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DeVore GR, Klas B, Cuneo B, Satou G, Sklansky M. Review of speckle tracking analysis to measure the size, shape, and contractility of the fetal heart in fetuses with congenital heart defects. Echocardiography 2024; 41:e15870. [PMID: 38979798 DOI: 10.1111/echo.15870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 06/05/2024] [Accepted: 06/10/2024] [Indexed: 07/10/2024] Open
Abstract
Evaluation of the fetal heart involves two approaches. The first describes a screening protocol in which the heart is imaged in transverse planes that includes the four-chamber view (4CV), left and right outflow tracts, and the 3-vessel-tracheal view. The second approach is a fetal echocardiogram that requires additional cardiac images as well as evaluating ventricular function using diagnostic tools such as M-mode and pulsed Doppler ultrasound. Speckle tracking analysis of the ventricular and atrial endocardium of the fetal heart has focused primarily on computing longitudinal global strain. However, the technology enabling this measurement to occur has recently been adapted to enable the clinician to obtain numerous additional measurements of the size, shape, and contractility of the ventricles and atrial chambers. By using the increased number of measurements derived from speckle tracking analysis, we have reported the ability to screen for tetralogy of Fallot, D-transposition of the great arteries (D-TGA), and coarctation of the aorta by only imaging the 4CV. In addition, we have found that measurements derived from speckle tracking analysis of the ventricular and atrial chambers can be used to compute the risk for emergent neonatal balloon atrial septostomy in fetuses with D-TGA. The purpose of this review is to consolidate our experience in one source to provide perspective on the benefits of speckle tracking analysis to measure the size, shape, and contractility of the ventricles and atria imaged in the 4CV in fetuses with congenital heart defects.
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Affiliation(s)
- Greggory R DeVore
- Fetal Diagnostic Centers, Pasadena, California, USA
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA
| | | | - Bettina Cuneo
- Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Gary Satou
- Division of Pediatric Cardiology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Mark Sklansky
- Division of Pediatric Cardiology, Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Gupta D, Vuong T, Wang S, Korst LM, Pruetz JD. Update on Prenatal Detection Rate of Critical Congenital Heart Disease Before and During the COVID-19 Pandemic. Pediatr Cardiol 2024; 45:1015-1022. [PMID: 38565667 PMCID: PMC11056324 DOI: 10.1007/s00246-024-03487-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/25/2024] [Indexed: 04/04/2024]
Abstract
Prenatal diagnosis of critical congenital heart disease (CCHD) has improved over time, and previous studies have identified CCHD subtype and socioeconomic status as factors influencing rates of prenatal diagnosis. Our objective of this single-center study was to compare prenatal diagnosis rates of newborns with CCHD admitted for cardiac intervention from the COVID-19 pandemic period (March 2020 to March 2021) to the pre-pandemic period and identify factors associated with the lack of CCHD prenatal diagnosis. The overall rate of CCHD and rates of the various CCHD diagnoses were calculated and compared with historical data collection periods (2009-2012 and 2013-2016). Compared with the 2009-2012 pre-pandemic period, patients had 2.17 times higher odds of having a prenatal diagnosis of CCHD during the pandemic period controlling for lesion type (aOR = 2.17, 95% CI 1.36-3.48, p = 0.001). Single ventricle lesions (aOR 6.74 [4.64-9.80], p < 0.001) and outflow tract anomalies (aOR 2.20 [1.56-3.12], p < 0.001) had the highest odds of prenatal diagnosis compared with the remaining lesions. Patients with outflow tract anomalies had higher odds for prenatal detection in the pandemic period compared with during the 2009-2012 pre-pandemic period (aOR 2.01 [1.06-3.78], p = 0.031). In conclusion, prenatal detection of CCHD among newborns presenting for cardiac intervention appeared to have improved during the pandemic period.
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Affiliation(s)
- Deepak Gupta
- Children's Hospital Los Angeles, Department of Pediatrics, Los Angeles, California, USA
| | - Tiffany Vuong
- Keck School of Medicine of USC, Los Angeles, California, USA
| | - Shuo Wang
- Children's Hospital Los Angeles, Division of Cardiology, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Lisa M Korst
- Childbirth Research Associates, LLC, North Hollywood, Los Angeles, California, USA
| | - Jay D Pruetz
- Children's Hospital Los Angeles, Division of Cardiology, Fetal Cardiology Program, Keck School of Medicine of USC, 4650 Sunset Blvd, Los Angeles, California, 90027, USA.
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Bromley B, Platt LD. First-Trimester Ultrasound Screening in Routine Obstetric Practice. Obstet Gynecol 2024; 143:730-744. [PMID: 38723258 DOI: 10.1097/aog.0000000000005594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/07/2024] [Indexed: 05/18/2024]
Abstract
Technologic advances and ultrasonographer-physician experience in fetal imaging have led to significant improvements in our ability to distinguish between normal and abnormal fetal structural development in the latter part of the first trimester. As a critical component of pregnancy care, assessment of fetal anatomy at the end of the first trimester with a standardized imaging protocol should be offered to all pregnant patients regardless of aneuploidy screening results because it has been demonstrated to identify approximately half of fetal structural malformations. Early identification of abnormalities allows focused genetic counseling, timely diagnostic testing, and subspecialist consultation. In addition, a normal ultrasound examination result offers some degree of reassurance to most patients. Use of cell-free DNA alone for aneuploidy screening while foregoing an accompanying early anatomic evaluation of the fetus will result in many anomalies that are typically detected in the first trimester not being identified until later in pregnancy, thus potentially diminishing the quality of obstetric care for pregnant individuals and possibly limiting their reproductive options, including pregnancy termination.
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Affiliation(s)
- Bryann Bromley
- Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Harvard Medical School, Boston, and Diagnostic Ultrasound Associates, Brookline, Massachusetts; and the Center for Fetal Medicine and Women's Ultrasound, Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, California
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4
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Freud LR, Simpson LL. Fetal cardiac screening: 1st trimester and beyond. Prenat Diagn 2024; 44:679-687. [PMID: 38613152 DOI: 10.1002/pd.6571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/29/2024] [Accepted: 03/30/2024] [Indexed: 04/14/2024]
Abstract
Congenital heart defects (CHD) are the most common birth defect and a leading cause of infant morbidity and mortality. CHD often occurs in low-risk pregnant patients, which underscores the importance of routine fetal cardiac screening at the time of the 2nd trimester ultrasound. Prenatal diagnosis of CHD is important for counseling and decision-making, focused diagnostic testing, and optimal perinatal and delivery management. As a result, prenatal diagnosis has led to improved neonatal and infant outcomes. Updated fetal cardiac screening guidelines, coupled with technological advancements and educational efforts, have resulted in increased prenatal detection of CHD in both low- and high-risk populations. However, room for improvement remains. In recent years, fetal cardiac screening for specific high-risk populations has started in the 1st trimester, which is a trend that is likely to expand over time. This review discusses fetal cardiac screening throughout pregnancy.
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Affiliation(s)
- Lindsay R Freud
- Paediatrics, Fetal Cardiology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Lynn L Simpson
- Hillary Rodham Clinton Professor of Women's Health, Department of Obstetrics & Gynecology, Columbia University Irving Medical Center, New York, New York, USA
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Kühle H, Cho SKS, Charest-Pekeski AJ, Chow JSM, Lee FT, Aujla T, Saini BS, Lim JM, Darby JRT, Mroczek D, Floh AA, McVey MJ, Morrison JL, Seed M, Sun L, Haller C. Echocardiographic assessment of cardiovascular physiology of preterm miniature piglets supported with a pumped artificial placenta system. Prenat Diagn 2024; 44:888-898. [PMID: 38809178 DOI: 10.1002/pd.6612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/27/2024] [Accepted: 05/12/2024] [Indexed: 05/30/2024]
Abstract
OBJECTIVES We evaluated fetal cardiovascular physiology and mode of cardiac failure in premature miniature piglets on a pumped artificial placenta (AP) circuit. METHODS Fetal pigs were cannulated via the umbilical vessels and transitioned to an AP circuit composed of a centrifugal pump and neonatal oxygenator and maintained in a fluid-filled biobag. Echocardiographic studies were conducted to measure ventricular function, umbilical blood flow, and fluid status. In utero scans were used as control data. RESULTS AP fetuses (n = 13; 102±4d gestational age [term 115d]; 616 ± 139 g [g]; survival 46.4 ± 46.8 h) were tachycardic and hypertensive with initially supraphysiologic circuit flows. Increased myocardial wall thickness was observed. Signs of fetal hydrops were present in all piglets. Global longitudinal strain (GLS) measurements increased in the left ventricle (LV) after transition to the circuit. Right ventricle (RV) and LV strain rate decreased early during AP support compared with in utero measurements but recovered toward the end of the experiment. Fetuses supported for >24 h had similar RV GLS to in utero controls and significantly higher GLS compared to piglets surviving only up to 24 h. CONCLUSIONS Fetuses on a pump-supported AP circuit experienced an increase in afterload, and redistribution of blood flow between the AP and systemic circulations, associated with elevated end-diastolic filling pressures. This resulted in heart failure and hydrops. These preterm fetuses were unable to tolerate the hemodynamic changes associated with connection to the current AP circuit. To better mimic the physiology of the native placenta and preserve normal fetal cardiovascular physiology, further optimization of the circuit will be required.
