Volume 53, Issue 9

Introduction Recent advancements in four-dimensional (4D) ultrasonography have enabled detailed observation of fetal behavior in utero , including facial movements, limb gestures, and stimulus responses. These developments have prompted renewed inquiry into whether such behaviors are merely reflexive or represent early signs of integrated neural function. However, the relationship between fetal movement patterns and conscious awareness remains scientifically uncertain and ethically contested. Content A systematic review was conducted in accordance with PRISMA 2020 guidelines. Four databases (PubMed, Scopus, Embase, Web of Science) were searched for English-language articles published from 2000 to 2025, using keywords including “fetal behavior,” “4D ultrasound,” “neurodevelopment,” and “consciousness.” Studies were included if they involved human fetuses, used 4D ultrasound or functional imaging modalities, and offered interpretation relevant to neurobehavioral or ethical analysis. A structured appraisal using AMSTAR-2 was applied to assess study quality. Data were synthesized narratively to map fetal behaviors onto developmental milestones and evaluate their interpretive limits. Summary Seventy-four studies met inclusion criteria, with 23 rated as high-quality. Fetal behaviors such as yawning, hand-to-face movement, and startle responses increased in complexity between 24–34 weeks gestation. These patterns aligned with known neurodevelopmental events, including thalamocortical connectivity and cortical folding. However, no study provided definitive evidence linking observed behaviors to conscious experience. Emerging applications of artificial intelligence in ultrasound analysis were found to enhance pattern recognition but lack external validation. Outlook Fetal behavior observed via 4D ultrasound may reflect increasing neural integration but should not be equated with awareness. Interpretations must remain cautious, avoiding anthropomorphic assumptions. Ethical engagement requires attention to scientific limits, sociocultural diversity, and respect for maternal autonomy as imaging technologies continue to evolve.

Introduction Maternal stress during pregnancy has been increasingly recognized as a significant factor influencing fetal development, with potential long-term effects on neurodevelopmental outcomes in offspring. Understanding the mechanisms and implications of prenatal stress exposure is crucial for informing preventative and interventional strategies in perinatal care. Content This narrative review synthesizes findings from epidemiological, neurobiological, and clinical research on the long-term consequences of prenatal maternal stress. It explores a broad spectrum of stressors – including psychological distress, depression, anxiety, and acute traumatic events such as natural disasters – and their associations with cognitive, behavioral, and emotional outcomes in offspring from infancy through adolescence. Key biological mechanisms are discussed, including alterations in the maternal-placental-fetal axis, HPA axis dysregulation, placental gene expression changes, epigenetic modifications, and neuroinflammatory responses. Neuroimaging and biomarker studies are highlighted to provide evidence for stress-related changes in brain structure and function. Summary Current literature supports a robust association between maternal stress during pregnancy and a heightened risk of neurodevelopmental challenges in children. These include deficits in executive function, increased anxiety and depressive symptoms, emotional dysregulation, and susceptibility to psychiatric disorders. The effects appear to be moderated by timing of exposure, genetic predispositions, and the postnatal environment. Outlook While the evidence base is growing, methodological limitations such as variability in stress assessment and inconsistent follow-up durations persist. Future research should emphasize longitudinal, biomarker-informed designs and evaluate interventions aimed at reducing prenatal stress. Integrating maternal mental health support into routine prenatal care may offer a promising pathway to improving both maternal and child outcomes.

Introduction Neural tube defects (NTDs) are severe congenital anomalies arising from incomplete closure of the neural tube during early embryogenesis. Among cranial NTDs, exencephaly, acrania, and anencephaly represent a progressive developmental continuum, leading to major cerebral destruction and absence of cranial structures. Content This narrative integrative review synthesizes embryological mechanisms, historical documentation, epidemiology, genetic and environmental risk factors, and advances in prenatal imaging for acrania, exencephaly, and anencephaly. Special focus is placed on the sequential ultrasonographic findings from the first to third trimester, highlighting the transformation across this continuum. Future research possibilities, including predictive artificial intelligence models, noninvasive genetic risk profiling, and experimental in utero therapies, are also discussed. Summary Drawing on data from over 50 peer-reviewed studies, this review integrates knowledge across embryology, teratology, maternal-fetal medicine, genetics, imaging, and bioethics. It aims to guide fetal medicine specialists, radiologists, genetic counsellors, and researchers in understanding, diagnosing, and counselling for these cranial neural tube defects. Outlook Future directions emphasize precision prevention strategies, including optimized maternal folate supplementation, enhanced prenatal screening, and potential genomic therapies for high-risk pregnancies.

