Fetal forearm anomalies: prenatal diagnosis, associations and management strategy

Pre-natal and post-natal diagnosis of congenital upper limb differences: The first 3 years of the Australian Hand Difference Register

AIMS

Children with a congenital upper limb difference (CoULD) are a diverse group who often require multidisciplinary care and long-term support for functional and social impacts. The Australian Hand Difference Register (AHDR) provides a national database of children born with a CoULD and aims to facilitate research and improve health care for affected children. Using data from the first 3 years of its operation, we analysed the demographic and clinical features of participating families, including type of CoULDs and the frequency of pre-natal and syndromic diagnoses.

METHODS

Families were recruited from tertiary plastic surgery, orthopaedic and genetics clinics, as well as by self-referral. Hand differences were classified by the consulting physician according to the Oberg-Manske-Tonkin classification system. Primary carers were invited to complete an online questionnaire covering demographic information, pregnancy and newborn outcomes and diagnostic details.

RESULTS

Between August 2017 and September 2020, 822 families consented and 320 questionnaires were reviewed. CoULDs were detected pre-natally in 66 (20.6%) and post-natally in 248 children (77.5%); data for 6 (1.9%) children were missing. The most common CoULDs were radial polydactyly, symbrachydactyly with ectodermal elements and radial longitudinal deficiency, hypoplastic thumb. Twenty-seven children (8.4%) had an associated syndrome, 7 diagnosed pre-natally and 19 post-natally; the most common were VACTERL association, Poland anomaly, Holt-Oram and ectrodactyly-ectodermal dysplasia-clefting syndromes.

CONCLUSIONS

The AHDR is a valuable resource for understanding the relative frequencies of CoULDs. Participation will assist future research into the diagnostic journeys of children with CoULDs, including risk factors, diagnosis and psychosocial impacts.

Non-syndromic bilateral ulnar aplasia with humero-radial synostosis and oligo-ectro-dactyly

Congenital anomalies of the upper limbs are rare and etiologically heterogeneous. Herein, we report a male infant with non-syndromic bilateral Type Vb ulnar longitudinal dysplasia with radiohumeral synostosis (apparent humeral bifurcation), and bilateral oligo-ectro-syndactyly who was born following an uncomplicated pregnancy, with no maternal use of prescription or illicit medication. Array CGH (60,000 probes) and chromosomal breakage analysis (DEB) were normal. Similar appearances have been reported in children exposed to thalidomide or cocaine, but sporadic patients have also been reported without a prior history of exposure to known teratogens.

Prenatal diagnosis of upper extremity malformations with ultrasonography: Diagnostic features and perinatal outcome

OBJECTIVE

The aim of this study was to assess the sonographic (US) characteristics, associated malformations, chromosomal status, and perinatal outcomes of fetuses with an upper extremity malformation (UEM) detected by US examination.

METHODS

The data of all patients evaluated in the Department of Obstetrics and Gynecology, Prenatal Diagnosis Unit between 2010 and 2015 were searched for UEM.

RESULTS

A total of 51 cases with UEM were detected. Eighteen cases (35.2%) had defects in the formation of body parts (absence of hand/forearm/digits); 25 cases (49%) had defects in differentiation (contractures, syndactyly), and 8 cases (15.6%) had duplication defects (polydactyly). The specificity of prenatal US for UEM was 96.2%. Ten cases (19.7%) had isolated UEM, and 41 cases (80.3%) had additional anomalies, most of which were cardiac, central nervous system, or facial malformations. Although chromosomal structure in isolated cases was normal in 9 of 10 cases (90%), 15 of 41 cases (36.5%) with multiple defects showed abnormal karyotypes. The chromosomal constituents of nine cases (17.6%) were not available. Although the postnatal outcome of isolated cases was favorable except for the presence of orthopedic problems, complex UEMs with or without abnormal karyotypes were always lethal (97.5%).

CONCLUSIONS

UEMs associated with other malformations are usually a sign of underlying severe chromosomal abnormalities, and the prognosis is poor. In contrast, chromosomal structure in isolated cases is normal, and the perinatal and postnatal outcomes are good. In general, US is an effective tool in differentiating fetuses with isolated UEM from those with UEM associated with additional malformations. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:267-276, 2017.

Heterogeneous Diagnoses Underlying Radial Ray Anomalies

OBJECTIVE

To review perinatal Radial Ray Anomaly (RRA) cases born at the National Institute of Perinatology, Mexico, and to reveal the heterogeneous diagnoses of these patients.

METHODS

All patients with RRA over a 18 mo period were included; 4/15 were detected prenatally and 11/15 postnatally. Karyotype was performed for all patients with bilateral RRA; and chromosomal breakage analysis, when the karyotype was normal.

RESULTS

Fifteen RRA patients were identified: one with trisomy 18, three with an isolated defect, six with monogenic disease, four with a genetic association and one with diabetic embryopathy. Five were stillborn and two died during the early neonatal period; all of whom presented with multiple defects. Three of the live born patients and one stillborn with multiple defects had Fanconi anemia. RRAs carry a high perinatal mortality rate (47%) when they occur in association with other defects.

