Congenital diaphragmatic hernia (CDH) is a rare anatomical malformation characterized by failure of the diaphragm to close during embryogenesis, allowing abdominal viscera to migrate into the thoracic cavity and impairing fetal lung development. The left-sided (Bochdalek) form is by far the most common, while the right-sided form remains rare, accounting for only 10% to 15% of cases [1,2].

From a pathophysiological standpoint, right-sided CDH is characterized by frequent ascension of the liver into the thoracic cavity, which increases the risk of bilateral pulmonary hypoplasia and persistent pulmonary hypertension of the newborn (PPHN)[1,2]. Although prenatal diagnosis using ultrasound and fetal MRI has improved considerably, the right-sided form still poses significant diagnostic challenges in the delivery room, as the herniated liver can obscure the diaphragmatic defect on standard radiographs and mimic a common thoracic opacity, sometimes delaying critical management [3].

prognosis of these newborns now depends on a standardized treatment strategy in the neonatal intensive care unit that prioritizes rigorous cardiorespiratory stabilization before surgical treatment is considered[4].

We report the case of a newborn with right-sided congenital diaphragmatic hernia complicated by severe intrauterine growth restriction. The objective of this report is to illustrate the diagnostic and therapeutic challenges of this rare condition, to analyze its multidisciplinary management during the neonatal period, and to compare our experience with recent data from the literature.

Case Report

We report the case of a male newborn, the product of a well-monitored, singleton first pregnancy, delivered at an estimated gestational age of 37 weeks and 5 days based on an early first-trimester ultrasound. The mother, aged 24 years, had no history of diabetes or parental consanguinity; she had iron-deficiency anemia and was receiving iron supplementation. The perinatal history was notable for premature rupture of membranes (PROM) of 3 days’ duration, with associated suspicion of maternal infection.

Delivery was by cesarean section for acute fetal distress. The amniotic fluid was clear. The Apgar score was 4/10 at 1 minute and 5/10 at 5 minutes. The infant had severe intrauterine growth restriction (IUGR), with a birth weight of 1,600 g. Respiratory distress was present from birth, with nasal flaring, intercostal retractions, and moderate xiphoid retraction, corresponding to a Silverman score of 3/10. The infant was immediately transferred to the neonatal intensive care unit for further management.

On admission, the newborn was cyanotic and tachypneic, with a pulse oxygen saturation of 88%, but was hemodynamically stable. The chest appeared symmetrical, with vesicular breath sounds absent over the right hemithorax on auscultation; the abdomen was soft. Initial clinical examination found no other congenital anomalies.

Given the unilateral absence of right-sided breath sounds and the respiratory distress, an emergency frontal chest radiograph was obtained. It showed gastrointestinal opacities occupying the right hemithorax, associated with leftward mediastinal shift and ipsilateral pulmonary hypoplasia, confirming the diagnosis of right-sided congenital diaphragmatic hernia (Figure 1).

Transthoracic echocardiography performed on day 1 of life showed situs solitus, pulmonary arterial hypertension, and a right-sided liver within the thoracic cavity (Figure 2). Transfontanellar ultrasound was normal, and initial laboratory results were unremarkable.

Therapeutic management consisted of multidisciplinary medical stabilization in the neonatal intensive care unit. A double-lumen drainage tube was placed to decompress the intrathoracic digestive tract. Respiratory support was provided by noninvasive oxygen therapy, and probabilistic antibiotic therapy with a third-generation cephalosporin and intravenous gentamicin was started for suspected early-onset neonatal bacterial infection.

Despite aggressive resuscitation, optimization of protective ventilation settings, and maximal hemodynamic support, the infant’s cardiorespiratory status continued to deteriorate because of refractory hypoxemia and severe, treatment-resistant pulmonary arterial hypertension. The patient died 48 hours after birth, before the stability criteria required for surgical treatment could be met.

Figure 1: Frontal chest radiograph showing gastrointestinal opacities occupying the right hemithorax, leftward mediastinal shift, and ipsilateral pulmonary hypoplasia, consistent with right-sided congenital diaphragmatic hernia.

Figure 2: Transthoracic echocardiographic images obtained on day 1 of life, showing situs solitus with a right-sided intrathoracic liver. [Authors: please confirm/complete the specific echocardiographic views and any additional findings shown in each panel.]

Figure 3: [Legend to be provided by the authors — imaging modality, view, and relevant findings for each panel were not specified in the source material.]