Systematic reviews, PubMed, Scopus, and Web of Science on the ability of lung-to-head ratio (LHR), observed-to-expected LHR (o/e LHR), total fetal lung volume (TFLV), o/e TFLV, percentage predicted lung volume (PPLV) and degree of liver herniation to predict neonatal morbidity and mortality in fetuses with CDH. Primary outcome was perinatal survival and secondary was the use of extracorporeal membrane oxygenation (ECMO).

Results

Until April 2016, 1067 articles were found, of which 22 were included in our meta-analysis. This showed that the odds of survival with LHR < 1.0 and liver herniation on ultrasound were 0.14 (CI 0.10–0.27) and 0.21 (CI 0.13–0.35) respectively. Mean LHR, o/e LHR, absolute TFLV, o/e TFLV, PPLV and liver herniation all predicted survival, however o/e LHR and o/e TFLV performed best in this prediction. When the longest diameter measurement method was used, the o/e TFLV (summary area under curve (AUC) 0.8) was slightly superior to o/e LHR (summary AUC 0.78). This difference disappeared when LHR was measured by the trace method. The most discriminatory threshold for O/E LHR and O/E TFLV was 25%. LHR < 1 was predictive of extracorporeal life support (ECLS) use.

Conclusion

O/E LHR, o/e TFLV (thresholds of 25%) and liver herniation are good predictors of mortality in CDH.

Level of evidence

Level II

Type of study: Systematic review and meta-analysis

Section snippets

Search strategy

Two investigators (AL, VK) created a preliminary search strategy that was subsequently refined by a medical librarian (HLR) and an investigator (TO). Citations were found by searching the following databases from the first date available to April 8, 2016: Ovid MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, PubMed, Scopus, and Web of Science. Combinations of subject headings, keywords and synonyms used included: congenital diaphragmatic hernia, Bochdalek hernia, lung-to-head ratio,

Results

The search results are shown in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart (Fig. 1). One thousand sixty-seven studies were found by online search after removal of duplicates from the first date available to April 2016. The title and abstracts of the electronic searches were examined, and the full manuscripts of all the potentially relevant citations were obtained. The final inclusion/exclusion decisions were made after evaluation of the full papers

Discussion

The ability to predict neonatal disease severity in CDH is important as it enables informed antenatal discussions regarding delivery location and plan, complications, anticipated length of hospital stay, resource allocation (both human and material) and all management options (including FETO and palliation). Our review has shown that US-based o/e LHR (using the trace method) and MRI-based o/e TFLV are similar in their ability to predict survival and can be useful in prognostication. While our

Acknowledgments

We would like to thank Dr. Sven Kehl and Dr. Arin Madenci for their time, effort and resources in providing data for this review. We would like to thank Jehovah Shammah and Ferdinand Obi for their support and motivation during this review and Dr. Olayinka Olutoye for offering human resources for the review.

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Thoracoscopic CDH repair is increasingly performed for Type A and small Type B defects that are amenable to primary repair. However, the thoracoscopic approach is controversial for larger defects necessitating a patch due to technical complexity, intraoperative acidosis, and recurrence risk. We aim to compare clinical outcomes between thoracoscopic and open patch repair of Type B/C defects, using a standardized technique.
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View all citing articles on Scopus

¹

http://vassarstats.net/median_range.html (medians to means, standard deviations)

http://www.rapidtables.com/calc/math/weighted-average-calculator.htm (weighted means)

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Review ArticleAntenatal predictors of outcome in prenatally diagnosed congenital diaphragmatic hernia (CDH)

Abstract

Background

Method

Results

Conclusion

Level of evidence

Section snippets

Search strategy

Results

Discussion

Acknowledgments

J Pediatr Surg

Am J Pathol

Semin Pediatr Surg

J Pediatr Surg

J Pediatr Surg

BJOG

J Pediatr Surg

Use of ultrasound and MRI for evaluation of lung volumes in fetuses with isolated left congenital diaphragmatic hernia

Semin Pediatr Surg

Lung hypoplasia in congenital diaphragmatic hernia. A quantitative study of airway, artery, and alveolar development

Br J Surg

Persistent hypoplasia of the lung after repair of congenital diaphragmatic hernia

Thorax

Persistent pulmonary hypertension of the newborn in the era before nitric oxide: practice variation and outcomes

Pediatrics

Value of liver herniation in prediction of outcome in fetal congenital diaphragmatic hernia: a systematic review and meta-analysis

Ultrasound Obstet Gynecol

Statistical methods in diagnostic medicine

Assessment of lung area in normal fetuses at 12–32 weeks

Ultrasound Obstet Gynecol

Fetal lung volume: estimation at MR imaging—initial results

Radiology

Estimating the mean and variance from the median, range, and the size of a sample

BMC Med Res Methodol

Cochrane handbook of systematic reviews of interventions—7.7.7.2 standard errors from confidence intervals and P values

Cochrane Collab

Liver position and lung-to-head ratio for prediction of extracorporeal membrane oxygenation and survival in isolated left congenital diaphragmatic hernia

Am J Obstet Gynecol

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

J Matern Fetal Neonatal Med

Review Article
Antenatal predictors of outcome in prenatally diagnosed congenital diaphragmatic hernia (CDH)