Fetoception refers to the maternal detection and integration of signals originating from the fetus, particularly the perception of fetal movements. This process reflects a specific form of maternal interoception, the central nervous system’s capacity to process internal bodily signals. As such, fetoception offers a unique window into maternal interoceptive processing during pregnancy, a period marked by profound physiological and sensory changes. Exploring the mechanisms underlying fetoception may provide novel insights into the dynamic interactions between interoceptive systems and the maternal adaptation to pregnancy. Furthermore, potential links between fetoception, interoception, and perinatal mental health remain largely unexplored and warrant further investigation.

Fetal hydrocephalus causes irreversible neural injury in utero , yet no prenatal therapy currently exists. Postnatal treatments such as ventriculoperitoneal shunts and endoscopic third ventriculostomy with choroid plexus cauterization cannot reverse pre-existing brain injury. We propose that the ventriculosubgaleal shunt (VSGS), widely used as a temporizing measure in severely premature neonates, may offer a feasible and ethically justifiable approach for in utero treatment. VSGS placement avoids the complications of ventriculoamniotic shunts and leverages a closed system that can relieve intracranial pressure and potentially preserve brain tissue integrity. Given its technical simplicity, established safety profile, and alignment with core ethical principles – including maternal autonomy and proportional risk-benefit, we argue for consideration of VSGS as an investigational fetal therapy in selected cases of progressive hydrocephalus. Given its investigational status, implementation should be limited to clinical trials with stringent IRB supervision and ethical safeguards.

Objectives To evaluate the diagnostic utility of the fetal occiput-spine angle (OSA) measured by transabdominal ultrasonography in predicting successful vaginal delivery (VD) during the first stage of labor. Methods A systematic search of MEDLINE, Scopus, EMBASE databases, and Google Scholar was conducted from January 15, 2025, to February 1, 2025, following the Preferred Reporting Items for Systematic Reviews and Meta-analyses for diagnostic test accuracy guidelines. Two independent reviewers selected studies according to inclusion criteria, extracted data, and assessed risk of bias assessed by the Quality Assessment of Diagnostic Accuracy Studies-2. Results Six studies with 1,129 participants were included. The pooled sensitivity and specificity of OSA for predicting VD were 86 % (95 % confidence interval (CI): 73–93 %) and 80 % (95 % CI: 37–97 %), respectively. The DOR was 23.71 (95 % CI: 2.5–223.36 %). The mean OSA of women with successful VD was 10.44° wider than that of women who underwent cesarean delivery, although not significant (p=0.16). High heterogeneity (I 2 >88.2 %) was observed. The risk of bias was low across most domains. Conclusions The fetal OSA demonstrated moderate diagnostic value in predicting successful VD. Furthermore, additional high-quality, large-scale studies with standardized cut-offs are necessary to verify its clinical utility.

Objectives To compare a composite hemorrhage-related maternal morbidity in individuals with secondary to primary postpartum hemorrhage and treatment interventions utilized. Methods A retrospective case-control study of deliveries complicated by secondary postpartum hemorrhage was performed at a tertiary care center. To estimate a clinically relevant increase of 50 % in the composite maternal hemorrhage-related maternal morbidity (35–53 % absolute increase) in individuals with secondary postpartum hemorrhage, a correlation coefficient of 0.2, at an 80 % power with a p < 0.05 with a two-sided test would require 95 individuals with secondary postpartum hemorrhage be matched to 95 individuals with a primary postpartum hemorrhage. Logistic regression analysis was used to evaluate the outcome of the composite of hemorrhage-related maternal morbidity. Results From January 2018 through December 2022, 33,026 deliveries occurred, and 94 individuals were identified that were admitted with secondary postpartum hemorrhage, 0.28 % of deliveries, 95 % confidence interval (CI) 0.21–0.35 %. The composite hemorrhage-related maternal morbidity was increased in individuals with secondary compared to primary postpartum hemorrhage, adjusted odds ratio (OR) 14.0, 95 % CI 4.6 to 42.2. Most individuals with secondary postpartum hemorrhage had a dilation and curettage 91.5 % (86/94). In individuals with secondary postpartum hemorrhage that underwent uterine evacuation, histology revealed 45.2 % (38/84) had retained placenta, and 20.2 % (17/84) subinvolution. Conclusions A composite maternal hemorrhage-related outcome is associated more often with secondary compared to primary postpartum hemorrhage and nearly all individuals with secondary postpartum hemorrhage undergo a dilation and curettage.