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Affiliation(s)
- Henriette Kühle
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Department of Cardiac and Thoracic Surgery, University Hospital Magdeburg, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Steven K S Cho
- Translational Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alex J Charest-Pekeski
- Translational Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jessica S M Chow
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Fu-Tsuen Lee
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tanroop Aujla
- Translational Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Brahmdeep S Saini
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jessie Mei Lim
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jack R T Darby
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Dariusz Mroczek
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Alejandro A Floh
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mark J McVey
- Department of Anesthesiology and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Department of Physics, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Janna L Morrison
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Mike Seed
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Liqun Sun
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christoph Haller
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Gao YP, Deng YB. Ultrasound evaluation of the cardiovascular system in offspring conceived through assisted reproductive technology. J Assist Reprod Genet 2024; 41:623-634. [PMID: 38244152 PMCID: PMC10957808 DOI: 10.1007/s10815-024-03029-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 01/09/2024] [Indexed: 01/22/2024] Open
Abstract
With the widespread application of assisted reproductive technology, the health issues of offspring conceived through assisted reproductive technology have also received increasing attention. Animal experiments and clinical studies have found subclinical adverse changes in the cardiovascular system of assisted reproductive offspring. Assisted reproductive technology itself may be just one of the many factors contributing to this phenomenon, with epigenetics playing an important role. Ultrasound technology can be used to assess the morphological structure and function of the cardiovascular system in assisted reproductive offspring from the fetal stage, providing the possibility to study the potential cardiovascular damage in this large population. This review aims to explore the effects and mechanisms of assisted reproductive technology on the cardiovascular system of offspring and provide a review of the research progress in ultrasound technology in this area.
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Affiliation(s)
- Yi-Peng Gao
- Department of Medical Ultrasound, Huazhong University of Science and Technology Tongji Medical College Tongji Hospital, Wuhan, 430030, China
| | - You-Bin Deng
- Department of Medical Ultrasound, Huazhong University of Science and Technology Tongji Medical College Tongji Hospital, Wuhan, 430030, China.
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Cody F, Franklin O, Mc Cay N, Molphy Z, Dicker P, Breathnach FM. Critical congenital heart disease: contemporary prenatal screening performance and outcomes in a multi-centre perinatology service. BMC Pregnancy Childbirth 2024; 24:163. [PMID: 38402176 PMCID: PMC10893667 DOI: 10.1186/s12884-024-06350-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/14/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Prenatal detection of critical congenital heart disease (CCHD) optimises perinatal decision-making and neonatal outcomes. The objective of this study was to determine the prenatal screening performance, care pathways and perinatal outcomes for prenatally and postnatally diagnosed cases of CCHD over a four-year period. STUDY DESIGN This retrospective cohort study in a tertiary centre and its two affiliated secondary sites examined all cases of CCHD, including cases of pregnancy termination and in-utero fetal death, neonatal death and liveborn babies that underwent cardiac catheterization or surgery in the first six weeks of life. Prenatal and postnatal data were ascertained from the first trimester assessment for all patients diagnosed prenatally. Cases requiring intervention that were first identified in the postnatal period were included to determine prenatal detection rates. Follow-up for all cases of CCHD continued to one year of age. RESULTS In a consecutive cohort of 49,950 pregnancies in a 4-year period 01/2019 to 12/2022, a prenatal diagnosis of CCHD was made in 96 cases, yielding a prevalence of 1.9 per 1000 births. The prenatal detection for right duct-dependant heart pathology and congenital heart block was 100%, 85% for left duct-dependant pathology and 93% for transposition of the great arteries (TGA). In the prenatally diagnosed group, 37% of cases were complicated by extracardiac structural abnormalities, a genetic diagnosis or both. All cases of prenatal detection were identified in the context of routine anatomy screening rather than specialist Fetal Cardiac screening services. Almost half of all pregnancies complicated by CCHD did not undergo neonatal cardiac intervention, by virtue of parental choice determined either prenatally or after birth. An additional eight babies were diagnosed with CCHD in the neonatal period, such that the prenatal detection rate for CCHD was 92% (96/104, 95% CI = 84%-96%). Survival at 1-year for infants deemed suitable for CCHD surgery was 85%. CONCLUSION In a large unselected population, optimal rates of prenatal detection of critical congenital heart disease can be achieved by a protocolised approach to mid-trimester fetal anatomy ultrasound, underpinned by a programme of sonographer education and training. The cardiac abnormalities most likely to evade prenatal detection are left-sided obstructive lesions.
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Affiliation(s)
- Fiona Cody
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland (RCSI, Dublin, Ireland.
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Parnell Square East, Dublin, D01P5W9, Ireland.
| | - Orla Franklin
- Department of Paediatric Cardiology, Children's Health Ireland CHI@Crumlin, Dublin, Ireland
- Department of Paediatrics, Trinity College Dublin, Dublin, Ireland
| | - Nicola Mc Cay
- Department of Paediatric Cardiology, Children's Health Ireland CHI@Crumlin, Dublin, Ireland
| | - Zara Molphy
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland (RCSI, Dublin, Ireland
| | - Patrick Dicker
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland (RCSI, Dublin, Ireland
- School of Population Health, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Fionnuala M Breathnach
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland (RCSI, Dublin, Ireland
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Parnell Square East, Dublin, D01P5W9, Ireland
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Scher MS. The science of uncertainty guides fetal-neonatal neurology principles and practice: diagnostic-prognostic opportunities and challenges. Front Neurol 2024; 15:1335933. [PMID: 38352135 PMCID: PMC10861710 DOI: 10.3389/fneur.2024.1335933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/08/2024] [Indexed: 02/16/2024] Open
Abstract
Fetal-neonatal neurologists (FNNs) consider diagnostic, therapeutic, and prognostic decisions strengthened by interdisciplinary collaborations. Bio-social perspectives of the woman's health influence evaluations of maternal-placental-fetal (MPF) triad, neonate, and child. A dual cognitive process integrates "fast thinking-slow thinking" to reach shared decisions that minimize bias and maintain trust. Assessing the science of uncertainty with uncertainties in science improves diagnostic choices across the developmental-aging continuum. Three case vignettes highlight challenges that illustrate this approach. The first maternal-fetal dyad involved a woman who had been recommended to terminate her pregnancy based on an incorrect diagnosis of an encephalocele. A meningocele was subsequently identified when she sought a second opinion with normal outcome for her child. The second vignette involved two pregnancies during which fetal cardiac rhabdomyoma was identified, suggesting tuberous sclerosis complex (TSC). One woman sought an out-of-state termination without confirmation using fetal brain MRI or postmortem examination. The second woman requested pregnancy care with postnatal evaluations. Her adult child experiences challenges associated with TSC sequelae. The third vignette involved a prenatal diagnosis of an open neural tube defect with arthrogryposis multiplex congenita. The family requested prenatal surgical closure of the defect at another institution at their personal expense despite receiving a grave prognosis. The subsequent Management of Myelomeningocele Study (MOMS) would not have recommended this procedure. Their adult child requires medical care for global developmental delay, intractable epilepsy, and autism. These three evaluations involved uncertainties requiring shared clinical decisions among all stakeholders. Falsely negative or misleading positive interpretation of results reduced chances for optimal outcomes. FNN diagnostic skills require an understanding of dynamic gene-environment interactions affecting reproductive followed by pregnancy exposomes that influence the MPF triad health with fetal neuroplasticity consequences. Toxic stressor interplay can impair the neural exposome, expressed as anomalous and/or destructive fetal brain lesions. Functional improvements or permanent sequelae may be expressed across the lifespan. Equitable and compassionate healthcare for women and families require shared decisions that preserve pregnancy health, guided by person-specific racial-ethnic, religious, and bio-social perspectives. Applying developmental origins theory to neurologic principles and practice supports a brain health capital strategy for all persons across each generation.
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Affiliation(s)
- Mark Steven Scher
- Fetal/Neonatal Neurology Program, Division of Pediatric Neurology, Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
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Pietrolucci ME, Maqina P, Mappa I, Marra MC, D' Antonio F, Rizzo G. Evaluation of an artificial intelligent algorithm (Heartassist™) to automatically assess the quality of second trimester cardiac views: a prospective study. J Perinat Med 2023; 51:920-924. [PMID: 37097825 DOI: 10.1515/jpm-2023-0052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 03/25/2023] [Indexed: 04/26/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate the agreement between visual and automatic methods in assessing the adequacy of fetal cardiac views obtained during second trimester ultrasonographic examination. METHODS In a prospective observational study frames of the four-chamber view left and right outflow tracts, and three-vessel trachea view were obtained from 120 consecutive singleton low-risk women undergoing second trimester ultrasound at 19-23 weeks of gestation. For each frame, the quality assessment was performed by an expert sonographer and by an artificial intelligence software (Heartassist™). The Cohen's κ coefficient was used to evaluate the agreement rates between both techniques. RESULTS The number and percentage of images considered adequate visually by the expert or with Heartassist™ were similar with a percentage >87 % for all the cardiac views considered. The Cohen's κ coefficient values were for the four-chamber view 0.827 (95 % CI 0.662-0.992), 0.814 (95 % CI 0.638-0.990) for left ventricle outflow tract, 0.838 (95 % CI 0.683-0.992) and three vessel trachea view 0.866 (95 % CI 0.717-0.999), indicating a good agreement between the two techniques. CONCLUSIONS Heartassist™ allows to obtain the automatic evaluation of fetal cardiac views, reached the same accuracy of expert visual assessment and has the potential to be applied in the evaluation of fetal heart during second trimester ultrasonographic screening of fetal anomalies.
