Correlation between fetal cardiac diagnosis by obstetric and pediatric cardiologist sonographers and comparison with postnatal findings

Comparison of the Results of Prenatal and Postnatal Echocardiography and Postnatal Cardiac MRI in Children with a Congenital Heart Defect

OBJECTIVE

In fetuses with suspicion of congenital heart disease (CHD), assessment by segmental fetal echocardiography is of great importance. This study sought to examine the concordance of expert fetal echocardiography and postnatal MRI of the heart at a high-volume paediatric heart centre.

METHODS

The data of two hundred forty-two fetuses have been gathered under the condition of full pre- and postnatal and the presence of a pre- and postnatal diagnosis of CHD. The haemodynamically leading diagnosis was determined for each test person and was then sorted into diagnostic groups. The diagnoses and diagnostic groups were used for the comparison of diagnostic accuracy in fetal echocardiography.

RESULTS

All comparisons between the diagnostic methods for detection of congenital heart disease showed an "almost perfect" (Cohen's Kappa > 0.9) strength of agreement for the diagnostic groups. The diagnosis made by prenatal echocardiography showed a sensitivity of 90-100%, a specificity and a negative predictive value of 97-100%, and a positive predictive value of 85-100%. The diagnostic congruence resulted in an "almost perfect" strength of agreement for all evaluated diagnoses (transposition of great arteries, double outlet right ventricle, hypoplastic left heart, tetralogy of Fallot, atrioventricular septal defect). An agreement of Cohen's Kappa > 0.9 was achieved for all groups, with exception of the diagnosis of double outlet right ventricle (0.8) in prenatal echocardiography compared to postnatal echocardiography. This study came to the result of a sensitivity of 88-100%, a specificity and negative predictive value of 97-100%, and a positive predictive value of 84-100%. The performance of cardiac magnetic resonance imaging (MRI) as an additional measure to echocardiography had an added value in the description of the malposition of the great arteries when diagnosed with double outlet right ventricle and in the detailed description of the anatomy of the lung circulation.

CONCLUSIONS

Prenatal echocardiography could be shown to be a reliable method for detection of congenital heart disease when regarding the slightly lower accuracy of diagnosis for double outlet right ventricle and right heart anomalies. Furthermore, the impact of examiner experience and the consideration of follow-up examinations for further improvement of diagnosis accuracy may not be underestimated. The main advantage of an additional MRI is the possibility to obtain a detailed anatomic description of the blood vessels of the lung and the outflow tract. The conduction of further studies that include false-negative and false-positive cases, and studies that are not set within the high-risk-group, as well as studies in a less specialized setting, would allow the completion and investigation of possible differences and discrepancies when comparing the results that have been obtained in this study.

Fetal arrhythmias case series: Experiences from a fetal screening center in Taiwan

OBJECTIVE

Fetal arrhythmias are common and in rare cases can be associated with severe mortality and morbidity. Most existing articles are focused on classification of fetal arrhythmias in referral centers. Our main objective was to analyze types, clinical characteristics, and outcomes for arrhythmia cases in general practice.

CASE REPORT

We retrospectively reviewed a case series of fetal arrhythmias in a fetal medicine clinic between September 2017 and August 2021.

FETAL ARRHYTHMIAS IN OUR SAMPLE PRESENTED BY

Ectopies (86%, n = 57), bradyarrhythmias (11%, n = 7), and tachyarrhythmias (3%, n = 2). One tachyarrhythmia case was associated with Ebstein's anomaly. Two cases of second-degree AV block received transplacental fluorinated steroid therapy with recovery of fetal cardiac rhythm in later gestation. One case of complete AV block developed hydrops fetalis.

CONCLUSION

Detection and careful stratification of fetal arrhythmias in obstetric screening is crucial. While most arrhythmias are benign and self-limited, some require prompt referral and timely intervention.

Accuracy of fetal echocardiography diagnosis and anticipated perinatal and early postnatal care in congenital heart disease in mid-gestation

INTRODUCTION

The aim of this study was to determine discrepancies in fetal congenital heart disease (CHD) diagnoses and anticipated early postnatal care and outcomes.

MATERIAL AND METHODS

A retrospective review of 462 randomly selected cases (23% of all cases) referred to a fetal cardiac assessment during the second trimester (mean 26 weeks) at the Children's Hospital in Helsinki between October 2010 and December 2020. Discrepancy between prenatal and postnatal CHD case evaluations was assessed with independently provided cardiac severity and surgical complexity scores.

