Congenital Diaphragmatic Hernia (CDH) Fetal MRI

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Lung volume/liver position assessment
   Lung volume (o/e LHR, o/e TFLV) and liver position (mostly left CDH)? (Fetal MRI can distinguish liver/lung/bowel and estimate residual lung volume. Prognostic parameters: o/e LHR (ultrasound lung-to-head ratio, ~22 weeks+), o/e TFLV (MRI total fetal lung volume), liver position (liver herniated into the chest, liver up, is worse, raising ECMO/pulmonary hypertension), stomach position. MRI also differentiates pulmonary sequestration/thoracic masses.)
   • o/e LHR >45% or o/e TFLV >45%, liver in the abdomen (liver down) → Mild · relatively good prognosis
   • o/e LHR 26–45% or o/e TFLV 26–45% → Moderate · quantify + ECMO-capable delivery
   • o/e LHR <25–26% or o/e TFLV <25%, liver herniated into the chest (liver up) → Severe → assess FETO
2. [End] Mild · relatively good prognosis
   Mild (o/e LHR/TFLV >45%, liver down): relatively good prognosis; prenatal serial lung volume monitoring, deliver at a center with neonatal surgery/ECMO capability; postnatal repair.
3. [End] Moderate · quantify + ECMO-capable delivery
   Moderate (o/e LHR/TFLV 26–45%): fetal MRI to quantify lung volume + liver position + stomach position; prenatal counseling, plan delivery at an ECMO-capable center; decide on FETO referral by dynamic assessment.
4. [End] Severe → assess FETO
   Severe (o/e LHR <25–26% or o/e TFLV <25%, liver up): high risk of lung hypoplasia/pulmonary hypertension, high postnatal mortality, often needs ECMO; refer to a fetal therapy center to assess FETO (fetoscopic tracheal occlusion); deliver at an ECMO-capable center + multidisciplinary.

Source guidelines & references

• CDH fetal MRI lung volume/liver position prognostic parameters (o/e LHR, o/e TFLV, FETO)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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