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Diaphragmatic hernia in children is relatively common (1 in 1700). Mortality in this disease is 1-3% of the total mortality of newborns, and during the first year of life - 12% of mortality among children dying due to malformations.

Origin of diaphragmatic hernia in children

The formation of a thinned zone or a through defect in the dome of the diaphragm occurs in early stages development in the embryo or fetus. Deviations in the laying of the muscular layer of the diaphragm occur as a result of violations of trophic processes associated with the peculiarities of metabolism in the body of the mother and fetus. In the future, the forces of intra-abdominal pressure of the fetus, which contribute to the movement of internal organs through an underdeveloped diaphragm. At the same time, air-intestinal pockets remain unblistered, which turn into preformed hernial sacs, similar to the vaginal process of the peritoneum when inguinal hernia. Acquired hernia of the diaphragm in children occurs more often due to closed injury pelvis, abdomen and chest or as a result of an infectious-toxic process (poliomyelitis, tuberculosis).

Diaphragmatic hernia symptoms in children

The clinical picture is due to changes that occur when moving organs abdominal cavity. These include disorders of respiratory function, impaired passage of food through digestive tract and traumatization of it, deviations in cardiac activity and general disorders. The combination of these symptoms depends on age, type of hernia. How less age child, the more pronounced the signs of a hernia. With diaphragmatic hernia in children, shortness of breath is noted during exercise (running, walking, crying), abdominal pain, weakness, fatigue. Developmental delay is associated with oxygen starvation and recurrent pneumonia, which are often the cause of death of these patients. In newborns and infants attacks of cyanosis, vomiting, sometimes cough, hiccups are noted. The borders of the heart are sharply displaced in the direction opposite to the hernia, usually to the right. Among the hernias of the diaphragm proper great danger for the patient, false hernias are presented, in which infringement is possible. Hernias esophageal opening present with persistent vomiting. As a result of erosive and ulcerative esophagitis and gastritis, patients develop hematemesis, tarry stools, develop ( hemorrhagic syndrome). The lag in the development of children with esophageal hernias is the result of malnutrition. Hernias anterior section diaphragms may be asymptomatic or with abdominal pain, shortness of breath, stridor breathing. More vivid symptoms observed in patients with frenopericardial hernia. In 30% of all children with diaphragmatic hernias, chest deformity is noted; 25% of children are asymptomatic.

Physical examination of children reveals pathological abnormalities(the presence of areas of tympanitis or dullness of percussion sound, the disappearance and weakening of respiratory sounds, the appearance of audible intestinal peristalsis, rumbling, splashing) in areas of the chest corresponding to localization a certain kind hernia. With a hernia of the diaphragm, changes are noted in the corresponding half of the chest, with an esophageal hernia - in the interscapular region, with an anterior hernia - at the level of the sternum and parasternally. In these areas, deviations are found during X-ray examination, which allows you to establish a final and accurate topical diagnosis. Diaphragmatic hernia is characterized by a number of symptoms: the appearance in the lung field of air bubbles of a cellular structure or bubbles with the presence of a level and blackout areas; inconstancy of data noted during repeated studies (“symptom of variability”); high standing of the diaphragm, violation of the continuity or correctness of its contour, violation of the mobility of the diaphragm; displacement of the borders of the heart. Clarification of the diagnosis in most cases requires the use of a contrast study of the gastrointestinal tract (in newborns and infants - lipoidol, in older children - barium suspension). Sometimes it is necessary to apply a pneumoperitoneum. Differential Diagnosis when examining patients, it is carried out between partial and complete (relaxation) thinning of the dome of the diaphragm. When the diaphragm relaxes, the presence of a highly located boundary line is noted, which does not shift and is a regular arcuate curve; at deep breath its rocking movements are not observed, which indicates the absence of functioning muscle layers in the abdominal barrier. Establishing a preoperative diagnosis of complete thinning of the dome of the diaphragm (relaxation) is important, in order to avoid recurrence, it is advisable to use an alloplastic material. Hiatus hernia in children is differentiated from undescended stomach (thoracic stomach, short esophagus). The differential diagnosis of hernia and undescended stomach is practical value, because with a hernia, an operation is indicated, and with an undescended stomach, conservative treatment.

