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Andrew B. Kairalla MD, Editor
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Timing of Delivery in CDH
Survival in Early- and Late-Term Infants With Congenital Diaphragmatic Hernia Treated With Extracorporeal Membrane Oxygenation. Stevens TP, Chess PR, McConnochie KM, et al. PEDIATRICS (September 2002);110: 590-596.
Design
. Retrospective cohort study of infants with CDH treated with ECMO.Data Sources. The Extracorporeal Life Support Organization registry.
Analysis. Survival and clinical predictors of survival were compared between infants born early term (38 0/7–39 6/7 weeks’ gestation) and infants born late term (40 0/7–41 6/7 weeks’ gestation).
Results. Among full-term infants with CDH treated with ECMO, late-term compared with early-term delivery was associated with improved survival (63% vs 53%). Among full-term survivors of ECMO, late-term infants spent less time on ECMO (181 vs 197 hours) and less time in the hospital (60 vs 67 days). In multivariate analysis, greater birth weight, higher 5-minute Apgar score, higher arterial pH and PCO2 <50 torr before ECMO, and absence of a prenatal diagnosis of CDH were associated with survival.
Since the late 1980s, survival of infants with CDH requiring ECMO decreased from 63% to 52%. The decreased survival rate was associated with increased rates of prenatal diagnosis, early-term delivery, lower birth weight, longer ECMO runs, and more frequent complications on ECMO.
Conclusions. Among term infants with CDH receiving ECMO, late-term delivery compared with early-term delivery is associated with improved survival, shorter ECMO duration, shorter hospital length of stay, and fewer complications on ECMO. These data suggest that, at least for the 50% of CDH patients treated with ECMO, outcomes for infants with CDH may be improved by delay of elective delivery until 40 completed weeks of gestation.
Comment: It is interesting that despite all the advances in respiratory care and in management of pulmonary hypertension since the late 1980s, the mortality rate of CDH patients treated with ECMO has actually increased! Could it be that we are just too anxious to deliver these babies? The data make a strong case for delaying elective delivery of babies with diaphragmatic hernia until after their due dates. ABK.
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