Congenital diaphragmatic hernia-associated neonatal morbidity and mortality based on TOTAL trial severity designation

Objective: Congenital diaphragmatic hernia (CDH) severity designation and criteria for in-utero therapy are increasingly based on observed to expected lung head ratio (O/E LHR) and liver position. Our aim was to assess CDH-associated neonatal morbidity and mortality in an academic center with advanced neonatal care and ECMO, based on O/E LHR and liver position TOTAL trial severity designation. Study Design: All pregnancies complicated by CDH in a single academic center between 2007-2017 were reviewed. Cases with prenatal, obstetric, neonatal and surgical outcomes were included. LHR was determined by the tracing method of the contralateral lung area at the level of the 4-chamber view, divided by the head circumference. The observed LHR was then divided by the expected LHR per gestational age. CDH cases were classified as severe if O/E LHR < 25%, moderate if O/E LHR 25%-34.9% regardless of liver herniation, or 35% to 44.9% with liver herniation, or mild if O/E LHR > 35% without liver herniation or > 45% with liver herniation. Neonatal data were compared between mild, moderate and severe CDH cases, stratified by the presence or absence of associated genetic syndromes and/or anomalies. Results: Of 35 total CDH cases, 18 were mild, 13 were moderate and 4 were severe by O/E LHR and liver position criteria (Table 1). There was no difference in rates of left sided CDH, GA at delivery, or birthweight between the groups. A statistically significant difference in ECMO use was seen between the groups, although there was no difference in survival to discharge, which ranged from 72.2% for mild CDH to 75.0% for severe CDH. When excluding 6 cases with genetic syndromes and/or structural anomalies, 16 cases were mild, 9 were moderate and 4 were severe (Table 2). Among those, a significant difference in ECMO use was seen, but there was no difference in survival to discharge, which ranged from 81.2% for mild CDH to 75.0% for severe CDH. Conclusion: CDH disease severity based on O/E LHR centiles and liver position was not associated with differences in survival to discharge in our center, and survival rates for moderate and severe CDH were higher than those reported in the published literature. Potential benefits of in-utero therapy for pregnancies complicated by CDH should be assessed based on institution-specific baseline mortality rates. [Figure presented] [Figure presented]