Complications

The main complication of diaphragmatic hernia in children is its infringement. In newborns, it is distinguished by a certain peculiarity: flatulence of intestinal loops located in the chest cavity causes a sharp displacement of the heart and atelectasis lung tissue. The cause of death of children in such cases is asphyxia. Circulatory disorders in the digestive tract or obstruction of its patency is usually not observed. Such an infringement is more correctly called asphyctic. In older children in the clinical picture strangulated hernia combination of gastrointestinal symptoms intestinal obstruction and respiratory failure.

Diaphragmatic hernia treatment in children

Tactics for diaphragmatic hernia should be active: all patients are subject to surgery, with the exception of children with limited protrusion of the right dome of the diaphragm, which is usually asymptomatic and does not threaten the child with complications. An emergency operation is performed when the diaphragm is ruptured or in newborns when a hernia is incarcerated. Elective surgeries in children, especially younger ones, should be performed in specialized institutions where there is experience in using surgical methods treatment, modern anesthesia and nursing children after surgery, which often decides the final success of the operation.

Anesthesia- intratracheal anesthesia with nitrous oxide or ether using short-term relaxants (ditilin, listenone).

Online access- transabdominal. With limited protrusions of the central zone of the dome, with right-sided localization of the hernia, as well as with esophageal hernias, transthoracic access can be used.

Operational techniques depend on the type of diaphragmatic hernia in children. They should be simple and non-traumatic. The absence of adhesions allows the organs to be easily brought down into the abdominal cavity. With false hernias in pleural cavity air is introduced through a thick catheter, which helps to bring down the intestinal loops. With small defects in the diaphragm, traumatic and anterior hernias, a simple suturing of the hernial orifice with one or two rows of interrupted sutures is sufficient, without refreshing the hernial orifice. Enjoy thick (No. 3-4) suture material(kapron or silk) to avoid muscle eruption. In the presence of a thinned zone of the diaphragm large area it is strengthened either by plicating the hernial sac, suturing it with prefabricated sutures, tamponade of a weak area with a dense organ (liver, spleen), or by using an alloplastic material (polyvinyl alcohol, nylon fabric or mesh). With a significant defect in the diaphragm, a number of techniques are used to help reduce the defect (resection of the ribs, moving the diaphragm 1-2 ribs higher). However, even then it is advisable to use alloplastic material, provided that it is isolated from the free pleural cavity with a peritoneal flap (to avoid prolonged pleurisy).

With a hernia of the esophageal opening in children, the operation consists in lowering the stomach and other displaced organs into the abdomen, excising the hernial sac or dissecting it in two circular fixation zones - in the region of the cardia of the stomach and along the line of the esophageal opening of the diaphragm. The main stage of the intervention is the movement of the esophagus from its bed near the spine to the anterior-outer section of the esophageal ring, where the most favorable conditions for circular coverage of the esophagus by the muscle and prevention of relapse. During surgery for an esophageal hernia, you should not injure vagus nerves to avoid atony of the stomach and persistent postoperative vomiting. In some cases, the child's abdominal cavity is underdeveloped and the relegated organs do not fit in it. Then the suturing of the abdominal wall is divided into two stages: first, only the skin is sutured, after a week or later, the abdominal wall is sutured in layers.

The results of the treatment of diaphragmatic hernia in children

The study of the results of operations for diaphragmatic hernia in children shows that the surgeon's active tactics are correct: children develop normally after surgery, catching up and even ahead of their peers.

The article was prepared and edited by: surgeon

DEFINITION

congenital diaphragmatic hernia- a defect in the diaphragm through which the abdominal organs move into the chest.

ICD-10 CODE

(^79.0. Congenital diaphragmatic hernia.

