Management of congenital diaphragmatic hernia

Management of congenital diaphragmatic herniaCongenital diaphragmatic hernia (CDH) has an incidence of between one in 2000-5000 live births.The hidden mortality associated with CDH includes spontaneous abortions and stillbirths as well as therapeutic abortions (often for other identified anomalies).The management of CDH has been intensely debated since Ladd and Gross stated in 1940 that early surgery was the proper treatment for these patients. 1Controversies have surrounded ideal preoperative management, timing of surgery, and indeed whether surgery should be oVered to all. 2 Despite the advances in neonatal care, inroads into mortality which might have been anticipated have not materialised and it remains relatively unchanged at 40-50%. 3 However, we now stand on the threshold of an exciting stage in the development of neonatal cardiorespiratory support.The role of new therapeutic modalities such as extracorporeal membrane oxygenation (ECMO), surfactant, high frequency ventilation (HFV), inhaled nitric oxide (iNO), in utero interventions, and liquid ventilation have intensified the debate. Antenatal managementPrenatal diagnostic rates vary from 10-90% depending on local antenatal ultrasound screening protocols.Prenatal diagnosis allows for counselling of parents and planned management but does not predict outcome. 4Prenatal diagnosis of CDH should lead to careful inspection for other major anomalies and chromosomal analysis is justified.Laterality, presence of liver and stomach in chest, left ventricular mass, presence of polyhydramnios, and ultrasound indices of relative lung volume have been used in attempts to predict outcome, but are not reliable.Only the presence of associated major anomalies is reliably associated with a poor prognosis. 5