RESULTS

In all, 250 cases, 181 CHD and 69 normal, with complete prenatal and postnatal live birth data as well as seven fetal autopsy reports available were included in the analysis. There were 12 false normal and seven false abnormal prenatal assessments. The prenatally anticipated level of early neonatal care was actualized in 62% and prostaglandin infusion in 95%. In total, 32.7% (84/257) cardiac severity scores were discrepant and in 12,4% (32/257) cases the discrepancies were considered significant (≥ +/- 2 scores). Among significant discrepancies, CHD severity score was overestimated in 13 and underestimated in 19 in fetal assessment. Progression of CHD severity after mid-gestation and during early neonatal phase explained eight of 19 underestimated fetal assessments. The most common discrepant diagnostic categories included ventricular septal defects (n = 7), borderline ventricles (n = 7; 5 left heart, 1 right heart and 1 double outlet right ventricle/transposition of the great arteries), arch anomalies including coarctations (n = 5) and tricuspid valve dysplasias (n = 4) with a significant change in postnatal diagnoses and treatment.

CONCLUSIONS

Although fetal CHD diagnosis and counseling is accurate and reliable in general, the study elaborates specific areas of uncertainty in clinical fetal cardiology practice that may be important to consider in fetal CHD evaluation and counseling provided in mid-gestation.

Clinical utility of fetal echocardiography: an Egyptian center experience

BACKGROUND

The impact of early diagnosis of fetal cardiac abnormalities on the postnatal outcome has been controversial in literature. We aimed to evaluate the role of fetal echocardiography (FE) as a diagnostic tool for early detection and proper management of fetal cardiac abnormalities, study the indications of referral and detect the perinatal outcome in our institution.

RESULTS

This is a cross-sectional observational and descriptive study that included one hundred and one singleton pregnant women (101 fetuses) who were referred for FE over a period of one year. Indications for referral and perinatal risk factors were documented. FE and postnatal transthoracic echocardiography were done. Fetal cardiac abnormalities were detected in 46.5% of cases. Congenital heart defects (CHDs) in 34.6%, fetal arrythmias in 9.9%, cardiomyopathy in 2.9% and cardiac mass (Rhabdomyoma) in 1% (combined structural and rhythm abnormalities were observed in two fetuses). Of the CHDs, complex heart lesions were diagnosed in 57.1%, common atrioventricular canal in 28.6% and conotrunchal anomalies in 14.3%. Of the ten cases with fetal arrythmias, five fetuses had tachyarrhythmias, four had ectopics and one fetus had congenital heart block in association with maternal lupus. The indications for referral were abnormal obstetric ultrasound (52.5%), maternal medical illnesses (23.8%), multiple neonatal deaths (13.9%) and positive family history of CHD (10.9%). The number of fetuses with cardiac abnormalities was significantly higher than those without cardiac abnormalities in mothers not exposed to perinatal risk factors (p = 0.009) and was statistically lower in mothers exposed to perinatal risk factors (p = 0.005). FE showed 100% accuracy in diagnosing complex lesions, common atrio-ventricular canals, cono-truncal anomalies, cardiac masses and fetal arrhythmias. It missed two cases of tiny muscular ventricular septal defects and one case of aortic coarctation. Cases of fetal supraventricular tachycardia were successfully treated in-utero.

CONCLUSIONS

CHDs exist in fetuses with no underlying perinatal risk factors. FE can accurately diagnose most of the cardiac anomalies though few errors remain challenging (aortic coarctation). It also offers a good chance for successful early life-saving management of some types of fetal arrhythmia.

Prenatal diagnosis of congenital heart defects: echocardiography

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.

