Evolution of Antenatal Management of Congenital Diaphragmatic Hernia: A Systematic Review

Background

Congenital diaphragmatic hernia (CDH), despite the advances in perinatal care is still a menacing disease carrying high mortality and morbidity. The review in this current update critically examines the development of antenatal management of CDH over the past four decades methodically.

Methods

A systematic literature search using the PubMed, Embase, Cochrane Library, and Web of Science databases for studies on CDH in the last 4 decades i.e from 1980 to 2024, was performed. The following search terms in varying combinations were included: congenital diaphragmatic hernia, antenatal management, fetal therapy, prenatal diagnosis, and fetal intervention. PRISMA guidelines were followed for the purposes of study selection and data extraction. The studies were divided based on management strategy and timeline order to look for patterns of evolution.

Results

Screening of 1,472 records yielded 187 pertinent studies. Antenatal treatment of CDH has evolved through four phases: (1) initial diagnostic approaches (1980s); (2) developing prognostic predictors (1990s); (3) experimental fetal treatments (2000s); and (4) evidence-based optimized approaches (2010s to date). Among the most important developments are improved imaging techniques, calculation of lung-to-head ratio (LHR) and observed-to-expected LHR, fetal endoscopic tracheal occlusion (FETO), and protocolized evaluation. Current practice puts focus on multidisciplinary care, proper risk stratification, and early referral to secondary-level facilities.

Conclusion

Antenatal management of CDH has been revolutionized from the time of initial diagnosis to high-technology intervention methods. Present care is focused on accurate prenatal diagnosis, proper case selection for therapy, and optimal perinatal management. While the mortality due to CDH has reduced over the last few decades, we still need more studies to zero in on the optimal timing of interventions, to optimize selection criteria for antenatal management, and to be able to introduce new therapeutic interventions.