EPIDEMIOLOGY

Frequency - 1 per 2000-5000 newborns. In 80% of cases, left-sided diaphragmatic hernias occur, in 19% of cases - right-sided, in 1% - bilateral. In most cases (90-95%), the abdominal organs, not limited by the hernial sac, move freely into the chest through natural or newly formed openings (false hernia). In 15-57% of cases, diaphragmatic hernia is combined with other malformations:

Cardiovascular system (14-25%);

CNS (10-30%);

Gastrointestinal tract (17-20%);

Genitourinary system (10-15%).

Chromosomal abnormalities (10-12%) include:

Trisomy 18;

Turner syndrome (45X0);

Cantrell pentad.

PATHOGENESIS

The defect begins to form between the 4th and 9th weeks of intrauterine development, when a pleuroperitoneal membrane is formed that separates the pleural and abdominal cavities. As a result of underdevelopment of the pleuroperitoneal septum or its rupture, a through hole is formed in the diaphragm, which leads to the formation of a false diaphragmatic hernia. With a true diaphragmatic hernia, muscle fibers are underdeveloped in the diaphragm, and the walls of the hernial sac consist of serous integuments - peritoneal and pleural. The organs of the abdominal cavity (stomach, spleen, intestines, liver) penetrate into the pleural cavity and cause compression of the lungs and mediastinum. In this case, secondary hypoplasia, structural and functional immaturity of the lungs occurs; both lungs suffer, although the changes are more pronounced on the side of the lesion. The severity of lung hypoplasia is determined both by the volume of organs that have penetrated from the abdominal cavity and by the time of movement. In the lungs, a pronounced decrease in branching is noted. bronchial tree, limited formation of alveoli, a decrease in the amount of surfactant. Number of branches pulmonary artery does not correspond to the number of bronchi, the arteries have a smaller diameter and a thicker muscular wall, which determines the development of pulmonary hypertension after birth.

PRENATAL DIAGNOSIS AND TREATMENT

Diagnosis of congenital diaphragmatic hernia is possible from the end of the first trimester of pregnancy (12-14 weeks) by the location of the abdominal organs in the chest. Average term diagnosis - 26-27 weeks, accuracy - 84-90%. Polyhydramnios, the location of the stomach and liver above the diaphragm, and the detection of these changes before the 20th week of intrauterine development are considered poor prognostic signs. When the lung hypoplasia index is less than 0.6, the prognosis is also unfavorable (the hypoplasia index is determined by multiplying two perpendicular diameters of the lungs from the side opposite from the hernia and dividing the resulting value by the head circumference). However, the failure of prenatal prognostic criteria does not allow one to reliably predict the outcome. perinatal treatment and outcome of pregnancy.

So far, positive experience has been accumulated surgical treatment fetuses with diaphragmatic hernia based on prenatal tracheal occlusion. After occlusion, pulmonary secretion accumulates and the lungs increase in volume, displacing the abdominal organs from the chest. These operations are indicated at 26-28 weeks, when the pulmonary index is less than 1.0 and the liver is displaced to chest cavity. In the III trimester of pregnancy, therapy is necessary aimed at maturation of the lungs of the fetus: betamethasone 12 mg intramuscularly twice. The question of the preferred method of delivery remains controversial.

CLINICAL PICTURE

Basic clinical sign diaphragmatic hernia after the birth of a child - ODN. Terms of manifestation respiratory failure often determine the prognosis of the disease, since the time of development of disorders reflects the severity of lung hypoplasia, the size of the defect and the volume of organs that have penetrated into the chest cavity. A navicular-shaped abdomen, weakening of breathing from the side of the hernia and a shift in heart sounds in the opposite direction constitute the classic clinical picture congenital diaphragmatic hernia. In some cases, intestinal peristalsis is heard on the side of the lesion. Pulmonary hypertension leads to shunting of blood around the lungs through oval window and ductus arteriosus. This increases hypoxia, hypercapnia, and acidosis, which in turn exacerbate pulmonary vasoconstriction, thereby completing a vicious circle.