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Affiliation(s)
- Maria Elena Pietrolucci
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Roma, Italy
| | - Pavjola Maqina
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Roma, Italy
| | - Ilenia Mappa
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Roma, Italy
| | - Maria Chiara Marra
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Roma, Italy
| | | | - Giuseppe Rizzo
- Department of Obstetrics and Gynecology, Fondazione Policlinico Tor Vergata, Università di Roma Tor Vergata, Roma, Italy
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Regouin M, Mancini J, Lafouge A, Mace P, Fontaine N, Roussin S, Guichard J, Dumont C, Quarello E. The Left Outflow Tract in Fetal Cardiac Screening Examination: Introduction of Quality Criteria Is Not Always Associated With an Improvement of Practice When Supervised by Humans. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2095-2105. [PMID: 37163223 DOI: 10.1002/jum.16231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 03/11/2023] [Accepted: 04/01/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVES Since 2016, the French CNEOF included the left ventricular outflow tract (LVOT) in the second and third trimester of pregnancy in addition to the four-chamber view and the parasagittal view of the right outflow tract. The objective of this study was to define quality criteria for fetal LVOT assessment and to perform a human audit of past and current practices, before and after the implementation of those quality criteria at a large scale. METHODS Seven quality criteria were investigated and rated from 0 to 1 during three periods of interest. Files were randomly selected from three centers, and average total and specific scores were calculated. RESULTS LVOT pictures were present in more than 94.3% of reports. The average quality score was 5.49/7 (95% confidence interval [CI]: 5.36-5.62), 5.91/7 (95% CI: 5.80-6.03), and 5.70/7 (95% CI: 5.58-5.82) for the three centers in the three periods of interest. There was no significant difference following the introduction of the quality criteria, 2017 versus 2020, P = .054. CONCLUSION Fetal LVOT images were present in most of ultrasound reports but the introduction of the proposed quality criteria under human supervision seems not associated with a significant change in practice.
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Affiliation(s)
- Maud Regouin
- Département de Gynécologie Obstétrique, Hôpital Sud de la Réunion, Réunion, France
| | - Julien Mancini
- APHM, INSERM, IRD, SESSTIM, Hop Timone, Public Health Department (BIOSTIC), Aix Marseille University, Marseille, France
| | | | - Pierre Mace
- Institut Méditerranéen d'Imagerie Médicale Appliquée à la Gynécologie, la Grossesse et l'Enfance IMAGE2, Marseille, France
- Hôpital Beauregard, Marseille, France
| | - Nathalie Fontaine
- Département de Gynécologie Obstétrique, Hôpital Sud de la Réunion, Réunion, France
| | | | - Jimmy Guichard
- Cabinet d'Echographie Gynécologique et Obstétricale-Espace 9 Mois, Montreuil, France
| | - Coralie Dumont
- Département de Gynécologie Obstétrique, Hôpital Sud de la Réunion, Réunion, France
| | - Edwin Quarello
- Institut Méditerranéen d'Imagerie Médicale Appliquée à la Gynécologie, la Grossesse et l'Enfance IMAGE2, Marseille, France
- Unité de Dépistage et de Diagnostic Prénatal, Hôpital Saint-Joseph, Marseille, France
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Kegel S, Abi Habib P, Seger L, Turan OM, Turan S. The impact of early diagnosis of fetal single-ventricle cardiac defects on reproductive choices. Am J Obstet Gynecol MFM 2023; 5:101093. [PMID: 37451368 DOI: 10.1016/j.ajogmf.2023.101093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Congenital heart defects are the most common fetal anomaly. Congenital heart defects with single-ventricle cardiac defects have high mortality rates, and in pregnancies diagnosed with this condition, patients are often offered termination of pregnancy as an option. OBJECTIVE This study aimed to investigate the relationship between gestational age at diagnosis and reproductive choices in fetuses diagnosed with single-ventricle cardiac defects. STUDY DESIGN This was a retrospective single-center cohort study in which 158 patients with a fetal diagnosis of single-ventricle cardiac defects were reviewed. Cases were categorized as isolated or complex. Complex cases included fetuses with single-ventricle cardiac defects in addition to other fetal extracardiac anomalies or chromosomal abnormalities. RESULTS A total of 158 patients were diagnosed with single-ventricle cardiac defects during the study period. Of those patients, 37 (23.4%) underwent termination of pregnancy, 113 (71.5%) delivered, and 8 (5.1%) had an intrauterine fetal demise. Gestational age at diagnosis and race were significant predictors of the termination decision. The median gestational age at diagnosis was earlier in the termination of pregnancy group (20.4 vs 23.6 weeks; P<.001). Pregnancies complicated by single-ventricle cardiac defects diagnosed in early gestation (11 0/7 to 14 5/7 weeks of gestation) were more likely to be terminated than pregnancies complicated by single-ventricle cardiac defects diagnosed in middle gestation (15 0/7 to 27 5/7 weeks of gestation) and late gestation (≥28 weeks of gestation) (54.2% vs 23.2% and 2.9%; P<.001). Earlier gestational age at diagnosis was correlated with earlier gestational age at termination (r=0.92; P<.001). CONCLUSION Termination of pregnancy was more common when the single-ventricle cardiac defect was diagnosed earlier in pregnancy. This could be explained by the fact that early diagnoses allow parents to make deliberate and informed decisions.
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Affiliation(s)
- Samantha Kegel
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD
| | - Paola Abi Habib
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD
| | - Lindsey Seger
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD
| | - Ozhan M Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD
| | - Sifa Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD.
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12
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Buratti S, Mallamaci M, Tuo G, Severino M, Tortora D, Parodi C, Rossi A, Pasetti F, Castellan L, Capra V, Romano F, De Marco P, Pavanello M, Piatelli G, Paladini D, Calevo MG, Moscatelli A. Vein of Galen aneurysmal malformation in newborns: a retrospective study to describe a paradigm of treatment and identify risk factors of adverse outcome in a referral center. Front Pediatr 2023; 11:1193738. [PMID: 37587977 PMCID: PMC10426803 DOI: 10.3389/fped.2023.1193738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 07/03/2023] [Indexed: 08/18/2023] Open
Abstract
Background Vein of Galen aneurysmal malformation (VGAM) is a rare cerebral vascular malformation associated with significant morbidity and mortality. Newborns with VGAM without adequate treatment may develop rapidly deteriorating high output heart failure (HOHF) and are at risk for severe neurological outcomes. Objective To describe the clinical course and management of newborns with VGAM, and identify which echocardiographic and neuroradiologic factors may be associated with severe heart failure at birth and adverse short term outcomes. Methods This is a single center retrospective cohort study including all consecutive newborns with VGAM admitted to Gaslini Children's Hospital between 2009 and 2022. We reviewed clinical data, intensive care support, fetal and neonatal cardiologic and neuroradiologic findings and we studied the association with severe HOHF, endovascular complications and death. Results Out of 40 newborns, 17 (42.5%) developed severe HOHF requiring early endovascular procedures. Medical treatment was focused on the main components of HOHF by providing inotropic support and peripheral vasodilation. Pulmonary vasodilators were avoided to reduce the negative effects of pulmonary overflow and prevent vascular remodeling. Reduction of the obligatory left to right shunt through the VGAM was possible only through endovascular treatment. Fetal cardiothoracic ratio was significantly associated with severe HOHF at birth and death. Cardiologic parameters of right ventricular overload, pulmonary hypertension and systemic steal were the leading findings associated with haemodynamic compromise at birth. The mediolateral diameter of the straight or falcine sinus at its shortest section (SS-MD), and arterial pseudofeeders were significantly associated with severe HOHF at birth in prenatal and postnatal assessments. None of the postnatal echocardiographic and MRI variables, nor a higher inotropic support were associated with major periprocedural complications or death. Mortality was due to palliation for congenital severe brain damage (4/40, 10%), or major periprocedural complications (3/40, 7.5%). None of the patients died due to HOHF and multiorgan failure. Overall survival at discharge was 82.5% (33/40). Conclusions The complexity of neonatal VGAM pathophysiology requires a multidisciplinary approach, specialized intensive care management, and early endovascular treatment to reduce mortality and optimize clinical outcomes. Cardiologic and neuroradiologic parameters are key to define risk stratification and treatment strategies.
