O1111: Outcomes in the Premature Congenital Diaphragmatic Hernia Patient

Background: Congenital diaphragmatic hernia (CDH) is associated with pulmonary hypoplasia, pulmonary hypertension, and neonatal morbidity and mortality. Fetoscopic endotracheal occlusion (FETO) has recently been introduced in prenatal management of CDH and has demonstrated improvements in postnatal pulmonary hypertension and survival in patients with severe disease; however, FETO is accompanied by an increased risk of preterm delivery. The purpose of this study is to characterize the outcomes of CDH patients who are delivered at preterm gestational ages.

Methods: A single-center retrospective review was performed for CDH patients from 2011 to 2020. All patients treated with CDH were included in the study. Demographic, perinatal, perioperative, and postoperative outcomes were collected. FETO balloon was inserted between 26-32 weeks of gestation according to our institutional protocol. Data were analyzed with Wilcoxon rank-sum tests and t-tests where appropriate.

Results: One hundred and forty-six patients were treated for CDH at our institution with 32 (22%) prenatally treated with FETO. The median gestational age at delivery was 38 weeks gestation (IQR 36-39) for all patients and 35 weeks gestation (IQR 34-36) for the subset of FETO patients. Overall survival to discharge was 73%. Two patients, who did not undergo FETO, were delivered at < 28 weeks gestation and did not survive (Figure 1A). Median birth weight was significantly lower in preterm compared to term neonates generally (3.1 kg (IQR 2.9-3.5) vs. 2.3 kg (IQR 1.6-2.8), p< 0.001) and in the subset of FETO patients (3.0 kg (IQR 2.8-3.1) vs. 2.4 kg (1.6-2.7), p< 0.01) (Table 1). Among all patients, preterm neonates had an increased need for repair with patch (p=0.04). Among patients that underwent FETO, 63% survived to discharge (Figure 1B), and term and preterm neonates displayed no difference in ECMO use, ECMO duration, tracheostomy, length of stay, or survival to discharge (Table 1).

Conclusion: There is no difference in survival of premature and term CDH neonates. Furthermore, CDH patients treated with FETO do not have increased morbidity or mortality despite being born preterm and with more severe disease. Further risk stratification by indices of CDH severity may provide additional insight into outcomes in these populations. These data critically inform prenatal counseling and management of patients with prenatally diagnosed CDH, such as the utility of fetal monitoring and maternal interventions for fetal indications during the third trimester.