About 30-40% of children are not viable and die immediately after birth from severe respiratory failure. However, it should be remembered that approximately 5% of children with diaphragmatic hernia may be asymptomatic.

DIAGNOSTICS

On the radiograph of the chest and abdominal organs in the chest cavity of children with diaphragmatic hernia, intestinal loops are determined with a displacement of the mediastinal organs in the opposite direction and compression of the contralateral lung.

PREOPERATIVE PREPARATION

primary goal preoperative preparation- stabilization of the child's condition. A newborn with diaphragmatic hernia does not require emergency surgery, and surgical treatment can be delayed for a period of several hours to several days: intestinal compression of the lungs is not a primary problem, and surgery does not eliminate respiratory failure, on the contrary, it can aggravate it. The operation is performed only if stable, at least within 12 hours, stabilization of the state of hemodynamics and breathing of the child is achieved. When deciding on an operation, they are guided by the following main indicators:

Preductal pa02 greater than 70 mm Hg;

Normal pH values;

Mean blood pressure is greater than 50 mm Hg. (for full-term newborns);

Hourly diuresis more than 1 ml/kg/h.

If these indicators cannot be achieved within 3-6 hours, the prognosis is poor. Survival of children with delayed surgery is higher.

The nature of the priority measures at the birth of a child with a diaphragmatic hernia depends on the severity respiratory disorders.

The main efforts should be aimed at maintaining pulmonary gas exchange.

Immediately after birth, tracheal intubation is performed and mechanical ventilation is started. It is very important not to allow the stomach and intestines to swell with gases, so the stomach must be decompressed through a nasogastric tube. Any procedures that can cause overinflating of the stomach should be avoided - mechanical ventilation through a mask and CPAP. It is necessary to exclude the participation of the child himself in the act of breathing, for which they use sedatives(diazepam at a dose of 0.3-0.5 mg/kg, midazolam at a dose of 0.05-0.1 mg/kg), opioids (fentanyl at a dose of 5-10 mcg/kg, trimeperidine at a dose of 0.5 mg/kg kg, morphine at a dose of 0.05 mg/kg) or muscle relaxants.

The ventilation strategy is based on the exclusion of lung injury: inspiratory pressure (P1P) is set to ensure tidal volume 3-5 ml/kg, preferably not higher than 25 cm of water column, PEEP - 2-3 cm of water column, pH > 7.25 in the preductal arterial blood. The inhaled fraction of oxygen should be minimal to maintain a preductal SPO2 of more than 85-90%. If the child has persistent acidosis (respiratory and/or metabolic) despite P1P >30 cmH2O, or persistent hypoxemia with PIO2=1.0, consideration should be given to alternative ways respiratory therapy: VFO IVL, inhalation of nitric oxide.

To reduce the right-left shunt of blood through fetal communications it is necessary to achieve a steady increase in systemic blood pressure, which should exceed the pressure in the pulmonary artery. For this purpose, dobutamine, dopamine are administered, and in conditions of decompensated acidosis - epinephrine. Infusion therapy, antibiotics are prescribed a wide range actions and hemostatic drugs. If the operation is postponed, parenteral nutrition is started from the second day.

Central venous catheterization is used to provide venous access: catheterization is preferred femoral vein or insert a catheter through an antecubital or axillary vein into the superior vena cava. In newborns with diaphragmatic hernia, puncture and catheterization of the subclavian and internal jugular veins are contraindicated due to high risk development of pneumothorax and injury to intestinal loops. For monitoring gas composition preductal blood and invasive blood pressure, the right radial artery is catheterized.

In some cases (when performing IVO mechanical ventilation, inhalation of nitric oxide), in order to exclude problems associated with transportation, the operation is performed in the intensive care unit.

SURGERY

Target surgical intervention- Bringing organs down into the abdominal cavity, suturing a diaphragm defect in false hernias or diaphragm plastic surgery in true hernias. With aplasia of the muscles of the diaphragm or with large defects, synthetic material is used for plastic surgery. AT recent times drainage of the pleural cavity is not carried out.

