Congenital limb deficiencies in newborn infants: prevalence, characteristics and prenatal diagnosis

Difference between affected and unaffected sides of forearm bone length in children with congenital terminal transverse deficiencies at the level of carpal bone

The forearm of the affected sideis often shorter than that of the unaffected side in children with congenital terminal transverse deficiencies at the level of proximal or distal carpals. The aim of this study is to clarify the characteristics of forearm bone length in those children, especially to quantify the difference in forearm bone length between affected and unaffected sides. The subjects were children with carpal partial transverse deficiencies. The lengths of the radius and the ulna were measured in the radiographs. The lengths of affected and unaffected sides (A/U) were compared in order to quantify the discrepancy. The A/U ratio was defined as the length of the affected side divided by that of the unaffected side. The A/U ratios ranged from 77.1 to 99.0% in the radii and from 74.1 to 99.6% in the ulnae. In both the radius and ulna, the A/U ratios were significantly lower than the left/right ratios of normal adults. Additionally, the A/U ratios of the ulna were significantly lower than the A/U ratios of the radius. The forearm bones of affected side are significantly shorter than those of unaffected side. Although the cause remains unclear, it is possible that not only congenital factors but also acquired factors such as infrequent use of the affected upper limb are involved. A future longitudinal study is necessary to investigate whether length discrepancies can be reduced by using prostheses to increase the frequency of use on the affected limb.

Fetal Hands: A Comprehensive Review of Prenatal Assessment and Diagnosis Over the Past 40 Years

Fetal skeletal dysplasias involving limbs and hands are rare congenital malformations. Prenatal two-dimensional ultrasound diagnosis of fetal limb defects has a sensitivity of about 30%; however, an increased detection rate may be obtained using three-dimensional (3-D) ultrasound in the rendering mode. 3-D ultrasound may be used as a complementary method providing additional information. Currently, magnetic resonance imaging (MRI), with the emergence of ultrafast imaging techniques and new sequences, allows for better diagnosis of several fetal skeletal dysplasias such as limb reduction defects and neuromuscular disorders. 3-D volumetric images from ultrasound or MRI scan data allow 3-D ultrasound reconstructions of virtual/physical models, and virtual reality can help researchers to improve our understanding of both normal and abnormal fetal limb/hand anatomy. In this article, we review the embryological development of fetal hands and their main anomalies including prenatal diagnostic methods, genetic counseling, the role of orthopedic and plastic surgery reconstruction, and new perspectives in fetal surgery.

Congenital Upper Limb Deficiency with Oligodactyly: A Case Report

Congenital upper limb deficiency care and management have undergone drastic changes over the past 50 years. Given the low incidence of this defect nationwide, this case report adds to the existing database to analyze the etiological investigations, descriptive epidemiology, and trend detection. We present a case of a 2-month-old male child with congenital upper limb deficiency and explore the possible etiologies and difficulties during early diagnosis of such rare disorders in a low and middle-income countrries and present implications at the primary health care level to improve the prognosis. Poor nutrition during pregnancy due to an unplanned pregnancy is a possible cause. The prognosis is unfavourable due to sociocultural barriers. To address these limitations, it is pertinent to address disability-adequate knowledge among communities, promote early diagnosis, and timely rehabilitation using a multidisciplinary approach. Further, we provide a framework to optimize care.

Keywords

congenital limb deficiency; prevalence; upper limb defect.

Folic acid supplementation and risk for congenital limb reduction defects in China

BACKGROUND

Folic acid (FA) supplementation prevents neural tube defects, but there are mixed results for its ability to prevent limb reduction defects. We examined whether a preventive effect of FA supplementation exists for congenital limb reduction defects in a large population in China.

METHODS

Data from a large population-based cohort study in China were used to evaluate the effects of FA supplementation on birth defects. All births at 20 complete gestational weeks, including live births, stillbirths and pregnancy terminations, and all structural congenital anomalies, regardless of gestational week, were recorded. A total of 247 831 singleton live births delivered at gestational ages of 20-42 weeks to women from northern and southern China with full information on FA intake were included. Limb reduction defects were classified by subtype and maternal FA supplementation.

