Congenital Diaphragmatic Hernia - Emergency Treatment

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V.P. Videnovic 1, N.D. Videnovic 2,3, J.M. Mladenovic 2,4, M.B. Filipovic 2,4, D. Kocic 5, Z. Cakic 5, S. Filipovic 5
1 - Department of Neonatology, General Hospital in Leskovac, Serbia;
2 - Medical Faculty University of Pristina –Kosovska Mitrovica, Serbia;
3 - Department of Anesthesiology, Clinical Center Gracanica, Serbia;
4 –Department of Surgery, Clinical Center Gracanica, Serbia,
5 - Department of Gynecology, General Hospital in Leskovac, Serbia.
INTRODUCTION
Congenital diaphragmatic hernia (CDH) is a developmental abnormality of the diaphragm that allows the abdominal viscera to enter
the thoracic cavity (Figure 1). Bochdalek hernia is a severe birth defect especially if it occurs on the left side, where it is 5 - 10 times
more common. When the abdominal organs are in the chest, there is limited room for the lungs to grow. This prevents the lungs from
developing normally, resulting in pulmonary hypoplasia (or underdeveloped lungs). This can cause reduced blood flow to the lungs and
pulmonary hypertension (high blood pressure in the pulmonary circulation), as well as asthma, gastrointestinal reflux, feeding disorders
and developmental delays. The severity of congenital diaphragmatic hernia (CDH) is largely determined by the position of the liver.
Outcomes are generally better in cases where the liver remains down in the abdomen and the LHR is higher. The overall survival rate is
70 percent.
Key words: Congenital diaphragmatic hernia, Emergency Treatment, newborn, pulmonary hypoplasion
Clinical Cases & Summary Results
A newborn male infant born via spontaneous vaginal delivery, body weight 3500 gr, height 54 cm, head circumference 54 cm
and Apgar score 10/9/9. Irregular monitoring during pregnancy. The course of pregnancy was smooth, no fetal hypoxia diagnosed by
cardiotocography, amniotic fluid clear, with normal volume. Clinical examination upon admission to the neonatal intensive care unit
confirmed presence of dyspnea; pale, livid color of skin and visible mucous membranes. Respiratory pattern rhythmical, quiet, no
pathological murmurs, both sides of the breath sounds weakened with rare early inspiratory crackles. Suctioning of the mouth
performed for presence of frothy secretions. Weak muscle tone, absent primitive reflexes. Occasional expiratory sobbing. Neonate
capillary blood gas analysis carried out (table 1). Oxygen was administered at a flow rate of 4 l / min with the help of a hood oxygen
mask, with occasional secretion suction. In an adaptation period of two hours, no signs of improvement noted. Signs of respiratory
distress, with intense expiratory sobbing noted in the fourth hour after birth. The baby became dyspneic, with convex formed chest and
scaphoid abdomen. Skin color pale and livid with more pronounced signs of central cyanosis.
On auscultation, clear breathing sound heard, ictus cordis shifted towards right parasternal line, disajni zvuk desnog plućnog
krila skoro nečujan,dok je levo oslabljen. Capillary blood gas analysis detected the presence of mixed acidity (pH-7.16), hypercapnia
(PcCO2-66.3 mmHg) and hypoxemia (PcO2-36 mmHg), bicarbonates 24 mmol / l, actual base excess -5.4 mmol/l, oxygen saturation
(ScO2) 8l%.
Neonatal chest radiograph carried out: homogenous opacity corresponding heart shadow observed in the right lung,
Transparency in the left lung does not show normal airiness, but corresponds to intestinal contents (Figure 2). Chest radiograph
confirmed the diagnosis: Hernia diaphragmatica congenita. The degree of pulmonary hypoplasia could not be determined; this would
affect the outcome of the operation and the further prognosis of the newborn.
After the hemodynamic stabilization (administered crystalloid solutions, bicarbonates ...) and placement of a nasogastric tube
with occasional vacuum-aspiration and upper respiratory tract suction, the baby was transferred to department of pediatric surgery in
the eighth hour of life. Maintaining the hemodynamic stability of newborns with CDH is a prerequisite for determining the time of
surgical intervention. At 12th hour of life, operation in performed under general anesthesia. An incision is made just below the baby’s rib
cage, the organs in the chest are guided back down into the abdomen and the hole in the diaphragm is sewn closed. The space created
in the chest allows the lungs to continue to grow; children will continue to grow more air sacs or alveoli through early childhood.
After the intervention, the patient was admitted to the intensive care unit where he received mechanical ventilation of CPPV
type (Continuous positive-pressure ventilation) for a certain period of time. Postoperative course was uneventful, without
complications, and the newborn was released home on the fourteenth day after operation.
Conclusion
Congenital diaphragmatic hernia is characterized by a varying degree of pulmonary hypoplasia with pulmonary circulation disorder
and surfactant deficiency, resulting in increased pulmonary vascular resistance. Timely diagnosis, hemodynamic and respiratory stabilization
of the newborn increase child’s chances for successful operative treatment. Emergency surgery in cases of a properly observed and
evaluated condition is a beneficial therapeutic approach.
Congenital Diaphragmatic Hernia - Emergency
Treatment
Figure 2. Bebigram. A–hearty shadow moved to the right.
B–congenital defect of the diaphragm that establishes a
protrusion intestine from the abdominal cavity into the
chest cavity.
Figure 1. Congenital diaphragmatic hernia (CDH) is a
developmental abnormality of the diaphragm that allows
the abdominal viscera to enter the thoracic cavity