INTENSIVE CARE IN THE POSTOPERATIVE PERIOD

After immersion of organs in the abdominal cavity, increased intra-abdominal pressure can lead to circulatory disorders lower limbs, OPN, which will require a second operation.

Usually, a hypoplastic lung does not immediately expand enough to fill the entire pleural cavity on its side, so simultaneous air evacuation can lead to a sharp displacement of the mediastinum and cardiac arrest. The expansion of the lung and the movement of the mediastinum occurs gradually and sometimes takes several weeks.

Chylothorax after surgery occurs in 20% of newborns and may serve as an indication for prolonged drainage of the chest cavity. The issue of pleural puncture and partial evacuation of air and fluid is decided individually.

The duration of mechanical ventilation in the postoperative period depends on:

The magnitude of intra-abdominal tension;

Associated anomalies of development;

Degrees of pulmonary dysplasia.

The duration of IVL can be from several hours to several months.

Aspiration of sputum from the trachea should be carried out only according to strict indications, in order to prevent even short-term hypoxemia. The main task is to prevent sudden fluctuations in Pa02.

In the postoperative period, use high doses opioid analgesics, not only preventing the humoral stress response to the operating room

injury and improving postoperative recovery, but also reducing or completely eliminating high blood pressure in the pulmonary artery system. For this purpose, an infusion of fentanyl at a dose of 5-15 μg Dcghh) or morphine at a dose of 5-10 μg Dcghh) is carried out for 3-15 days after the operation. If a catheter is inserted into the epidural space during the operation, epidural analgesia can be used for postoperative analgesia for 3-4 days.

Continue therapy inotropic drugs, in some children with defects of cardio-vascular system may be required long-term therapy cardiac glycosides.

Calculation infusion therapy after surgery, it is carried out taking into account the physiological needs of the child, adjusted for heart failure or hypovolemia.

Hypoproteinemia is corrected by transfusion of 10-20% albumin at the rate of 10-20 ml/kg.

Parenteral nutrition begins after 24-48 hours, and enteral - on the 5-7th day after the resolution of postoperative paresis of the gastrointestinal tract.

High risk of development septic complications after surgery in children with diaphragmatic hernia requires monitoring of the microecological status and long-term antibacterial and antifungal therapy.

Complications in the immediate postoperative period:

Pneumothorax;

Chylothorax;

Adhesive intestinal obstruction;

severe pulmonary hypertension;

bronchopulmonary dysplasia;

Mortality remains high to date: postoperative survival is about 60%. However, only a third of operated children develop normally. With mild respiratory failure, the prognosis is favorable. As a rule, malnutrition and developmental delay are noted during the first year of life. In children with severe forms respiratory disorders and pulmonary hypertension, bronchopulmonary dysplasia may develop and cor pulmonale may form.

The diaphragm is a domed muscular barrier between the thoracic and abdominal cavities. It separates the heart and lungs from the abdominal organs - the stomach, intestines, spleen, liver and other organs. A diaphragmatic hernia occurs when one of the abdominal organs moves up into the chest cavity through a defect in the form of a hole in the diaphragm. This type of defect can be congenital or acquired later in life. Diaphragmatic hernia is always a cause for emergency medical care and requires surgical correction.

Reasons for the development of diaphragmatic hernias and their classification

Congenital diaphragmatic hernia is associated with abnormal development of the diaphragm during fetal development. A defect in a child's diaphragm allows one or more of the abdominal organs to pass into the chest cavity and occupy the lung space. As a result, the baby's lungs cannot develop properly. In most cases, this pathological process is unilateral.

Acquired diaphragmatic hernia is usually the result of blunt or penetrating trauma. Road traffic accidents and falls cause most blunt injuries. Penetrating injuries are usually the result of stab or gunshot wounds. Surgery on the abdomen or chest can also cause accidental damage to the diaphragm.