Objectives Hyperemesis gravidarum is a severe form of nausea and vomiting that affects approximately 0.3–2 % of pregnancies, leading to significant perinatal complications. This systematic review and meta-analysis aims to investigate the potential link between hyperemesis gravidarum and maternal serum pregnancy-associated plasma protein-A (PAPP-A) levels in the first trimester. Methods A thorough literature search of PubMed/MEDLINE, ScienceDirect, the Cochrane Library, and Google Scholar was conducted to identify relevant studies comparing PAPP-A levels in pregnant women diagnosed with hyperemesis gravidarum compared to healthy controls. Six studies met the inclusion criteria, with a total of 1,049 participants. Meta-analysis was performed to estimate the pooled mean difference in PAPP-A levels between hyperemesis gravidarum and control groups. A p-curve analysis and funnel plot assessment were conducted to evaluate publication bias and statistical power. Results The meta-analysis demonstrated a pooled mean difference of 0.16 (95 % CI: 0.07–0.25), indicating that PAPP-A levels were significantly higher in pregnancies affected by HG. The heterogeneity statistic (I 2 =46 %) suggested moderate variability among studies. P-curve analysis showed a right-skewed distribution of significant p-values (p=0.033), suggesting evidential value and ruling out selective reporting bias. However, the prediction interval (−0.08–0.4) indicated that some future studies might yield non-significant or even negative findings. Funnel plot analysis revealed minimal publication bias, though a slight asymmetry suggested potential underrepresentation of small, non-significant studies. Conclusions This study provides evidence that PAPP-A levels are elevated in pregnancies complicated by hyperemesis gravidarum, implicating potential placental dysfunction and hormonal influences in its pathogenesis. While the findings are statistically significant and robust against publication bias, moderate heterogeneity highlights the need for larger prospective studies with standardized methodologies to confirm this association and explore possible underlying mechanisms. Understanding the role of PAPP-A in hyperemesis gravidarum may contribute to improved screening and management strategies for affected pregnancies and as a result, improved perinatal care.

Objectives To assess the relationship of cerebroplacental ratio (CPR) with non-reassuring/abnormal cardiotocography (CTG) tracing and perinatal outcomes like operative delivery, birth weight, NICU admission, meconium-stained liquor, and APGAR score in low-risk pregnancy. Methods This was a prospective cohort study at tertiary center in western India which included low risk singleton pregnancies between 35 and 37+6 weeks with cephalic presentation. Ultrasound was done between 35 and 37+6 weeks gestation including fetal biometry and Doppler for CPR calculation. Patients were divided into two groups, with normal CPR (>10th centile) and abnormal CPR (≤10th centile), and maternal and neonatal outcomes were compared. Results Out of 172 cases enrolled, CPR was abnormal in 55 (31.97 %) patients and normal in 117 (68.02 %) patients. In abnormal CPR group, CTG tracing was reassuring in 61.81 %, non-reassuring in 18.18 %, and abnormal in 20 %. While in normal CPR group, CTG tracing was reassuring in 81.19 %, non-reassuring in 11.11 %, and abnormal in 7.69 %. This was significant difference between the two groups (p=0.027). Cesarean and operative vaginal delivery rates were comparable in both groups, (p value=0.63, 0.33). Lower birth weight was observed in 45.45 % of women in the abnormal CPR group, while 21.36 % of women had low birth weight in the normal CPR group (p-value=0.006). No significant difference was found in APGAR score and NICU admissions between the two groups (p-value-0.94, 0.87). Conclusions We conclude that CPR measurement has good negative predictive value for fetal outcome in low risk pregnancy.