CONCLUSIONS

The assessment of these patients needs to involve the combined use of ultrasound, clinical, genetic, cytogenetic and molecular testing. The present results indicate that the chromosome breakage test should always be performed to rule out Fanconi anemia in this group.

Is the diagnostic yield influenced by the indication for fetal autopsy?

The utility of fetal autopsy to corroborate antenatal ultrasound findings and to aid genetic counseling is well known. However, the ability to identify an underlying cause for the common indications for which it is performed is not well studied. This study aimed to determine if the diagnostic yield of fetal autopsy in identifying the underlying cause is determined by the indication of the autopsy. Five groups of fetuses were defined based on the indication for the autopsy performed in 903 cases: (i) malformations, (ii) intrauterine death (IUD), (iii) cystic hygroma and hydrops fetalis, (iv) isolated abnormalities of amniotic fluid, and (v) intrauterine growth restriction (IUGR). The highest diagnostic yield was in fetuses with isolated abnormalities of amniotic fluid (77%), followed by those with IUGR (75%), with IUD (69.6%), those in group five (55.2%) and lowest (45%) in fetuses with malformations (P < 0.001). A cause was identified in 77.8% fetuses with multiple malformations compared to 37.5% with isolated malformations (P < 0.001), with chromosomal abnormalities in 31.8% versus 9.9% respectively (P < 0.001) and malformation syndromes in 42.5% versus 26.3% (P < 0.001). Placental examination provided the highest yield in IUD, IUGR, and oligohydramnios (43.1%; P < 0.003) whereas chromosomal analysis was most useful in cystic hygroma/NIHF (28.9%; P < 0.001). This information on the diagnostic yield in fetal autopsy related its common indications, can be utilized to counsel families of the utility of autopsy to establish cause and recurrence risks and thereby assist then to make an informed decision to consent for the procedure. © 2016 Wiley Periodicals, Inc.

Prenatal Detection of Upper Limb Differences With Obstetric Ultrasound

PURPOSE

To determine the sensitivity, specificity, and predictive values of prenatal ultrasound detection of fetal upper extremity anomalies at a single tertiary care center in a large patient cohort. Our secondary purpose was to assess factors affecting prenatal detection including the presence of associated anomalies.

METHODS

We performed a retrospective review of prenatal ultrasound and postnatal clinical records from each pregnancy evaluated with a prenatal ultrasound at the Washington University Department of Obstetrics and Gynecology over a 20-year period. We searched for upper extremity anomaly diagnosis codes pre- and postnatally and correlated with clinical postnatal follow-up to determine prevalence, sensitivity, specificity, predictive values, and associated conditions.

RESULTS

A total of 100,856 pregnancies were evaluated by prenatal ultrasound, which included 843 fetuses diagnosed with a musculoskeletal anomaly (prevalence, 1 of 120) and 642 with an upper extremity anomaly (prevalence, 1 of 157). The postnatally confirmed sensitivity for prenatal ultrasound detection of an upper extremity anomaly was 42%. Sensitivity was lower in cases isolated to the upper extremity (25% vs 55%). Sensitivity was highest for conditions affecting the entire upper extremity (70%-100%) and lowest for those affecting the digits alone (4%-19%). Fetuses with limb reduction defects, radial longitudinal deficiency, phocomelia, arthrogryposis, abnormal hand positioning, and cleft hand had a higher likelihood of having an associated anomaly.

CONCLUSIONS

At our tertiary referral center, there was a notable prevalence of upper extremity anomalies; however, the overall sensitivity for detecting them with prenatal ultrasound was low. This was disappointing given the value of prenatal identification of anomalies for parental counseling. Prenatal diagnosis of anomalies affecting the entire upper limb was more reliable than diagnosis of more distal anomalies.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

The utility of ultrasound for the detection of fetal limb abnormalities--a 20-year single-center experience

Objective

The standard obstetric ultrasound examination includes documentation of arms and legs. The purpose of this study is to review the efficacy of ultrasound for the detection of limb anomalies, the type and incidence of associated malformations and pregnancy outcomes.

Method

All cases of polydactyly (POD), abnormal hand position (AHP), limb reduction defects (LRD) and arthrogryposis (ART) scanned in our Unit between 1990 and 2010 were identified. Cases were categorized as isolated (ISO) or non-isolated (NISO). The accuracy of prenatal diagnosis, type and incidence of associated malformations and aneuploidy and pregnancy outcomes were determined.

Results

Most cases were NISO. The sensitivity of ultrasound was 19.1% for POD, 76.0% for AHP, 76.0% for LRD involving the long bones and 81.3% for ART. Cardiothoracic and facial defects were the most common accompanying malformations. The risk for aneuploidy ranged from 3.6% for POD to 47.2% for AHP. The live birth rate ranged from 85.5% for POD to 24.5% for AHP.

Conclusion

While imaging of the arms and legs allows detection of most cases of AHP, LRD involving the limbs and ART, a probable minimum of 20% to 25% of cases will escape prenatal diagnosis. Identification of these defects should prompt an extended anatomic survey and consideration of invasive testing for aneuploidy. © 2014 The Authors. Prenatal Diagnosis published by John Wiley & Sons Ltd.