Most congenital diaphragmatic are idiopathic in nature - the cause of their occurrence is unknown. Nonetheless, chromosomal abnormalities were involved in 30% of cases.

What factors can increase the risk of acquired diaphragmatic hernia?

Blunt injuries resulting from a traffic accident.
Surgical procedures on the chest or abdomen.
Falls.
Stab wounds.
Gunshot wounds.

The role of drugs and chemical substances in the development of congenital diaphragmatic hernia is uncertain, but nitrofen, quinine, thalidomide, phenmetrazine, and polybrominated biphenyls are often cited as causes of congenital diaphragmatic hernia.

Typical for diaphragmatic hernia symptoms and features of their development in newborns

Congenital diaphragmatic hernia is often diagnosed in utero before 25 weeks of gestation.

Congenital diaphragmatic hernia is typically detected in the antenatal period in 46-97% of cases, depending on the use of ultrasound techniques. It shows polyhydramnios, intra-abdominal absence of a stomach, an air bladder in the mediastinum, and fetal dropsy. The dynamic nature of visceral hernia is observed in a fetus with congenital diaphragmatic hernia.

The differential diagnosis of diaphragmatic hernia on prenatal ultrasound is made in case of difference from certain diseases.

Congenital malformation - cystic adenomatoid.
Pulmonary sequestration.
Cystic processes in the mediastinum, for example, cystic teratoma, thymus cyst, non-glandular duplication of the cyst.
neurogenic tumors.

AT postpartum period history and clinical findings vary with the presence of concomitant anomalies, degree of pulmonary hypoplasia, and diaphragmatic hernia. A number of symptoms are observed during the infantile neonatal period.

Variable respiratory distress.
Cyanosis.
Food intolerance.
Tachycardia.

At objective research the abdomen is scaphoid if there is a significant diaphragmatic hernia.

On auscultation, breath sounds are reduced, bowel sounds can be heard in the chest, heart sounds are distant or displaced. Patients may have symptoms of respiratory failure, intestinal obstruction, intestinal ischemia.

In addition, some symptoms are observed in young patients, regardless of the date of birth.

Labored breathing.
Blue discoloration of the skin.
Tachypnea (rapid breathing).
Tachycardia (rapid heart rate).
Decrease or absence of breathing.
Feeling of an empty abdomen.

Diagnosis of diaphragmatic hernia

As already noted, congenital diaphragmatic hernia is usually diagnosed before the birth of a child. Ultrasound can reveal an abnormal position of the abdominal organs in the fetus. A pregnant woman may also have increased amount amniotic fluid.

After birth, some abnormalities may appear during the physical examination.

Abnormal movements of the chest.
Labored breathing.
The breath is fixed on one side of the chest.
Bowel sounds in chest.

What tests typically help clarify any type of diaphragmatic hernia?

X-ray study.
Ultrasound to obtain images of the chest and abdominal cavities, as well as their contents.
Computed tomography allows direct viewing of the abdominal organs.
The nature and amount of gases in the arterial. With a hernia, oxygen levels often change, carbon dioxide and acidity (pH).

Diaphragmatic hernia treatment, prognosis and prevention

Congenital and acquired diaphragmatic hernias are surgically emergencies. Surgery must be performed to remove the abdominal organs from the chest and place them in their physiological location. The hernia in the diaphragm must be completely closed.

The operation is ideally performed 24 to 48 hours after the birth of the baby in case of congenital hernia. The first step is to stabilize the baby and increase the level of oxygen saturation in the blood. This can be achieved by tracheal intubation - a tube is placed in the mouth and passed down into the child's trachea. On the other side, the tube is connected to a mechanical ventilator. After the baby is stabilized, the operation can be performed.

In the case of an acquired hernia, the patient must also be stabilized prior to surgery, since in most cases of injury there may be other complications, such as internal bleeding. That is, the operation is usually performed as quickly as possible.