Objectives This study aimed to compare noninvasive liver fibrosis markers, including the Aspartate Aminotransferase Platelet Ratio Index (APRI) and FIB-4, between patients with hypertensive disorders of pregnancy (HDP) and healthy controls and to investigate the association between these markers and adverse maternal and perinatal outcomes. Methods In this retrospective case-control study, 205 patients with HDP and 192 normotensive controls were included for evaluation. Demographic data, laboratory findings, and maternal and perinatal outcomes were compared. FIB-4 and APRI scores were calculated using second-trimester AST, ALT, and platelet levels. ROC curve analysis was used to assess the predictive accuracy of these indices for HELLP syndrome and other complications. Linear regression analysis was applied to evaluate the parameters associated with the FIB-4 score. Results FIB-4 and APRI scores were significantly higher in patients with HDP compared to controls (p<0.05). Among patients with severe preeclampsia and HELLP syndrome, fibrosis scores were markedly elevated. FIB-4 and APRI showed excellent diagnostic performance for HELLP syndrome (AUC: 0.976 and 0.992, respectively), with optimal cutoffs of 1.52 and 0.7. However, their predictive role for general adverse maternal and perinatal outcomes was limited. In multivariate regression, systolic blood pressure, maternal age, and adverse maternal outcomes were independent predictors of increased FIB-4 scores (p<0.05). Conclusions FIB-4 and APRI may be considered simple, noninvasive indices that could contribute to early risk stratification for HELLP syndrome among patients with HDP. Although their predictive capacity remains to be validated in larger prospective studies, they may offer preliminary insights into hepatic dysfunction during pregnancy.

Objectives To evaluate the evidence linking prenatal exposure to environmental endocrine-disrupting chemicals (EDCs) – including bisphenol A (BPA), phthalates, and per- and polyfluoroalkyl substances (PFAS) – with adverse pregnancy and fetal developmental outcomes, and to assess the potential translation of this evidence into clinical perinatal risk assessment. Methods A systematic literature search was conducted in PubMed, Scopus, and Web of Science for studies published between January 2000 and May 2025. Eligible studies included epidemiological and experimental research addressing prenatal EDC exposure and fetal-placental outcomes. After duplicate removal and screening, 52 studies met inclusion criteria and were categorized by study type (epidemiological, mechanistic, translational). Data extraction included exposure metrics, critical developmental windows, and reported effect sizes (odds ratios, risk ratios, hazard ratios). Results Evidence suggests that EDC exposure during early pregnancy is associated with placental dysfunction, altered fetal growth trajectories, endocrine and epigenetic modifications, and increased risk of selected neonatal outcomes. Effect sizes were variable, often modest (many<2.0), but consistently indicated biological plausibility supported by mechanistic data. Biomonitoring studies demonstrate widespread EDC exposure across populations, including higher body burdens in lower-income and racially diverse groups. Despite robust basic science evidence, clinical screening for EDC exposure remains limited, and routine risk assessment frameworks rarely incorporate environmental chemical exposures. Conclusions Prenatal EDC exposure is biologically linked to disrupted fetal-placental development, yet translation into clinical practice remains incomplete. Integrating environmental exposure assessment and preventive counseling into perinatal care may improve maternal-fetal health and reduce disparities.

Objectives The aim of our study was to examine the relationship between lower uterine segment (LUS) thickness and cesarean delivery (CD) and compare the capacity two measurement methods of LUS thickness in the prediction of successful induction of labor (IOL). Methods This was a prospective cross-sectional study of consecutive pregnancies undergoing IOL between 2022 and 2023. The inclusion criteria were women with singleton pregnancies with cephalic presentation whose Bishop scores were below six undergoing IOL after 37 weeks of gestation. Patients with a history of CD, fetal anomalies, multiple gestations, and any contraindication to vaginal delivery were excluded from the study group. Results A total of 124 pregnant women were included in the study. LUS (10.13 ± 1.98 mm vs. 7.07 ± 1.66 mm, p<0.001) and myometrial LUS (MLUS) (5.63 ± 1.48 mm vs. 4.10 ± 1.22 mm, p<0.001) in the CD group were significantly higher than in the non-CD group. In the logistic regression analyses, significant independent effects of height (OR:0.88, 95 % CI: 0.79–0.98) and LUS (OR:2.71, 95 % CI: 1.66–4.43) values were observed in the prediction of CD. In the ROC analysis, both LUS (AUC 0.882, p<0.001) and MLUS (AUC 0.756, p<0.001) significantly predicted CD with an optimal cut-off value of 9.8 mm (75.0 % sensitivity, 92.6 % specificity) for LUS, and 5.1 mm (68.8 % sensitivity, 82.4 % specificity) for MLUS. Conclusions Ultrasonographic evaluation of LUS before IOL is a promising ultrasound parameter to predict CD. Although LUS and MLUS thickness measurements can be used to predict CD, LUS thickness has better sensitivity and specificity compared to MLUS thickness.