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Affiliation(s)
- Silvia Buratti
- Neonatal and Pediatric Intensive Care Unit, Acceptance and Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy
| | - Marisa Mallamaci
- Neonatal and Pediatric Intensive Care Unit, Acceptance and Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Giulia Tuo
- Pediatric Cardiology and Cardiac Surgery Unit, Surgery Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Mariasavina Severino
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy
- Neuroradiology Unit, Services Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Domenico Tortora
- Neuroradiology Unit, Services Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Costanza Parodi
- Neuroradiology Unit, Services Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Rossi
- Pediatric Cardiology and Cardiac Surgery Unit, Surgery Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Neuroradiology Unit, Services Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Francesco Pasetti
- Pediatric Radiology Unit, Services Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Lucio Castellan
- Neuroradiology Unit, Diagnostic Imaging and Radiotherapy Department, San Martino Polyclinic Hospital, Genoa, Italy
| | - Valeria Capra
- Genomics and Clinical Genetics Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Ferruccio Romano
- Genomics and Clinical Genetics Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Patrizia De Marco
- Medical Genetics Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Marco Pavanello
- Neurosurgery Unit, Surgery Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Gianluca Piatelli
- Neurosurgery Unit, Surgery Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Dario Paladini
- Fetal Medicine and Surgery Unit, Department Mother and Child, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Maria Grazia Calevo
- Epidemiology, Biostatistics Unit, Scientific Direction, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Acceptance and Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 5. Obstet Gynecol 2023; 141:1262-1288. [PMID: 37486661 DOI: 10.1097/aog.0000000000005202] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
PURPOSE To assess the evidence regarding safety and efficacy of psychiatric medications to treat mental health conditions during pregnancy and lactation. The conditions reviewed include depression, anxiety and anxiety-related disorders, bipolar disorder, and acute psychosis. For information on screening and diagnosis, refer to American College of Obstetricians and Gynecologists (ACOG) Clinical Practice Guideline Number 4, "Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum" (1). TARGET POPULATION Pregnant or postpartum individuals with mental health conditions with onset that may have predated the perinatal period or may have occurred for the first time in pregnancy or the first year postpartum or may have been exacerbated in that time. METHODS This guideline was developed using an a priori protocol in conjunction with a writing team consisting of one specialist in obstetrics and gynecology and one maternal-fetal medicine subspecialist appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and two external subject matter experts. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements. RECOMMENDATIONS This Clinical Practice Guideline includes recommendations on treatment and management of perinatal mental health conditions including depression, anxiety, bipolar disorders, and acute postpartum psychosis, with a focus on psychopharmacotherapy. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.
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Carvalho JS, Axt-Fliedner R, Chaoui R, Copel JA, Cuneo BF, Goff D, Gordin Kopylov L, Hecher K, Lee W, Moon-Grady AJ, Mousa HA, Munoz H, Paladini D, Prefumo F, Quarello E, Rychik J, Tutschek B, Wiechec M, Yagel S. ISUOG Practice Guidelines (updated): fetal cardiac screening. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:788-803. [PMID: 37267096 DOI: 10.1002/uog.26224] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 06/04/2023]
Affiliation(s)
- J S Carvalho
- Royal Brompton Hospital, Guy's & St Thomas' NHS Foundation Trust; and Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust and Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
| | - R Axt-Fliedner
- Division of Prenatal Medicine & Fetal Therapy, Department of Obstetrics & Gynecology, Justus-Liebig-University Giessen, University Hospital Giessen & Marburg, Giessen, Germany
| | - R Chaoui
- Center of Prenatal Diagnosis and Human Genetics, Berlin, Germany
| | - J A Copel
- Departments of Obstetrics, Gynecology & Reproductive Sciences, and Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - B F Cuneo
- Children's Hospital Colorado, The Heart Institute, Aurora, CO, USA
| | - D Goff
- Pediatrix Cardiology of Houston and Loma Linda University School of Medicine, Houston, TX, USA
| | - L Gordin Kopylov
- Obstetrical Unit, Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel; and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - W Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - A J Moon-Grady
- Clinical Pediatrics, UC San Francisco, San Francisco, CA, USA
| | - H A Mousa
- Fetal Medicine Unit, University of Leicester, Leicester, UK
| | - H Munoz
- Obstetrics and Gynecology, Universidad de Chile and Clinica Las Condes, Santiago, Chile
| | - D Paladini
- Fetal Medicine and Surgery Unit, IRCCS Istituto G. Gaslini, Genoa, Italy
| | - F Prefumo
- Obstetrics and Gynecology Unit, IRCCS Istituto G. Gaslini, Genoa, Italy
| | - E Quarello
- Image 2 Center, Obstetrics and Gynecologic Department, St Joseph Hospital, Marseille, France
| | - J Rychik
- Fetal Heart Program at Children's Hospital of Philadelphia, and Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - B Tutschek
- Pränatal Zürich, Zürich, Switzerland; and Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - M Wiechec
- Department of Gynecology and Obstetrics, Jagiellonian University in Krakow, Krakow, Poland
| | - S Yagel
- Department of Obstetrics and Gynecology, Hadassah Medical Center, Mt. Scopus and the Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Kühle H, Cho SKS, Barber N, Goolaub DS, Darby JRT, Morrison JL, Haller C, Sun L, Seed M. Advanced imaging of fetal cardiac function. Front Cardiovasc Med 2023; 10:1206138. [PMID: 37288263 PMCID: PMC10242056 DOI: 10.3389/fcvm.2023.1206138] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 05/09/2023] [Indexed: 06/09/2023] Open
Abstract
Over recent decades, a variety of advanced imaging techniques for assessing cardiovascular physiology and cardiac function in adults and children have been applied in the fetus. In many cases, technical development has been required to allow feasibility in the fetus, while an appreciation of the unique physiology of the fetal circulation is required for proper interpretation of the findings. This review will focus on recent advances in fetal echocardiography and cardiovascular magnetic resonance (CMR), providing examples of their application in research and clinical settings. We will also consider future directions for these technologies, including their ongoing technical development and potential clinical value.
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Affiliation(s)
- Henriette Kühle
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Department of Cardiac and Thoracic Surgery, University Hospital Magdeburg, Otto von Guericke University Magdeburg, Magdeburg, Germany
- Division of Cardiac Surgery, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Steven K. S. Cho
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Early Origins of Adult Health Research Group, University of South Australia, Adelaide, SA, Australia
| | - Nathaniel Barber
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Datta Singh Goolaub
- Translational Medicine Program, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Jack R. T. Darby
- Early Origins of Adult Health Research Group, University of South Australia, Adelaide, SA, Australia
| | - Janna L. Morrison
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Early Origins of Adult Health Research Group, University of South Australia, Adelaide, SA, Australia
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Christoph Haller
- Division of Cardiac Surgery, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Liqun Sun
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Translational Medicine Program, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Mike Seed
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Translational Medicine Program, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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16
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Lesieur E, Zaffran S, Chaoui R, Quarello E. Prenatal screening and diagnosis of pulmonary artery anomalies. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:445-457. [PMID: 36178851 DOI: 10.1002/uog.26078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/08/2022] [Accepted: 09/11/2022] [Indexed: 06/16/2023]
Abstract
Congenital pulmonary artery anomalies are rare. Their antenatal diagnosis requires good knowledge of fetal cardiac anatomy because their clinical presentation varies depending on the type and severity of the underlying lesion. Screening of these vascular anomalies can be straightforward in some cases because of significant associated consequences that are detected easily on ultrasound, while other anomalies have considerably less obvious features. There may be an associated genetic syndrome. The aim of this review was to define anomalies of the main pulmonary artery and its branches and to propose, through the identification of suspicious findings during routine antenatal heart examination, an optimal screening method for the pulmonary artery pathway. We propose that pulmonary artery anomalies can be classified antenatally into four types of disorder. Herein we describe 14 cases subgrouped accordingly as: anomalies of the pulmonary valvular region, with stenosis or atresia of the valve (n = 4); conotruncal abnormalities (n = 4); anomalies associated with abnormal origin or course of the pulmonary artery (n = 4); and anomalies associated with abnormal growth of the pulmonary artery and its branches (n = 2). We highlight the need to differentiate the three-vessel view from the three-vessel-and-trachea view when assessing a fetus with a congenital pulmonary artery anomaly. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- E Lesieur
- Prenatal Diagnosis Center, Department of Obstetrics and Gynecology, Timone Hospital, Aix-Marseille University, Marseille, France
- UMR 7268 ADES, Aix-Marseille University, CNRS, EFS, Marseille, France
| | - S Zaffran
- Aix-Marseille University, INSERM, MMG, U1251, Marseille, France
| | - R Chaoui
- Center for Prenatal Diagnosis and Human Genetics, Berlin, Germany
| | - E Quarello
- Screening and Diagnosis Unit, Department of Obstetrics and Gynecology, Saint Joseph Hospital, Marseille, France
- IMAGE2 Center, Marseille, France
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Drukker L, Sharma H, Karim JN, Droste R, Noble JA, Papageorghiou AT. Clinical workflow of sonographers performing fetal anomaly ultrasound scans: deep-learning-based analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:759-765. [PMID: 35726505 PMCID: PMC10107110 DOI: 10.1002/uog.24975] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/04/2022] [Accepted: 06/10/2022] [Indexed: 05/31/2023]
