Fetal Stomach Position Predicts Neonatal Outcomes in Isolated Left-Sided Congenital Diaphragmatic Hernia

Abstract

Introduction: We sought to determine the relationship between the degree of stomach herniation by antenatal sonography and neonatal outcomes in fetuses with isolated left-sided congenital diaphragmatic hernia (CDH). Materials and Methods: We retrospectively reviewed neonatal medical records and antenatal sonography of fetuses with isolated left CDH cared for at a single institution (2000-2012). Fetal stomach position was classified on sonography as follows: intra-abdominal, anterior left chest, mid-to-posterior left chest, or retrocardiac (right chest). Results: Ninety fetuses were included with 70% surviving to neonatal discharge. Stomach position was intra-abdominal in 14% (n = 13), anterior left chest in 19% (n = 17), mid-to-posterior left chest in 41% (n = 37), and retrocardiac in 26% (n = 23). Increasingly abnormal stomach position was linearly associated with an increased odds of death (OR 4.8, 95% CI 2.1-10.9), extracorporeal membrane oxygenation (ECMO; OR 5.6, 95% CI 1.9-16.7), nonprimary diaphragmatic repair (OR 2.7, 95% CI 1.4-5.5), prolonged mechanical ventilation (OR 5.9, 95% CI 2.3-15.6), and prolonged respiratory support (OR 4.0, 95% CI 1.6-9.9).All fetuses with intra-abdominal stomach position survived without substantial respiratory morbidity or need for ECMO. Discussion: Fetal stomach position is strongly associated with neonatal outcomes in isolated left CDH. This objective tool may allow for accurate prognostication in a variety of clinical settings.

Standardization and reproducibility of sonographic stomach position grades in fetuses with congenital diaphragmatic hernia

“…Kitano et al first suggested a grading system for stomach position based on the degree of stomach herniation into the chest to determine CDH prognosis. Cordier et al and Basta et al modified this grading system further and showed that prenatal stomach position is an independent predictor of neonatal outcomes in CDH. Prenatal management by fetoscopic endoluminal tracheal occlusion (FETO) has been proposed for severe forms of CDH with a favorable outcome .…”

“…Prenatal management by fetoscopic endoluminal tracheal occlusion (FETO) has been proposed for severe forms of CDH with a favorable outcome . As of yet, the stomach position grading has not been used to select candidates for FETO . It is important to refine and standardize the prognostic tools used to appropriately select patients that could benefit from in‐utero surgery.…”

Congenital Diaphragmatic Hernia: 10-Year Evaluation of Survival, Extracorporeal Membrane Oxygenation, and Foetoscopic Endotracheal Occlusion in Four High-Volume Centres

“…Patient characteristics, such as foetal liver position (intra-abdominal or intrathoracic) [2], stomach position [3], lung-to-head ratio (LHR) [4], observed-to-expected LHR [5], and the diaphragmatic defect size [6] can influence outcome as well as treatment in a high- or low-volume centre. There are differences in opinion about whether extracorporeal membrane oxygenation (ECMO) improves survival as no specific trials have been conducted with the primary aim of evaluating the role of ECMO specifically for high-risk CDH patients [7,8].…”

Congenital diaphragmatic hernia: pathogenesis, prenatal diagnosis and management — literature review

“…According to some authors, these indices may be useful for predicting neonatal survival and severity of postnatal pulmonary hypertension [23]. Other ultrasound markers are also emerging -such as the position of the fetal stomach in the chest, for example [24]. The intra-abdominal fetal stomach position is associated with a more favorable prognosis, whereas the presence of the stomach within the thorax during the fetal or neonatal period has been shown in multiple studies to correlate with an adverse outcome.…”

“…Recently, Cordier et al have confirmed that fetal stomach position was predictive of postnatal survival and the need for patch repair [25]. According to some papers, there might be a strong association between neonatal death, ECMO (extracorporeal membrane oxygenation) requirement and short-term respiratory morbidity, depending on the position of the fetal stomach [24]. According to Russo et al, the need for ECMO may be predicted based on lung size and liver herniation [26].…”