RESULTS

The prevalence of limb reduction defects was 2.7 per 10 000 births among women who took FA compared with 9.7 per 10 000 births among those who did not take FA in northern China; the prevalence was 4.5 and 3.8 per 10 000 births, respectively, in southern China. In both unadjusted and adjusted analyses, the estimated relative risk for upper limb reduction defects [odds ratio (OR) = 0.17, 95% confidence interval (CI): 0.04, 0.63] and total limb reduction defects (OR = 0.24, 95% CI: 0.08, 0.70) in northern China, but not for lower limb reduction defects ,was significantly decreased in association with FA supplementation in northern China. There was no association between FA supplementation and either an increased or decreased risk for limb reduction defects in southern China.

CONCLUSIONS

FA supplementation successfully reduces the prevalence of limb reduction defects in northern China, whose population has low folate concentrations.

Prevalence of congenital limb defects: Data from birth defects registries in three provinces in Southern Thailand

This is the first population-based study in Thailand on the prevalence of congenital limb defects (CLD). Data were obtained from recently established birth defects registries in three southern Thailand provinces during 2009-2013. Entries in the birth defects registries included live births, stillbirths after 24 weeks gestational age, and terminations of pregnancy following a prenatal diagnosis of fetal anomaly. The total of 186 393 births recorded included 424 CLD cases, giving an average prevalence of 2.27 per 1000 births (95% CI, 2.05-2.49). The most common CLD was talipes equinovarus (44.1%), followed by polydactyly (13.9%) and syndactyly (9.4%). The prevalence significantly increased with maternal age from 1.81 in mothers aged <30 years to 2.75 in mothers 30 to  < 35 years, and to 2.94 in mothers ≥35 years (P = 0.004). Overall 9.4% of the CLDs were syndromic CLD, again with significantly greater percentages in pregnant women aged ≥35 years than the non-syndromic CLD (32.5% vs 17.5% respectively, P = 0.03). In conclusion, the overall prevalence of CLD in the 3 southern Thailand provinces examined was 2.27 per 1000 births, and syndromic CLD was significantly higher in pregnant women aged ≥35 years than younger pregnant women.

Birth prevalence of selected external structural birth defects at four hospitals in Dar es Salaam, Tanzania, 2011-2012

BACKGROUND

94% of all birth defects (BD) and 95% of deaths due to the BD occur in low and middle income countries, many of which are preventable. In Tanzania, there is currently a paucity of BD data necessary to develop data informed prevention activities.

METHODS

A cross-sectional analysis was conducted of deliveries identified with BD in the labor ward registers at four Dar es Salaam hospitals between October, 2011 and February, 2012. The birth prevalence of structural BD, case fatality proportion, and the distribution of structural defects associated deaths within total deaths were calculated.

RESULTS

A total of 28 217 resident births were encountered during the study period. Overall birth prevalence of selected defects was 28.3/10 000 live births. Neural tube defects and indeterminate sex were the most and least common defects at birth (9.9 and 1.1/10 000 live births, respectively). Among stillbirths (66.7%) and deaths that occurred within less than 5 days of an affected live birth (18.5%), neural tube defects were the most frequently associated structural defect.

CONCLUSION

Structural BD is common and contributes to perinatal mortality in Dar es Salaam. More than half of perinatal deaths encountered among the studied selected external structural BD are associated with neural tube defects, a birth defect with well-established evidence based prevention interventions. By establishing a population-based BD surveillance program, Tanzania would have the information about neural tube defects and other major structural BD needed to develop and monitor prevention activities.

Maternal periconceptional alcohol consumption and congenital limb deficiencies

BACKGROUND

Women of childbearing age report high rates of alcohol consumption, which may result in alcohol exposure during early pregnancy. Epidemiological research on congenital limb deficiencies (LDs) and periconceptional exposure to alcohol is inconclusive.

METHODS

Data from the National Birth Defects Prevention Study (NBDPS) were examined for associations between LDs and patterns of maternal periconceptional (1 month before conception through the first trimester) alcohol consumption among LD case (n = 906) and unaffected control (n = 8352) pregnancies with expected delivery dates from 10/1997 through 12/2007. Adjusted odds ratios (aORs) and 95% confidence intervals were estimated from unconditional logistic regression analysis for all LDs combined, specific LD subtypes (preaxial/terminal transverse), and LD anatomic groups (upper/lower limbs); interactions with folic acid (FA) supplementation were tested.

