Elsevier

Journal of Pediatric Surgery

Volume 45, Issue 12, December 2010, Pages 2334-2339
Journal of Pediatric Surgery

PAPS Papers
Perinatal management of congenital diaphragmatic hernia: when and how should babies be delivered? Results from the Canadian Pediatric Surgery Network

https://doi.org/10.1016/j.jpedsurg.2010.08.026Get rights and content

Abstract

Purpose

A prenatal diagnosis of congenital diaphragmatic hernia (CDH) enables therapeutic decision making during the intrapartum period. This study seeks to identify the gestational age and delivery mode associated with optimal outcomes.

Patients and methods

A national data set was used to study CDH babies born between 2005 and 2009. The primary outcome was survival to discharge. Primary and secondary outcomes were analyzed by categorical gestational age (preterm, <37 weeks; early term, 37-38 weeks; late term, >39 weeks) by intended and actual route of delivery and by birth plan conformity, regardless of route.

Results

Of 214 live born babies (gestational age, 37.6 ± 4.0 weeks; birth weight, 3064 ± 696 g), 143 (66.8%) had a prenatal diagnosis and 174 (81.3%) survived to discharge. Among 143 prenatally diagnosed pregnancies, 122 (85.3%) underwent abdominal delivery (AD) and 21 (14.6%) underwent cesarean delivery (CS). Conformity between intended and actual delivery occurred in 119 (83.2%). Neither categorical gestational age nor delivery route influenced outcome. Although babies delivered by planned CS had a lower mortality than those delivered by planned AD (2/21 and 36/122, respectively; P = .04), this difference was not significant by multivariate analysis. Conformity to any birth plan was associated with a trend toward improved survival.

Conclusion

Our data do not support advocacy of any specific delivery plan or route nor optimal gestational age for prenatally diagnosed CDH.

Section snippets

Methods

With Institutional Review Board approval, CDH cases for this study were accrued between May 2005 and November 2009 at the 16 perinatal centers, which comprise the Canadian Pediatric Surgery Network (CAPSNet). CAPSNet is a population-based, national network that collects disease-specific data on CDH from prenatal diagnosis until death or discharge from the initial hospitalization. Briefly, on-site trained research assistants abstract data from maternal and infant charts using a customized

Results

Two hundred fourteen live born babies (mean GA, 37.6 ± 4.0 weeks; mean birth weight, 3064 ± 696 g) composed the study cohort, which is summarized in Table 1. The distribution of babies by categorical GA at birth was PT, 40 (18.7%); ET, 66 (30.8%); and LT, 103 (48.1%). Birth time was specified in 192 babies, of which 69 (35.9%) were born between the hours of 8 pm and 8 am. There were 150 (70%) left-sided hernias, and 29 (13%) had major associated congenital anomalies. The mean SNAP-II score for

Discussion

The prenatal detection rate for CDH varies enormously in published studies, from 10% to 79% [13], [14], [15], reflecting variation in prenatal care protocols and sonographic surveillance. The phenomenon of “hidden mortality” associated with a prenatal diagnosis of CDH reflects increases in perceived institutional mortality rates that result from the inclusion of early deaths attributable to “severe disease” (i.e., associated malformations, severe pulmonary hypoplasia) [16], [17], [18], [19].

Acknowledgments

This work was supported by the Canadian Institutes of Health Research (MOP 69050). CAPSNet also wishes to acknowledge the Ontario Ministry of Health and Long-Term Care and the CIHR Team in Maternal Infant Care for their financial and infrastructural support.

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      In the initial analysis, survival to hospital discharge was significantly higher in high volume centers;16 however, a follow-up study with increased case numbers has shown that a survival difference attributable to center volume no longer exists within the registry.17 CAPSNet has studied the effect of gestational timing of delivery (preterm < 37 weeks; early term: 37–38 weeks; and late term > 39 weeks) and found no difference in mortality or survival outcomes according to gestational age at birth.18 The same study looked at the effect of cesarean section (C-section, planned, and unplanned) versus vaginal delivery.

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      Further studies, however, have not supported these results. Safavi and colleagues50 evaluated the Canadian Pediatric Surgery Network (214 infants with CDH) and found no difference between route of delivery or the gestational age at delivery. Most recently, in the largest study to date of infants with CDH (928 infants) evaluating the United States Period Linked Birth-Infant Death database, mortality was found to be higher in infants born at 37 weeks compared with those born at 40 weeks.51

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