title: Improving the Prediction of Neonatal Outcomes in Isolated Left-Sided Congenital Diaphragmatic Hernia by Direct and Indirect Sonographic Assessment of Liver Herniation.
abstract: OBJECTIVE
  Liver herniation can be assessed sonographically by either a direct (liver-to-thoracic area ratio) or an indirect (stomach position) method. Our objective was to evaluate the utility of those methods to assess liver herniation for the prediction of neonatal outcomes in patients with isolated left-sided congenital diaphragmatic hernia (CDH).
  
  
  METHODS
  We conducted a retrospective cohort study of all patients with CDH who had prenatal assessment and were delivered at Texas Children's Hospital between January 2004 and April 2014. The predictive value of sonographic parameters for mortality and the need for extracorporeal membrane oxygenation was evaluated by univariate, multivariate, and factor analysis and by receiver operating characteristics curves.
  
  
  RESULTS
  A total of 77 fetuses with isolated left-sided CDH were analyzed. The lung-to-head ratio, liver-to-thorax ratio, and stomach position (according to the classifications of Kitano et al [Ultrasound Obstet Gynecol 2011; 37:277-282] and Cordier et al [J Matern Fetal Neonatal Med 2015; 28:190-195]) were significantly associated with both neonatal outcomes (P < .03). Significant correlations were observed between all of these sonographic parameters. A combination of the liver-to-thorax ratio and stomach position (Kitano) or stomach position (Cordier) with the lung-to-head ratio increased the area under the receiver operating characteristic curve of the lung-to-head ratio for mortality prediction (0.86 [95% confidence interval, 0.74-0.98], 0.83 [0.72-0.95], and 0.83 [0.74-0.92], respectively).
  
  
  CONCLUSIONS
  Sonographic measurements of liver herniation (liver-to-thorax ratio and stomach position) are predictive of neonatal outcomes in isolated left-sided congenital diaphragmatic hernia. Our study shows that the combination of those sonographic measurements of liver herniation and lung size improves the accuracy of predicting mortality in those fetuses.
authors.affiliation: Department of Obstetrics and Gynecology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Sananes
authors.affiliation: Department of Obstetrics and Gynecology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA.
authors.forename: Ingrid
authors.initials: I
authors.lastname: Britto
authors.affiliation: Michael E. DeBakey Department of Surgery, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA.
authors.forename: Adesola C
authors.initials: AC
authors.lastname: Akinkuotu
authors.affiliation: Michael E. DeBakey Department of Surgery, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA.
authors.forename: Oluyinka O
authors.initials: OO
authors.lastname: Olutoye
authors.affiliation: Michael E. DeBakey Department of Surgery, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA.
authors.forename: Darrell L
authors.initials: DL
authors.lastname: Cass
authors.affiliation: Department of Obstetrics and Gynecology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA.
authors.forename: Haleh
authors.initials: H
authors.lastname: Sangi-Haghpeykar
authors.affiliation: Michael E. DeBakey Department of Surgery, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA.
authors.forename: Timothy C
authors.initials: TC
authors.lastname: Lee
authors.affiliation: Department of Radiology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA.
authors.forename: Christopher I
authors.initials: CI
authors.lastname: Cassady
authors.affiliation: Department of Radiology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA.
authors.forename: Amy
authors.initials: A
authors.lastname: Mehollin-Ray
authors.affiliation: Department of Pediatrics, Section of Neonatology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA.
authors.forename: Stephen
authors.initials: S
authors.lastname: Welty
authors.affiliation: Department of Pediatrics, Section of Neonatology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA.
authors.forename: Caraciolo
authors.initials: C
authors.lastname: Fernandes
authors.affiliation: Department of Obstetrics and Gynecology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Belfort
authors.affiliation: Department of Obstetrics and Gynecology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA.
authors.forename: Wesley
authors.initials: W
authors.lastname: Lee
authors.affiliation: Department of Obstetrics and Gynecology, Texas Children's Fetal Center and Baylor College of Medicine, Houston, Texas USA ruano@bcm.edu rodrigoruano@hotmail.com.
authors.forename: Rodrigo
authors.initials: R
authors.lastname: Ruano
mesh_terms: D015331:Cohort Studies; D005260:Female; D005315:Fetal Diseases / Q000000981:diagnostic imaging*; D065630:Hernias, Diaphragmatic, Congenital / Q000000981:diagnostic imaging*; D006801:Humans; D007231:Infant, Newborn; D008099:Liver / Q000000981:diagnostic imaging / Q000196:embryology; D008107:Liver Diseases / Q000000981:diagnostic imaging*; D011247:Pregnancy; D015203:Reproducibility of Results; D012189:Retrospective Studies; D016216:Ultrasonography, Prenatal / Q000379:methods*
keywords: congenital diaphragmatic hernia; liver herniation; lung-to-head ratio; obstetric ultrasound; prenatal predictors; pulmonary hypoplasia; stomach position