RESULTS

When compared with nondrinkers, inverse associations were found between all LDs combined, preaxial, and upper LDs and any reported periconceptional alcohol consumption (aORs ranged from 0.56-0.83), drinking without binging (aORs: 0.53-0.75), and binge drinking (≥4 drinks/occasion) (aORs: 0.64-0.94); however, none of the binge drinking aORs were statistically significant. Stratification by alcohol type showed inverse associations between all LDs combined, preaxial, transverse, and upper and lower LDs for drinking without binging of wine only (aORs: 0.39-0.67) and between all LDs combined and upper LDs for drinking without binging of combinations of alcohol (aORs: 0.63-0.87). FA did not modify observed associations.

CONCLUSION

Maternal periconceptional alcohol consumption did not emerge as a teratogen for selected LDs in the NBDPS. Future studies should evaluate additional rare LDs among more highly exposed populations.

The utility of prenatal ultrasound as a screening tool for upper extremity congenital anomalies

PURPOSE

To quantify the detection rate and accuracy of prenatal ultrasound in patients with congenital upper extremity anomalies.

METHODS

A total of 100 patients with congenital upper extremity reduction or duplication anomalies were enrolled prospectively in this investigation at the initial visit to our congenital hand clinic. Demographic and pregnancy-related data were collected along with prenatal diagnoses. We recorded all ultrasound-identified upper extremity anomalies as reported by the parents. Finally, we compared the prenatal diagnosis with the final congenital hand clinic diagnosis.

RESULTS

The first ultrasound was performed at a mean 11 weeks' gestation, and patients underwent an average of 8 prenatal ultrasounds (range, 1-40 prenatal ultrasounds). Sixty patients underwent standard ultrasound and 40 had a 3-dimensional ultrasound as well. Of the 100 patients, 31 had an upper extremity anomaly by ultrasound. Of the 31 prenatal ultrasound diagnoses, 18 were confirmed as accurate during evaluation in the congenital hand clinic. Three-dimensional ultrasound was more sensitive for the detection of upper extremity anomalies.

CONCLUSIONS

The overall detection rate and accuracy of ultrasonography for upper extremity anomalies were low despite advancements in imaging technology.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

[Sensitivity of ultrasonographic diagnosis in hand malformations. About 80 cases]

During pregnancy, the Haute Autorité de santé (HAS) recommends to realize three ultrasonographic evaluations, notably for the early detection of congenital malformations. Yet, in our experience, ultrasonographic antenatal diagnoses of hand malformations are rare. This is both a retrospective (years 2003-2008) and a prospective study (2009-2012). It quantifies the sensibility of hand malformations ultrasonographic diagnosis. Questionnaires have been sent or given during consultations to parents of children with upper limb malformation. The parents' acceptance of diagnosis and their anxiety have been evaluated. Eighty-eight malformations have been recruited for our series. Only 11 antenatal diagnoses have been made. Thus, sonographic diagnosis sensibility is 12.5% in our series. Thirty-nine percent of the parents have been shocked by the absence of diagnosis at birth. The sensibility of hand malformation ultrasonographic diagnosis is rarely documented in literature. It is generally low. This diagnosis may raise concerns about eugenism and legal issues. However, congenital malformations, even in the absence of a diagnosis, must be taken care of by a clearly determined network. Our results highlight difficulties of prenatal diagnosis of upper limb malformations. A lot of questions arise: what information should be delivered to the parents? Should antenatal ultrasonographic diagnosis be legislated? "Minor" malformations are often well managed by the parents, but "major" malformations ignored often raise legal issues.

Fetal transverse limb defects: case series and literature review

PURPOSE

To investigate the incidence and outcome of antenatally diagnosed isolated transverse limb defects at a major tertiary center and to review the literature relevant to this rare condition.