Objectives To evaluate ultrasonographic measurements of the fetal adrenal gland in pregnancies complicated by preeclampsia (PE), with and without fetal growth restriction (FGR), and to assess the utility of adrenal gland dimensions and ratios as potential diagnostic radiologic markers for PE. Methods This prospective study included pregnant women between 20 and 41 weeks of gestation followed at the Obstetrics and Gynecology Department of Başakşehir Çam and Sakura City Hospital. Participants were divided into three groups: PE (n=63), PE+FGR (n=63), and healthy controls (n=65). Fetal adrenal gland total width and medulla width were measured via ultrasonography. The cortex width = (total width-medulla width) / 2 and the adrenal gland ratio (cortex width/medulla width) were calculated. Statistical analyses were conducted to evaluate differences between groups and to determine the predictive value of the adrenal gland ratio. Results Fetal adrenal gland total width (adrenal width), cortex width, and adrenal gland ratio were significantly increased in both the PE and PE+FGR groups compared to healthy controls (p<0.001). An adrenal gland ratio ≥2.8 was significantly associated with PE and PE+FGR (p<0.001), showing high diagnostic accuracy. The adrenal gland ratio was not correlated with gestational age. Conclusions Fetal adrenal gland enlargement, particularly increased cortex width, is associated with preeclampsia and may serve as a noninvasive ultrasonographic biomarker. An adrenal glandthe ratio≥2.8 demonstrates strong diagnostic potential for identifying PE and PE+FGR, offering a valuable tool for early diagnosis and management.

Objectives The aim was to evaluate the sensitivity and specificity of CentaFlow (CF) in a prospective multicenter study, and secondary to evaluate the safety of the CF device in a randomized multicenter study. Methods A sponsor-initiated multicenter randomized controlled clinical trial with termination of the randomization after enough women had been included to evaluate safety. The study proceeded as a prospective multicenter study including high-risk women (estimated fetal weight <−15 %, FGR). The first part randomized women to either standard care (SC) or SC+CF. Participants underwent CF evaluation with subsequent analysis for sensitivity and specificity for FGR at birth. Secondarily, adverse events were evaluated. Clinical assessments of fetal size conducted by midwives served as a reference. The performance of CF and SC was compared by McNemar’s Test. The performance analysis of CF was done per-protocol sample. Results A total of 1,601 pregnant women were enrolled, with 886 undergoing CF evaluation. A total of 123 were FGR (<3rd percentile) at birth, of which 88 were evaluated by CF, and 117 had a clinical assessment of the estimated fetal weight. CF demonstrated no evidence of benefit for detecting FGR with a sensitivity of 50 % and specificity of 43 %. Adverse events associated with CF use were limited to minor skin irritation. McNemar’s test showed SC was superior to CF regarding specificity as a screening tool (p=0.014). Conclusions While CF was safe to use, we found no evidence that CF can be used as a predictor of FGR. Further refinement of signal analysis is necessary to enhance CFs diagnostic utility.

Objectives The objective was to demonstrate superiority of a fully vs. semi-automated approach (5D CNS+™) and to verify operators could handle and benefit from a fully automated rendering volumetric datasets to generate a complete fetal neurosonogram. Methods A total of 136 stored three-dimensional (3D) volumes of the brain of unselected, structurally normal fetuses were examined. Two operators applied both software versions for detailed assessment of the fetal central nervous system (CNS). The procession time was measured for each operator and for both program versions. The number of correctly calibrated planes were evaluated and necessity for manual adjustment of the planes was registered. Results The intraclass correlation coefficient was 0.507 (0.307–0.648) for semi-automated and 0.782 (0.693–0.846) for fully automated 5D CNS+™. The acquisition time of application for semi-automated 5D CNS+™ was 27.70 s ± 6.28 s for operator 1 and 33.20 s ± 9.67 s for operator 2, for fully automated 5D CNS+™ 10.89 s ± 0.85 s for operator 1 and 10.79 s ± 0.60 s for operator 2 (p<0.0001). The statistical analysis for manually corrected planes by both operators between both software algorithms showed a Bland-Altman-Bias of 1.44/9 planes for operator 1 and 1.45/9 planes for operator 2. Conclusions The fully automated 5D CNS+™ algorithm applied on 3D volume datasets provides examiners regardless their expertise not only enormous time efficiency, but also diagnostic confidence in evaluating details of the fetal CNS. This tremendously simplifies application in clinical routine.