The prognosis for a diaphragmatic hernia depends on how damaged the patient's lungs are. The survival rate for congenital hernia is over 80 percent. A similar indicator for acquired hernias directly depends on the type of injury and its severity.

Congenital diaphragmatic hernia in children is a rare anomaly prenatal development fetus, which is characterized by the movement of the abdominal organs into the chest through the esophageal opening in the diaphragm. Such a pathology in adults is not considered dangerous, but for children this defect can cost their lives. For the first time, a diaphragmatic hernia in a fetus can be detected even during prenatal diagnosis, but washed out signs will not allow an accurate diagnosis.

Already after birth, the baby can observe specific manifestations of pathology in the form of cyanosis, foamy discharge from the mouth, weak crying and heavy breathing.

Congenital diaphragmatic hernia begins its formation from the 4th week of pregnancy, when the wall is laid between the peritoneal and pericardial cavities. At this time by various reasons the development of individual muscle structures is disrupted, defects appear on the diaphragm, which become a factor in the appearance of a hernial sac with contents in the form of the stomach and part of the intestine.

Causes of congenital diaphragmatic hernia

Exactly established cause there is no congenital HH, but many risk factors are known that directly or indirectly affect the development of this pathology. A child can be diagnosed with a true and false hernia. In the first case, the hernial sac is formed by the pleural and abdominal leaf. False anomalies are manifested by the exit of organs that are not covered with a bag into the chest cavity, which provokes intrathoracic tension syndrome.

A frequent form of pathology in a child is Bogdalek's congenital diaphragmatic hernia, when the organs move through the posterior parietal defect of the diaphragm.

In addition, a diaphragmatic hernia can occur in a child after birth, then the treatment approach will be different, and the acquired form of the pathology has a favorable prognosis.

TWhy does congenital diaphragmatic(UNDER)herniain a newborn:

severe pregnancy with toxicosis;
exacerbation of systemic pathologies in a pregnant woman;
frequent constipation, bloating and other disorders of the digestive tract;
respiratory diseases;
reception medicines and narcotic drugs;
drinking alcohol, smoking;
severe stress, constant experiences of a pregnant woman.

Acquired diaphragmatic hernia in newborns occurs after birth in the first few months of life.

The reasons are frequent constipation, hysterical crying and a strong cry. Such a disease is associated with anomalies of intrauterine development, mainly with weakness of the thoracic diaphragm, but only this factor will not be able to start the pathological process. For the appearance of the disease, other conditions are also needed that provoke an increase in intra-abdominal pressure.

How the disease manifests itself

The abdominal organs that have penetrated through the diaphragm begin to put pressure on the lungs and heart of the baby, and therefore their formation is also disturbed. Congenital HH is often combined with other anomalies of intrauterine development, and this further exacerbates serious condition newborn. More often, a left-sided hernia is diagnosed in a child, but the defect can appear anywhere.

The symptoms of the pathology will not depend on the location of the hernial orifice, but their severity is affected by the contents of the sac, its size and associated disorders. A herniated diaphragm will have severe consequences for the baby, regardless of the clinic, and an asymptomatic course will only aggravate the condition.

The child immediately after birth may appear completely healthy on the outside.

Indirect sign pathology in this case there will be a weak cry, because the lungs do not fully open. However, it may be difficult for the baby to breathe, and then cyanosis can already be observed. Cyanosis of the skin appears already on the first day, and the sooner this happens, the less likely it is to provide adequate assistance to the child, saving his life.

Cyanosis often occurs after several bouts of asphyxia during feeding. The child begins to choke, the skin turns blue, the muscles are tense. These manifestations subside when the baby is placed on its side from the side of the hernia. With the first attack of asphyxia, the child is x-ray examination to confirm the disease.

Toopensymptomsdiaphragmatic herniaThe child has:

vomit - does not always appear, is not a specific manifestation;
cough - rarely occurs due to food particles getting stuck in the esophagus;
asymmetry of the chest- this speaks of dextrocardia, the movement of the heart;
superficial rapid breathing - tachypnea is accompanied by tachycardia, cyanosis, bloating, violation of important reflexes.