Abstract
OBJECTIVE Despite decades of obstetric scanning, the field of sonographer workflow remains largely unexplored. In the second trimester, sonographers use scan guidelines to guide their acquisition of standard planes and structures; however, the scan-acquisition order is not prescribed. Using deep-learning-based video analysis, the aim of this study was to develop a deeper understanding of the clinical workflow undertaken by sonographers during second-trimester anomaly scans. METHODS We collected prospectively full-length video recordings of routine second-trimester anomaly scans. Important scan events in the videos were identified by detecting automatically image freeze and image/clip save. The video immediately preceding and following the important event was extracted and labeled as one of 11 commonly acquired anatomical structures. We developed and used a purposely trained and tested deep-learning annotation model to label automatically the large number of scan events. Thus, anomaly scans were partitioned as a sequence of anatomical planes or fetal structures obtained over time. RESULTS A total of 496 anomaly scans performed by 14 sonographers were available for analysis. UK guidelines specify that an image or videoclip of five different anatomical regions must be stored and these were detected in the majority of scans: head/brain was detected in 97.2% of scans, coronal face view (nose/lips) in 86.1%, abdomen in 93.1%, spine in 95.0% and femur in 92.3%. Analyzing the clinical workflow, we observed that sonographers were most likely to begin their scan by capturing the head/brain (in 24.4% of scans), spine (in 23.2%) or thorax/heart (in 22.8%). The most commonly identified two-structure transitions were: placenta/amniotic fluid to maternal anatomy, occurring in 44.5% of scans; head/brain to coronal face (nose/lips) in 42.7%; abdomen to thorax/heart in 26.1%; and three-dimensional/four-dimensional face to sagittal face (profile) in 23.7%. Transitions between three or more consecutive structures in sequence were uncommon (up to 13% of scans). None of the captured anomaly scans shared an entirely identical sequence. CONCLUSIONS We present a novel evaluation of the anomaly scan acquisition process using a deep-learning-based analysis of ultrasound video. We note wide variation in the number and sequence of structures obtained during routine second-trimester anomaly scans. Overall, each anomaly scan was found to be unique in its scanning sequence, suggesting that sonographers take advantage of the fetal position and acquire the standard planes according to their visibility rather than following a strict acquisition order. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- L. Drukker
- Nuffield Department of Women's and Reproductive HealthJohn Radcliffe Hospital, University of OxfordOxfordUK
- Women's Ultrasound, Department of Obstetrics and GynecologyBeilinson Medical Center, Sackler Faculty of Medicine, Tel Aviv UniversityTel AvivIsrael
| | - H. Sharma
- Institute of Biomedical EngineeringUniversity of OxfordOxfordUK
| | - J. N. Karim
- Nuffield Department of Women's and Reproductive HealthJohn Radcliffe Hospital, University of OxfordOxfordUK
| | - R. Droste
- Institute of Biomedical EngineeringUniversity of OxfordOxfordUK
| | - J. A. Noble
- Institute of Biomedical EngineeringUniversity of OxfordOxfordUK
| | - A. T. Papageorghiou
- Nuffield Department of Women's and Reproductive HealthJohn Radcliffe Hospital, University of OxfordOxfordUK
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Rizzo G, Lu JLA, Mappa I. Should we include bicaval view in the study of the fetal heart? JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:803-804. [PMID: 35834666 DOI: 10.1002/jcu.23208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 03/21/2022] [Accepted: 03/23/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Giuseppe Rizzo
- Department of Obstetrics and Gynecology, Università di Roma Tor Vergata, Rome, Italy
| | - Jia Li Angela Lu
- Department of Obstetrics and Gynecology, Università di Roma Tor Vergata, Rome, Italy
| | - Ilenia Mappa
- Department of Obstetrics and Gynecology, Università di Roma Tor Vergata, Rome, Italy
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19
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Sethi N, Gai J, Bost J, Donofrio MT. Alterations in Cardiac Output in Fetuses with Congenital Heart Disease. Prenat Diagn 2022; 42:1133-1141. [PMID: 35698885 DOI: 10.1002/pd.6193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 05/31/2022] [Accepted: 06/02/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Fetuses with severe congenital heart disease (CHD) have altered blood flow patterns. Prior work to assess fetal combined cardiac output (CCO) is limited by sample size and lack of longitudinal gestational data. Our aim was to evaluate CCO in CHD fetuses to determine whether the presence of single ventricle (SV) physiology or aortic obstruction impacts fetal blood flow and cardiovascular hemodynamics. METHOD Prospective study including singleton fetuses with CHD (n=141) and controls (n=118) who underwent a mid and late gestation fetal echocardiogram. Ventricular cardiac output was calculated using the standard computation. CCO was derived as the sum of the right and left cardiac outputs and indexed to estimated fetal weight. RESULTS Fetuses with two ventricle (2V) CHD had significantly higher CCO compared to controls and SV-CHD fetuses. Fetuses with SV-CHD had similar CCO compared to controls. Fetuses with 2V-CHD and aortic obstruction had significantly higher CCO than fetuses with SV-CHD and aortic obstruction. CONCLUSION Our findings suggest that the SV can compensate and increase CCO despite the lack of a second functioning ventricle however, the degree of compensation may be insufficient to support the increased blood flow needed to overcome the hemodynamic and physiologic alternations seen with severe CHD. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Neeta Sethi
- Division of Cardiology, Children's National Hospital, Washington, DC, US
| | - Jiaxiang Gai
- Division of Biostatistics and Study Methodology, Children's Research Institute at Children's National Hospital, Washington, DC, US
| | - James Bost
- Division of Biostatistics and Study Methodology, Children's Research Institute at Children's National Hospital, Washington, DC, US
| | - Mary T Donofrio
- Division of Cardiology, Children's National Hospital, Washington, DC, US
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Wong J, Kohari K, Bahtiyar MO, Copel J. Impact of prenatally diagnosed congenital heart defects on outcomes and management. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:646-654. [PMID: 35543387 DOI: 10.1002/jcu.23219] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/13/2022] [Accepted: 04/26/2022] [Indexed: 06/14/2023]
Abstract
Fetal echocardiogram aids in prenatal identification of neonates at high risk for congenital heart defects (CHD). Prenatal detection rates for CHD have increased with improved ultrasound technology, the use of the early fetal echocardiography, and standardization of the performance of the fetal echocardiogram. Accurate prenatal detection of CHD, particularly complex CHD, is an important contributor to improved survival rates for patients with CHD. Early detection allows for families to choose whether or not to continue with pregnancy, referral to pediatric cardiology specialists for patient education, and delivery planning. Better psychosocial supports are needed for families with CHD.
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Affiliation(s)
- Jennifer Wong
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Katherine Kohari
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mert Ozan Bahtiyar
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joshua Copel
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA
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Gireadă R, Socolov D, Mihălceanu E, Matasariu R, Ursache A, Akad M, Bujor I, Scripcariu I, Popa RF, Socolov R. The Additional Role of the 3-Vessels and Trachea View in Screening for Congenital Heart Disease. Medicina (B Aires) 2022; 58:medicina58020262. [PMID: 35208585 PMCID: PMC8875090 DOI: 10.3390/medicina58020262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/03/2022] [Accepted: 02/07/2022] [Indexed: 11/19/2022] Open
Abstract
Background and Objectives: Although frequent and associated with high mortality and morbidity rate, congenital heart disease (CHD) has a suboptimal prenatal detection rate, with significant variation according to the scanning protocol. The aim of this study was to evaluate the role of the 3-vessels and trachea view (3VT) in detecting CHD, with or without the use of Color Doppler, with an emphasis on major CHD. Materials and Methods: We performed a retrospective study on 1596 unselected pregnant patients presenting at 11–37 weeks of gestation for a routine anomaly scan. We selected all CHD cases, and we analyzed the performance of the 4-chamber (4C) and 3VT view in detecting CHD. Results: A total of 46 fetuses with CHD were identified, yielding a 2.86% overall incidence, and 0.87% for major CHD. Grayscale 4C detected 47.8% of all CHD, going up to 71.7% by adding grayscale 3VT, with no major CHD remaining undetected by combining grayscale 4C and 3VT. Conclusions: Grayscale 4C and 3VT views are effective in detecting major CHD, thus proving their utility even in a low resource setting.
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Affiliation(s)
- Roxana Gireadă
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy ‘Gr. T. Popa’, 700115 Iaşi, Romania; (R.G.); (D.S.); (E.M.); (A.U.); (M.A.); (I.B.); (R.F.P.); (R.S.)
| | - Demetra Socolov
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy ‘Gr. T. Popa’, 700115 Iaşi, Romania; (R.G.); (D.S.); (E.M.); (A.U.); (M.A.); (I.B.); (R.F.P.); (R.S.)
- Department of Obstetrics and Gynecology, Cuza Vodă Hospital, 700038 Iaşi, Romania
| | - Elena Mihălceanu
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy ‘Gr. T. Popa’, 700115 Iaşi, Romania; (R.G.); (D.S.); (E.M.); (A.U.); (M.A.); (I.B.); (R.F.P.); (R.S.)
- Department of Obstetrics and Gynecology, Cuza Vodă Hospital, 700038 Iaşi, Romania
| | - Roxana Matasariu
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy ‘Gr. T. Popa’, 700115 Iaşi, Romania; (R.G.); (D.S.); (E.M.); (A.U.); (M.A.); (I.B.); (R.F.P.); (R.S.)
- Department of Obstetrics and Gynecology, Cuza Vodă Hospital, 700038 Iaşi, Romania
- Correspondence: (R.M.); (I.S.)
| | - Alexandra Ursache
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy ‘Gr. T. Popa’, 700115 Iaşi, Romania; (R.G.); (D.S.); (E.M.); (A.U.); (M.A.); (I.B.); (R.F.P.); (R.S.)
| | - Mona Akad
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy ‘Gr. T. Popa’, 700115 Iaşi, Romania; (R.G.); (D.S.); (E.M.); (A.U.); (M.A.); (I.B.); (R.F.P.); (R.S.)
| | - Iuliana Bujor
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy ‘Gr. T. Popa’, 700115 Iaşi, Romania; (R.G.); (D.S.); (E.M.); (A.U.); (M.A.); (I.B.); (R.F.P.); (R.S.)
| | - Ioana Scripcariu
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy ‘Gr. T. Popa’, 700115 Iaşi, Romania; (R.G.); (D.S.); (E.M.); (A.U.); (M.A.); (I.B.); (R.F.P.); (R.S.)