Objectives Echocardiography is the standard tool for assessing fetal cardiac function. Tricuspid annular plane systolic excursion (TAPSE) and mitral annular plane systolic excursion (MAPSE) are simple, reliable indicators of systolic function. Many studies have established reference ranges in adult and pediatric populations; however, data remain limited in fetuses, especially in Southeast Asia. The aim of the study was to establish normal reference ranges for TAPSE and MAPSE in fetuses born between 18 + 0 and 37 + 6 weeks’ gestation in a Southeast Asian population. Methods This prospective, cross-sectional study was conducted between January 2024 and February 2025. Data from 280 singleton pregnancies with normal fetal growth and no maternal comorbidities were included in the study. TAPSE and MAPSE were measured using M-mode imaging in a four-chamber view. Percentile reference values were determined using quantile regression models, with gestational age (GA) and estimated fetal weight (EFW) as predictors. The intraclass correlation coefficient (ICC) was used to assess intra- and interobserver reliability. Results TAPSE and MAPSE were significantly and positively correlated with GA and EFW. Mean TAPSE ranged from 3.76 to 9.08 mm (GA) and 3.42 to 9.30 mm (EFW), while MAPSE ranged from 3.10 to 6.34 mm (GA) and 2.71 to 6.60 mm (EFW). The TAPSE values consistently exceeded the MAPSE values across all GAs. The inter- and intra-observer ICCs were high (TAPSE, 0.94/0.91; MAPSE, 0.91/0.88). Conclusions This study established the first normal TAPSE and MAPSE reference ranges for a Southeast Asian population and provided reliable tools for fetal cardiac assessment.

Objectives The study aims to improve the classification of fetal anatomical planes using Deep Learning (DL) methods to enhance the accuracy of fetal ultrasound interpretation. Methods Five Convolutional Neural Network (CNN) architectures, such as VGG16, ResNet50, InceptionV3, DenseNet169, and MobileNetV2, are evaluated on a large-scale, clinically validated dataset of 12,400 ultrasound images from 1,792 patients. Preprocessing methods, including scaling, normalization, label encoding, and augmentation, are applied to the dataset, and the dataset is split into 80 % for training and 20 % for testing. Each model was fine-tuned and evaluated based on its classification accuracy for comparison. Results DenseNet169 achieved the highest classification accuracy of 92 % among all the tested models. Conclusions The study shows that CNN-based models, particularly DenseNet169, significantly improve diagnostic accuracy in fetal ultrasound interpretation. This advancement reduces error rates and provides support for clinical decision-making in prenatal care.

Objectives The average incidence of congenital diaphragmatic hernia (CDH) in the United States (US) is 2.6 per 10,000 live births but it varies based on the population studied, the database used, and the study period. Further, previous studies suggest that pre-discharge mortality in CDH is declining but this may not capture the ‘hidden mortality’ and post-discharge mortality. We examined a population-based database to evaluate the trends in the incidence (2016–2023) and CDH-related infant mortality rate (CDH-IMR) [2007–2022] in the US. Methods We conducted a retrospective cross-sectional analysis of the CDC WONDER database. First, we queried the 2016–2023 natality dataset derived from birth certificates for live births with CDH (ICD-10 code Q79.0). We expressed CDH incidence as per 10,000 live births. Next, we queried the linked birth/infant death dataset from 2007 to 2022 for CDH-IMR through 1 year of age. CDH-IMR was expressed per 100,000 live births. Trends were evaluated with Joinpoint regression and reported using average annual percentage change (AAPC) with 95 % confidence intervals (CI). Results Among 29, 880, 509 live births between 2016 and 2023, 3,797 had CDH (1.3 per 10,000). Of these, 33.4 % were transferred within 24 h after birth. There was no significant change in the CDH incidence during the study period (AAPC 0.93 %; CI: −0.1, 2.0). The overall CDH-IMR (per 100,000) was 5.7, and it declined significantly from 6.3 in 2007 to 4.7 in 2022 (AAPC: −1.5 %; CI: −2.2, −0.8). Conclusions The CDH incidence, which was lower than previously reported and did not change from 2016 to 2023, requires validation. The downward trend in mortality needs ongoing surveillance to monitor the impact of new management strategies on mortality rates.