OGeneral symptoms of HH since birth:

light weight and slow set;
lack of appetite;
pallor or blueness of the skin;
pneumonia;
blood in feces and vomit;
heart disease and respiratory system.

Types of HH in newborns

Congenital diaphragmatic hernia can be true and false. True, in turn, is parasternal, frenopericardial and esophageal openings. False can be traumatic, diaphragmatic-pleural. AT rare cases several forms of pathology are combined, and most often, hernias of the POD and diaphragmatic-pleural are diagnosed in babies.

To confirm the form of the disease, the child undergoes an ultrasound scan, a blood test is taken, CT scans are additionally prescribed, endoscopy, esophagogastroscopy.

Diagnosis before and after birth

Prenatal diagnosis is possible by ultrasound and magnetic resonance imaging. Both methods are safe during pregnancy and can be used repeatedly. An indirect sign of pathology is polyhydramnios due to a violation of the ingestion of amniotic fluid by the fetus.

It is rare to see a fluid-filled bowel in the chest, but the diagnosis is made when any abdominal organ is found above the diaphragm. A specific sign of the disease will be a violation of the position of the heart, which is shifted to the side. The fetus may also show dropsy due to a violation venous outflow. Differential prenatal diagnosis is carried out with such pathologies as a benign neoplasm, cyst and adenomatous transformation of the lungs.

After birth, the child is assigned x-rays. In the picture, the doctor sees areas of enlightenment in the form of honeycombs, which are located on the side of the defect. The heart is slightly displaced to the right, the dome of the diaphragm is practically not defined.

Differential diagnosis after the birth of a baby is carried out with atresia and stenosis of the esophagus, hemorrhage in the brain, neoplasms of the liver and impaired ventilation of the alveoli.

Treatment Methods

If a severe form of pathology is detected during pregnancy, treatment begins immediately. The main method of prenatal therapy is the correction of tracheal occlusion. The operation is scheduled between 26 and 28 weeks. The essence of the procedure will be the introduction of a balloon into the trachea of the fetus, which stimulates the development of the lungs. It is removed during childbirth or after the birth of the baby.

This operation is carried out with severe course pathology and only in specialized centers. The prognosis of the disease depends on many factors, and the probability of cure is 50%.

After birth, therapy begins with ventilation of the baby's lungs. the only effective method getting rid of a hernia will be an operation. Emergency intervention is carried out in case of infringement and internal bleeding. Planned operation performed in 2 stages. On the first one, an artificial ventral hernia is created to move the organs, and on the second one, it is removed with drainage of the pleural cavity.

PAfter the operation, the likelihood of complications is high:

General- fever, difficulty breathing, dehydration and swelling.
FROMon the sidegastrointestinal tract- intestinal obstruction.
FROMon the side of the respiratory system- pleurisy, swelling and inflammation.

Relapse of the disease after surgical removal often occurs after removal of paraesophageal hernias. To warn re-development pathology the child needs to provide proper nutrition, the feeding regimen is prescribed by the doctor. AT early period rehabilitation the child is constantly under artificial ventilation lungs.

Undesirable consequences of the operation occur in 15-25% of cases.

Prevention

Planning pregnancy and following certain rules during gestation is the main prevention congenital pathologies. Before conception, it is important for a woman to rehabilitate systemic pathologies, to refuse bad habits and take a course of vitamin therapy.

ATperiod of planning and gestationrecommended:

minimizationstressfulsituations, and yoga classes, meditation, breathing exercises, a visit to a psychologist contribute to this;
balanced and good nutrition , and the best option there will be a diet according to a specially created program, depending on the individual needs of the body;
moderate physical activity , regular hiking, healthy night sleep;
complete rejection of bad habits, namely drugs, tobacco, alcoholic and energy drinks.

An important prerequisite for prevention congenital anomalies there will be regular visits to the gynecologist and other doctors when the state of health changes for the timely detection of any deviations.