METHODS

This was a retrospective review of all cases (2000-2009) diagnosed with an isolated transverse limb defect referred to a tertiary fetal medicine center. Isolated transverse limb defects were defined as partial or complete absence of a part of one or more limbs in the absence of other abnormalities.

RESULTS

Nine cases were identified. The upper limbs were affected in seven cases. The median gestational age at diagnosis was 22+5 weeks (range 21-29 weeks). The defects ranged from absence of digits to the absence of three limbs in one case. Four women opted to have termination of pregnancy. Postnatal and postmortem examination confirmed the ultrasound findings. No obvious risk factors could be identified in the majority of cases.

CONCLUSIONS

Most cases of limb defects are believed to be secondary to a vascular insult occurring early in embryonic life. The reason for upper limb predominance remains unclear. Perinatal outcome in this series was poor with the majority of pregnancies terminated. Long-term functional outcome depends on the severity of the limb reduction defect.

Associated malformations in patients with limb reduction deficiencies

Infants with limb reduction deficiencies (LRD) often have other associated congenital malformations. The purpose of this investigation was to assess the prevalence and the types of associated malformations in a defined population. This study included special strengths: each affected child was examined by a geneticist, all elective terminations were ascertained, and the surveillance for malformations was continued until 1 year of age. The associated malformations in infants with LRD were collected in all livebirths, stillbirths and terminations of pregnancy during 25 years in 347,810 consecutive births in the area covered by our population based registry of congenital malformations. Of the 271 LRD infants born during this period, representing a prevalence of 7.8 per 10,000, 57.9% had associated malformations. There were 17(6.3%) patients with chromosomal abnormalities including 10 trisomies 18, and 62 (22.9%) nonchromosomal recognized dysmorphic conditions. There were no predominant recognized dysmorphic conditions, but VA(C)TER(L) association. However numerous recognized dysmorphic conditions were registered including Poland, ectrodactyly-ectodermal dysplasia-clefting, oral-facial-digital, Klippel-Trenaunay-Weber, oculo-auriculo-vertebral defect spectrum, CHARGE, Townes-Brocks, Moebius, Du Pan, Smith-Lemli-Opitz, hypoglossia-hypodactyly, amniotic band, De Lange, Rubinstein-Taybi, Fanconi, radius aplasia- thrombocytopenia, Roberts, Holt-Oram, and fetal diethylstilbestrol. Seventy eight (28.8%) of the patients were multiply, non-syndromic, non chromosomal malformed infants (MCA). Malformations in the cardiac system, in the genital system, and in the central nervous system were the most common other malformations, 11.4%, 9.4%, and 7.7% of the associated malformations, respectively, followed by malformations in the renal system (4.8%), and in the digestive system (4.6%). Prenatal diagnosis was performed in 48.4% of dysmorphic syndromes with LRD. The overall prevalence of associated malformations, which was more than one in two infants, emphasizes the need for a thorough investigation of infants with LRD.A routine screening for other malformations especially cardiovascular system, urogenital system, central nervous system, and digestive system may be considered in infants and in fetuses with LRD.

[Management of 103 limb reduction defects: a French-speaking fetal medicine club enquiry]

OBJECTIVES

Prenatal diagnosis of a limb reduction defect poses difficult medical and ethical problems. Prenatal diagnosis can be at the origin of two opposing medical attitudes, either a medical termination of pregnancy, or the specific management of the child at birth. The objective is to carry out an enquiry of practices and to determine whether there is a threshold in the gravity of the malformation from which the medical termination of pregnancy is accepted.

MATERIAL AND METHOD

The study was carried out by a questionnaire addressed to the members of the French-speaking Club of Fetal Medicine.

RESULTS

Outcome of 103 fetuses with limb reduction defect was described. Prenatal diagnosis and management of observed malformations were explained.

CONCLUSION

Decisions concerning the outcome of the pregnancy are very variable from one couple to another and from one medical team to another. Parents making a request must be given complete information and accompanying psychological support. Collegial with a multidisciplinary team is necessary. For the parents, it is the physician's duty to avoid judgement errors related to anxiety and ignorance of the medical consequences. The physician should guide the parents towards the continuation of the pregnancy or its interruption. The proper decision proceeds from the reunion of the confidence of the couple and the conscience of the physician.