- Department of Obstetrics and Gynecology, Cuza Vodă Hospital, 700038 Iaşi, Romania
- Correspondence: (R.M.); (I.S.)
| | - Radu Florin Popa
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy ‘Gr. T. Popa’, 700115 Iaşi, Romania; (R.G.); (D.S.); (E.M.); (A.U.); (M.A.); (I.B.); (R.F.P.); (R.S.)
| | - Răzvan Socolov
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy ‘Gr. T. Popa’, 700115 Iaşi, Romania; (R.G.); (D.S.); (E.M.); (A.U.); (M.A.); (I.B.); (R.F.P.); (R.S.)
- Department of Obstetrics and Gynecology, Elena Doamna Hospital, 700398 Iaşi, Romania
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22
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Akalın M, Demirci O, Kumru P, Yücel İK. Heterotaxy syndrome: Prenatal diagnosis, concomitant malformations and outcomes. Prenat Diagn 2022; 42:435-446. [PMID: 35102577 DOI: 10.1002/pd.6110] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/15/2022] [Accepted: 01/27/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The aim of this study is to define cardiac and extracardiac malformations in fetuses with heterotaxy syndrome and to determine perinatal and childhood prognosis. METHODS In this retrospective study, fetuses diagnosed with heterotaxy syndrome on antenatal ultrasonography in a tertiary center between January 2014 and January 2021 were analyzed. Fetuses with heterotaxy syndrome were grouped as right atrial isomerism (RAI) and left atrial isomerism (LAI). RESULTS A total of 62 fetuses, 32 (51.6%) with RAI and 30 (48.4%) with LAI, were included in the study. Extracardiac anomaly was detected in 25% of fetuses with RAI and 44% of fetuses with LAI (p = 0.13). Patients with univentricular repair had a higher childhood mortality than patients with biventricular repair (p = 0.031). The presence of conotruncal anomaly was an independent factor affecting mortality (HR = 5.09, CI 95% 1.09-23.71, p = 0.039). CONCLUSION Hydrops fetalis, univentricular physiology and conotruncal anomalies are associated with poor outcomes in heterotaxy syndrome. The severity of the cardiac malformation is the main determinant of the outcomes. The presence of extracardiac malformations is associated with increased morbidity and mortality.
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Affiliation(s)
- Münip Akalın
- Department of Perinatology, University of Health Sciences Zeynep Kamil Women's and Children's Disease Training and Research Hospital, Istanbul, Turkey
| | - Oya Demirci
- Department of Perinatology, University of Health Sciences Zeynep Kamil Women's and Children's Disease Training and Research Hospital, Istanbul, Turkey
| | - Pınar Kumru
- Department of Obstetrics and Gynaecology, University of Health Sciences Zeynep Kamil Women's and Children's Disease Training and Research Hospital, Istanbul, Turkey
| | - İlker Kemal Yücel
- Department of Pediatric Cardiology, University of Health Sciences Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training & Research Hospital, Istanbul, Turkey
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23
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Sompagdee N, Anuwutnavin S, Burapasikarin C, Ruangvutilert P, Thongkloung P. Nomograms of fetal cardiothoracic ratio from 17 to 37 weeks' gestation as assessed by three different measurement techniques and their correlation with gestational age. Prenat Diagn 2021; 41:1658-1667. [PMID: 34647342 DOI: 10.1002/pd.6057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 08/14/2021] [Accepted: 10/04/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To create nomograms for fetal cardiothoracic (CT) ratio as assessed by three different 2-dimensional sonographic measurements, including CT diameter, circumference, and area ratios, in Thai fetuses with a gestational age (GA) of 17-37 weeks, and to evaluate both their correlation with GA or biparietal diameter (BPD) and variability among the three measurement methods. METHODS Two-dimensional sonographic measurements of fetal CT ratio in 4-chamber view were assessed by three different measurement techniques. The 95% reference intervals and Z-scores of all measurement methods based on GA or BPD were constructed. Intraclass correlation coefficients (ICC) for the reproducibility of each technique were compared. RESULTS A total of 511 uncomplicated singleton pregnancies were included. The fetal CT ratio values by all measurement techniques gradually and smoothly increased with increasing GA and BPD. The fetal CT circumference ratio showed the least correlation with both GA and BPD. The intraobserver and interobserver reliability coefficients of all techniques demonstrated almost excellent agreement (all ICCs at least 0.87). CONCLUSION Reference intervals and Z-score reference ranges were developed using three different techniques for fetal CT ratio with a GA of 17-37 weeks. These nomograms are a simple and reliable screening tool for identifying abnormal fetal heart size.
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Affiliation(s)
- Nalat Sompagdee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sanitra Anuwutnavin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chada Burapasikarin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pornpimol Ruangvutilert
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Piyatida Thongkloung
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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24
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Sun HY. Prenatal diagnosis of congenital heart defects: echocardiography. Transl Pediatr 2021; 10:2210-2224. [PMID: 34584892 PMCID: PMC8429868 DOI: 10.21037/tp-20-164] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/07/2020] [Indexed: 12/22/2022] Open
Abstract
Congenital heart defects (CHD) are the most common congenital anomaly, and the majority can be diagnosed during prenatal life. Prenatal detection rates remain highly variable, as most CHD occur in low risk pregnancies and therefore depend on the maternal obstetric provider to recognize fetal cardiac abnormality on obstetric screening anatomic ultrasound. Fetuses with abnormal findings on obstetric screening anatomic ultrasound and/or risk factors for cardiac disease should be referred for evaluation with fetal echocardiography. Fetal echocardiography should be performed by specialized sonographers and interpreted by physicians with knowledge of evolving fetal cardiac anatomy and physiology throughout gestation. A fetal echocardiography examination, which can be done from the late first trimester onward, utilizes a standardized and systemic approach to diagnose fetuses with CHD or other forms of primary or secondary cardiac disease. The field of fetal cardiology has advanced past the accurate prenatal diagnosis of simple and complex CHD, as fetal echocardiography enables understanding of dynamic fetal cardiac physiology and consideration of potential fetal/neonatal treatment. The greatest impact of fetal echocardiography remains identification of critical CHD before birth to allow immediate cardiac management after delivery to decrease neonatal morbidity and mortality. Analyzing the severity of abnormal cardiac physiology in various forms of CHD before birth allows the fetal cardiologist to prognosticate effects on the developing fetus, predict risk of postnatal hemodynamic instability, guide delivery planning through multidisciplinary collaboration, and anticipate how the disease will impact the neonate after delivery.
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Affiliation(s)
- Heather Y Sun
- Division of Pediatric Cardiology, Department of Pediatrics, Rady Children's Hospital, University of California, San Diego, San Diego, CA, USA
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25
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Barris DM, Brailovschi Y, Shah A, Levasseur S, Nhan-Chang CL, Miller R, Simpson L, Freud LR. The role of fetal echocardiogram after detection of extracardiac anomalies in utero (fetal echocardiogram for extracardiac malformations). Prenat Diagn 2021; 41:1134-1139. [PMID: 34269470 DOI: 10.1002/pd.6012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/16/2021] [Accepted: 06/30/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We aimed to investigate the utility of comprehensive screening fetal echocardiography (FE) for patients diagnosed with any type of fetal extracardiac malformation (ECM) at a single multidisciplinary fetal center. METHODS We retrospectively reviewed all patients presenting to our referral center for FE due to a prenatal diagnosis of ECM (January 2013-December 2018). RESULTS Among 641 patients with ≥1 ECM referred for FE, 78 (12.2%) had CHD diagnosed at 25.6 ± 0.5 weeks. The frequency of CHD by type of ECM ranged from 35.1% for craniofacial to 9.8% for thoracic. Increasing number of fetal ECMs was strongly associated with CHD: odds ratio 2.01 (95% confidence interval: 1.06-3.69) for two ECMs, 9.57 (2.00-49.05) for three ECMs, and 11.68 (3.84-37.15) for more than three ECMs. Of fetuses with ECM and an abnormal genetic finding, 33.3% had CHD as compared to 10.9% of those without (p < 0.0001). Obstetric anatomy sonogram detected 43.6% of CHD. CONCLUSION CHD was commonly diagnosed among fetuses with any type of ECM at our center but was not always detected on obstetric sonogram. As the presence of CHD may impact decision-making and perinatal care, patients with a diagnosis of any fetal ECM should be considered for FE.
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Affiliation(s)
- David M Barris
- Department of Pediatrics, Columbia University Irving Medical Center, Morgan Stanley Children's Hospital of NewYork Presbyterian, New York City, New York, USA
| | - Yaniv Brailovschi
- Department of Obstetrics, Lenox Hill Hospital, Northwell Health, New York City, New York, USA
| | - Amee Shah
- Department of Pediatrics, Columbia University Irving Medical Center, Morgan Stanley Children's Hospital of NewYork Presbyterian, New York City, New York, USA
| | - Stéphanie Levasseur
- Department of Pediatrics, Columbia University Irving Medical Center, Morgan Stanley Children's Hospital of NewYork Presbyterian, New York City, New York, USA
| | - Chia-Ling Nhan-Chang
- Department of Obstetrics, Columbia University Irving Medical Center, Morgan Stanley Children's Hospital of NewYork Presbyterian, New York City, New York, USA
| | - Russell Miller
- Department of Obstetrics, Columbia University Irving Medical Center, Morgan Stanley Children's Hospital of NewYork Presbyterian, New York City, New York, USA
| | - Lynn Simpson
- Department of Obstetrics, Columbia University Irving Medical Center, Morgan Stanley Children's Hospital of NewYork Presbyterian, New York City, New York, USA
| | - Lindsay R Freud
- Department of Pediatrics, Columbia University Irving Medical Center, Morgan Stanley Children's Hospital of NewYork Presbyterian, New York City, New York, USA
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26
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Applications of Advanced Ultrasound Technology in Obstetrics. Diagnostics (Basel) 2021; 11:diagnostics11071217. [PMID: 34359300 PMCID: PMC8306830 DOI: 10.3390/diagnostics11071217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 06/28/2021] [Accepted: 07/03/2021] [Indexed: 12/21/2022] Open
Abstract
Over the years, there have been several improvements in ultrasound technologies including high-resolution ultrasonography, linear transducer, radiant flow, three-/four-dimensional (3D/4D) ultrasound, speckle tracking of the fetal heart, and artificial intelligence. The aims of this review are to evaluate the use of these advanced technologies in obstetrics in the midst of new guidelines on and new techniques of obstetric ultrasonography. In particular, whether these technologies can improve the diagnostic capability, functional analysis, workflow, and ergonomics of obstetric ultrasound examinations will be discussed.
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27
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Reference values for left and right ventricular systolic-to-diastolic duration ratio (SDR) found using both spectral and tissue Doppler of fetal heart between 20 and 36+6 weeks of gestation. Int J Cardiovasc Imaging 2021; 37:2717-2726. [PMID: 33844115 DOI: 10.1007/s10554-021-02239-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/03/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To establish reference values for the systolic-to-diastolic duration ratio (SDR) of the left ventricle (LV) using spectral Doppler, as well as for the SDR' of the interventricular septum (SEP), LV, and right ventricles (RV) using tissue Doppler of the fetal heart. METHOD This prospective and cross-sectional study evaluated 374 low-risk singleton pregnancies from 20 to 36 + 6 weeks of gestation. The ventricular filling time (FT) was obtained from LV inflow using spectral Doppler. Tissue Doppler was used to assess the FT of each ventricle by placing the cursor at the atrioventricular junction marked by the mitral and tricuspid valves, respectively. SDR was calculated as the sum of the isovolumic contraction time (ICT) and the ejection time (ET) divided by the sum of the isovolumic relaxation time (IRT) and the ventricular FT. We used regression analysis to obtain the best-fit model polynomial equation for the parameters. The concordance correlation coefficient (CCC) was used to assess intra- and inter-observer reproducibility. RESULTS SDR and SDR' LV showed a progressive decrease with gestational age (GA); the SDR' RV and SDR' SEP did not show a significant decrease with advancing GA. The SDR LV (r = 0.29, p < 0.0001), SDR' RV (r = 0.21, p < 0.0001), SDR' LV (r = 0.20, p = 0.0001), and SDR' SEP (r = 0.25, p < 0.0001) showed a significant weak positive correlation with fetal heart rate. The inter-observer SDR' SEP measurements demonstrated poor reproducibility (CCC: 0.50), whereas intra-observer SRD LV measurements demonstrated moderate reproducibility (CCC: 0.78). CONCLUSIONS Reference values for SDR SEP, LV, and RV using spectral and tissue Doppler of fetal heart were established between 20 and 36+6 weeks of gestation.
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28
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Weichert J, Weichert A. A "holistic" sonographic view on congenital heart disease: How automatic reconstruction using fetal intelligent navigation echocardiography eases unveiling of abnormal cardiac anatomy part II-Left heart anomalies. Echocardiography 2021; 38:777-789. [PMID: 33778977 DOI: 10.1111/echo.15037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 02/27/2021] [Accepted: 03/06/2021] [Indexed: 12/19/2022] Open
Abstract
Volume ultrasound has been shown to provide valid complementary information on fetal anatomy. Four-dimensional assessment (4D) of the fetal cardiovascular system using spatial-temporal image correlation (STIC) allows for detailed examination of a highly complex organ from the early second trimester onward. There is compelling evidence that this technique harbors quite a number of diagnostic opportunities, but manual navigation through STIC volume datasets is highly operator dependent. In fact, STIC is not incorporated yet into daily practice. Application of the novel fetal intelligent navigation echocardiography (FINE) considerably simplifies fetal cardiac volumetric examinations. This automatic technique applied on cardiac volume datasets reportedly has both high sensitivity and specificity for the detection of congenital heart defects (CHDs). Part I reviewed current data regarding detection rates of CHDs and illustrated the additional value of an automatic approach in delineating cardiac anatomy exemplified by congenital lesions of the right heart. In part II of this pictorial essay, we focused on left heart anomalies and aimed to tabulate recent findings on the quantification of normal and abnormal cardiac anatomy.
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Affiliation(s)
- Jan Weichert
- Division of Prenatal Medicine, Department of Gynecology and Obstetrics, University Hospital of Schleswig-Holstein, Luebeck, Germany.,Elbe Center of Prenatal Medicine and Human Genetics, Hamburg, Germany
| | - Alexander Weichert
- Department of Obstetrics, Charité-Universitätsmedizin Berlin - CCM, Berlin, Germany.,Prenatal Medicine Bergmannstrasse, Berlin, Germany
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29
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Klein J, Donofrio MT. Fetal Echocardiography for the General Pediatrician. Pediatr Ann 2021; 50:e121-e127. [PMID: 34038649 DOI: 10.3928/19382359-20210217-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Fetal echocardiography is now commonly used to assess fetuses for congenital heart disease. To care for their patients, it is important for the pediatrician to understand the utility of the test, the benefits, and the limitations of the results. This review outlines the indications, components, and limitations of fetal echocardiography with a focus on the care that the pediatrician provides to newborns and their families. An understanding of the fetal cardiac examination can assist the pediatrician in caring for patients with either normal or abnormal test results. The need for and timing of postnatal cardiology follow-up, and guidance on referral for fetal echocardiogram for future pregnancies are all critical roles that the pediatrician can play. Most importantly, an understanding of the limitations, including difficult-to-diagnose lesions, allows the pediatrician to maintain a high level of suspicion for cardiac defects regardless of fetal echocardiography findings. [Pediatr Ann. 2021;50(3):e121-e127.].
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30
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Pinto NM, Morris SA, Moon-Grady AJ, Donofrio MT. Prenatal cardiac care: Goals, priorities & gaps in knowledge in fetal cardiovascular disease: Perspectives of the Fetal Heart Society. PROGRESS IN PEDIATRIC CARDIOLOGY 2020; 59:101312. [PMID: 33100800 PMCID: PMC7568498 DOI: 10.1016/j.ppedcard.2020.101312] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/12/2020] [Indexed: 12/15/2022]
Abstract
Perinatal cardiovascular care has evolved considerably to become its own multidisciplinary field of care. Despite advancements, there remain significant gaps in providing optimal care for the fetus, child, mother, and family. Continued advancement in detection and diagnosis, perinatal care and delivery planning, and prediction and improvement of morbidity and mortality for fetuses affected by cardiac conditions such as heart defects or functional or rhythm disturbances requires collaboration between the multiple types of specialists and providers. The Fetal Heart Society was created to formalize and support collaboration between individuals, stakeholders, and institutions. This article summarizes the challenges faced to create the infrastructure for advancement of the field and the measures the FHS is undertaking to overcome the barriers to support progress in the field of perinatal cardiac care. Progress in perinatal cardiology is challenged by the rarity of fetal cardiac disease, care variation, and barriers to collaboration. The Fetal Heart Society was founded to formalize collaboration between the multiple disciplines in perinatal cardiac care. The FHS facilitates interdisciplinary multicenter research, education and advocacy to provide optimal perinatal cardiac care.
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Affiliation(s)
- Nelangi M Pinto
- Division of Cardiology, Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, UT, United States of America.,Fetal Heart Society, United States of America
| | - Shaine A Morris
- Division of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States of America.,Fetal Heart Society, United States of America
| | - Anita J Moon-Grady
- Division of Cardiology, Department of Pediatrics, University of California San Francisco and UCSF Benioff Children's Hospitals, United States of America
| | - Mary T Donofrio
- Division of Cardiology, Department of Pediatrics, Children's National Hospital and George Washington University School of Medicine and Health Sciences, United States of America.,Fetal Heart Society, United States of America
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31
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Bhambhani A, Mathew A, Varunya M, Uligada S, Kala P. Role of routine fetal echocardiography in an unselected group of pregnant women for prenatal detection of cardiac malformations. Indian Heart J 2020; 72:427-430. [PMID: 33189206 PMCID: PMC7670276 DOI: 10.1016/j.ihj.2020.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/13/2020] [Accepted: 08/04/2020] [Indexed: 11/05/2022] Open
Abstract
Objectives We investigated the potential for improvement in prenatal detection of congenital heart disease (CHD) by routinely performing detailed fetal echocardiography (FE) in all pregnant women. Methods Following routine obstetric sonography, 1445 unselected pregnant women were prospectively subjected to FE at gestational ages between 16 and 24 weeks, or at first visit, if they presented later. Maternal or fetal factors, conventionally known to be associated with risk of CHD, were noted. The prevalence and detection rates of cardiac abnormalities were determined, and confirmation of findings by postnatal follow-up was done to ensure accuracy of FE. Prevalence of CHD was compared in pregnancies with or without conventional risk factors. Results The overall prevalence of CHD was 8.3 per 1000; only 2 CHD cases belonged to the high maternal risk group, while 10 cases were observed without maternal risk factors. Cardiac malformations were suspected in 14 fetuses during obstetric scan; but, only 5 of them had CHD, remaining 9 had structurally normal hearts. 50% of CHD cases occurred in pregnancies not associate with any (fetal or maternal) risk factor. The sensitivity, and specificity for prenatal CHD detection were 91.7% and 100% respectively. Conclusions Our study indicates that a substantial proportion of CHD cases occur in women not having high risk of giving birth to children with CHD. FE is a highly sensitive and specific test with strong predictive values. We recommend that FE should be done in every pregnancy.
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Affiliation(s)
- Anupam Bhambhani
- Department of Cardiology, Vydehi Institute of Medical Sciences and Research Centre, Whitefield, Bangalore, India.
| | - Amalu Mathew
- Department of Cardiology, Vydehi Institute of Medical Sciences and Research Centre, Whitefield, Bangalore, India
| | - Mary Varunya
- Department of Radiodiagnosis, Vydehi Institute of Medical Sciences and Research Centre, Whitefield, Bangalore, India
| | - Seema Uligada
- Department of Radiodiagnosis, Vydehi Institute of Medical Sciences and Research Centre, Whitefield, Bangalore, India
| | - Prachi Kala
- Department of Radiodiagnosis, Vydehi Institute of Medical Sciences and Research Centre, Whitefield, Bangalore, India
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32
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Dong SZ, Zhu M, Ji H, Ren JY, Liu K. Fetal cardiac MRI: a single center experience over 14-years on the potential utility as an adjunct to fetal technically inadequate echocardiography. Sci Rep 2020; 10:12373. [PMID: 32704065 PMCID: PMC7378840 DOI: 10.1038/s41598-020-69375-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 07/07/2020] [Indexed: 12/26/2022] Open
Abstract
Unlike ultrasound (US) imaging, foetal magnetic resonance imaging (MRI) is not significantly limited by maternal obesity, oligohydramnios, uterine myoma, twins, and foetal lie, which impair US visualization of the foetus. The present study aimed to introduce our foetal cardiac MRI scanning technology and over 14-years of experience on the potential utility of foetal cardiac MRI examination as an adjunct to foetal technically inadequate echocardiography (Echo). This retrospective review included 1,573 pregnant women [1,619 foetuses (46 twins)] referred for a foetal cardiac MRI because of technically limited Echo. Foetal cardiac MRI was performed using two 1.5 T units. Among the 1,619 foetuses referred for cardiac MRI, 1,379 (85.2%) cases were followed up using postnatal imaging and/or surgery, 240 (14.8%), including three twins, had no follow-up confirmation because of pregnancy termination without autopsy or loss to follow-up. The results of the present study indicated that foetal cardiac MRI examinations can be a useful adjunct to foetal echocardiography when the technical limitations of echocardiography make it inadequate for diagnosis.
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Affiliation(s)
- Su-Zhen Dong
- Department of Radiology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, 200127, China.
| | - Ming Zhu
- Department of Radiology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, 200127, China.
| | - Hui Ji
- Department of Radiology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, 200127, China
| | - Jing-Ya Ren
- Department of Radiology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, 200127, China
| | - Ke Liu
- Department of Radiology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, 200127, China
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Nigam P, Weinberger S, Srivastava S, Lorber R. The evolution of fetal echocardiography before and during COVID-19. PROGRESS IN PEDIATRIC CARDIOLOGY 2020; 58:101259. [PMID: 32837145 PMCID: PMC7306716 DOI: 10.1016/j.ppedcard.2020.101259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 11/27/2022]
Abstract
The World Health Organization declared the novel coronavirus, or COVID-19, a pandemic in March 2020. Given the severity of COVID-19, appropriate use criteria have been implemented for fetal echocardiography. Screening low risk pregnancies for critical congenital heart disease has typically been a shared responsibility by pediatric cardiologists, obstetricians, and maternal fetal medicine (MFM). Currently, many of the fetal echocardiograms for low risk pregnancies for critical congenital heart disease have been deferred or cancelled with the emphasis on suspected abnormalities by MFMs and obstetricians. In this review, we discuss the literature that has been the basis of screening of low risk pregnancies by pediatric cardiologists. A new approach to more widespread usage of fetal tele-echocardiography may play a large part during COVID-19 and may continue after the pandemic. Appropriate use criteria for fetal echocardiography have been implemented during the COVID-19 pandemic. Pediatric cardiologists have deferred fetal echo for low risk pregnancies, emphasizing those with suspected abnormalities. Current fetal echo guidelines highlight maternal, familial, and fetal risk factors, and the associated incidence of CHD. Fetal tele-echocardiography and telehealth consultation may enhance the ability to provide care during and beyond COVID-19.
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Affiliation(s)
- Priya Nigam
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States of America
| | - Sharon Weinberger
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States of America
| | - Shubhika Srivastava
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States of America
| | - Richard Lorber
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States of America
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Wen SW, Miao Q, Taljaard M, Lougheed J, Gaudet L, Davies M, Lanes A, Leader A, Corsi DJ, Sprague AE, Walker M. Associations of Assisted Reproductive Technology and Twin Pregnancy With Risk of Congenital Heart Defects. JAMA Pediatr 2020; 174:446-454. [PMID: 32091547 PMCID: PMC7042937 DOI: 10.1001/jamapediatrics.2019.6096] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE The extent to which assisted reproductive technology is associated with increased risk of congenital heart defects independent of its known association with twinning remains uncertain. OBJECTIVE To assess the extent to which assisted pregnancy is associated with increased risk of congenital heart defects independent of its known association with twinning. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study linked records of congenital heart defect diagnoses with assisted reproductive technology cycles in 507 390 singleton or twin pregnancies (10 149 assisted pregnancies and 497 241 nonassisted pregnancies), including singleton and twin early pregnancy losses, stillbirths, and live births (follow-up to 1 year of age) in Ontario, Canada, between April 1, 2012, and October 31, 2015. Statistical analysis was performed from January 1, 2017, to September 9, 2019. EXPOSURES Assisted reproductive technology and its 2 subtypes: intracytoplasmic sperm injection and in vitro fertilization without intracytoplasmic sperm injection. MAIN OUTCOMES AND MEASURES The main outcome was congenital heart defects (prevalence and relative risk measured as odds ratios [ORs]). Mediation analysis was performed to assess the extent to which the association between assisted reproductive technology and congenital heart defects was mediated by twinning. RESULTS Of 507 390 mother-infant pairs with singleton or twin pregnancies evaluated, the prevalence of congenital heart defects in assisted pregnancies (223 [2.2%]) was higher than that in nonassisted pregnancies (6057 [1.2%]; crude OR, 1.82; 95% CI, 1.59-2.09). The strength of the association between assisted pregnancy and congenital heart defects decreased after adjusting for several risk factors simultaneously (adjusted OR, 1.70; 95% CI, 1.48-1.95). Further mediation analysis indicated that most of the association between assisted pregnancy and congenital heart defects was mediated by twinning (adjusted OR, 1.68; 95% CI, 1.44-1.92), and the natural direct association of assisted pregnancy with congenital heart defects among singleton pregnancies was 1.09 (95% CI, 0.93-1.25). Mediation of twinning accounted for 87.3% of the association. CONCLUSIONS AND RELEVANCE Our study results suggest that the association between assisted reproductive technology and congenital heart defects may be mediated by twinning.
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Affiliation(s)
- Shi Wu Wen
- OMNI Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada,Department of Obstetrics and Gynecology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada,School of Epidemiology and Public Health, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada,Nanhai Hospital, Southern Medical University, Foshan, Guangdong, China
| | - Qun Miao
- Better Outcomes Registry & Network (BORN) Ontario, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada,Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Monica Taljaard
- Department of Obstetrics and Gynecology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada,School of Epidemiology and Public Health, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Jane Lougheed
- Division of Cardiology, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada,Department of Pediatrics, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Laura Gaudet
- OMNI Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada,Department of Obstetrics and Gynecology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada,School of Epidemiology and Public Health, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Michael Davies
- Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
| | - Andrea Lanes
- Better Outcomes Registry & Network (BORN) Ontario, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Art Leader
- Department of Obstetrics and Gynecology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Daniel J. Corsi
- OMNI Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada,Department of Obstetrics and Gynecology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada,School of Epidemiology and Public Health, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada,Better Outcomes Registry & Network (BORN) Ontario, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Ann E. Sprague
- Better Outcomes Registry & Network (BORN) Ontario, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada,Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Mark Walker
- OMNI Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada,Department of Obstetrics and Gynecology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada,School of Epidemiology and Public Health, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada,Better Outcomes Registry & Network (BORN) Ontario, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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