Early detection of significant congenital heart disease: The contribution of fetal cardiac ultrasound and newborn pulse oximetry screening

Fetal cardiac and newborn pulse oximetry screening has greatly facilitated the detection of cardiac abnormalities, which may be serious with potentially dire neonatal consequences. The prenatal diagnosis of a serious cardiac abnormality allows the attending obstetrician to organise the much safer in-utero transfer of the fetus for delivery at a tertiary centre, particularly if there is evidence of a duct-dependent lesion that may require the infusion of Prostaglandin E1 to maintain duct patency pending surgical intervention. Newborn pulse oximetry alerts the paediatrician that the baby may have a significant cardiac abnormality, which warrants further elucidation prior to discharge, rather than for the baby to represent unwell a few days later. Despite these advances, serious cardiac abnormalities may be missed on screening. Their detection then falls back onto the clinical acumen of the attending paediatrician/family physician to review the history, carefully elicit and evaluate the clinical signs further aided by whatever investigations that may be available at the birthing hospital, frequently less resourced than the tertiary centres. At the outset, a brief synopsis is provided of the clinical findings that may point to a cardiac abnormality. That is followed by a critical review of the accuracy of prenatal and newborn pulse oximetry screening with emphasis on the lesions that may be missed. Suggestions are made as to how to improve the diagnostic accuracy.

Impact of the expanded examination of fetal heart to the prenatal diagnosis of congenital heart diseases

Objective:

In the present study, for which reasons fetal cardiac evaluation was requested from our pediatric cardiology clinic, the effects of routine fetal cardiac evaluation in obstetric ultrasonography (USG) on the detection of congenital heart disease (CHD) and the distribution of intrauterine diagnosis of CHD according to pregnancy risk profiles were retrospectively analyzed.

Materials and Methods:

Fetal echocardiography reports which containing the nineteen-month period were retrospectively examined. We performed a fetal echocardiography for all pregnant women who were referred to pediatric cardiology clinic after detail obstetric USG screening. The pregnancies were categorized into two groups based on the risk of CHD: Low-risk and high-risk groups. Detected congenital cardiac structural malformations were classified as complex, moderate, and mild according to perinatal mortality risk.

Results:

Of the 736 pregnancies, 22 were twin, and fetal cardiac evaluation was performed in 758 fetuses. There were 341 (46.3%) pregnancies in the high-risk group and 395 (53.6%) pregnancies in the low-risk group. The most common reason for fetal cardiac evaluation request was inability to adequately visualize the fetal heart (36.1%), while suspected fetal cardiac abnormality was the second most common cause (21.3%). Number of fetuses detected with cardiac abnormalities was 80 (23.5%) among high-risk pregnancies, and 20 (5%) among low-risk pregnancies. The most common type of malformation was simple cardiac abnormalities (6%) followed by complex lesions (4.1%). The most common cardiac abnormality was ventricular septal defect comprised of 18 cases (2.4%) while the most common complex cardiac abnormality was pulmonary atresia (1.2%). The rate of consistency was 40.1% between obstetricians and pediatric cardiologist in terms of the diagnosis of the congenital cardiac malformations.

Conclusion:

Routine evaluation of the fetal heart by means of obstetric USG, including four chambers, outflow tracts’ and three vessel views, would allow for diagnosing congenital cardiac malformations to a large extent during the intrauterine period.

Fetal Echocardiography Indications and Lack of Association between Abnormal Exams and Advanced Maternal Age: A Cross-Sectional Study - Fetal Abnormal Echocardiography

OBJECTIVE

 To analyze the most frequent referrals for fetal echocardiography, including advanced maternal age and its association with abnormal results.

METHODS

 We included all pregnant women referred to perform fetal echocardiography (gestational age 22-32 weeks) in 2 health centers in Rio de Janeiro, from June 2015 to June 2016. Advanced maternal age was considered when age was > 35 years at the time of delivery). Referral reasons and results were recorded, according to the Brazilian Fetal Cardiology Statement. Crude and adjusted prevalence ratios were calculated (Poisson regression). We considered p < 0.05 as significant.

RESULTS

 A total of 1,221 tests were analyzed. Abnormal fetal echocardiography was observed in 14.82% of the cases. The most frequent abnormalities were interventricular septal defect (6.39%), septal hypertrophy (3.35%) and atrioventricular septal defect (1.14%). Routine exams were performed in 559 women, 289 were referred for advanced maternal age and 373 were referred according to the Brazilian Fetal Cardiology Statement criteria. An obstetric ultrasound suggesting fetal cardiac abnormality, maternal diabetes, increased nuchal translucency, and obstetric ultrasound suggesting a noncardiac abnormality were strongly associated with an abnormal fetal echocardiography. Abnormal results were not more frequent in women with advanced maternal age when compared with the rest of the study group.

CONCLUSIONS

 It was observed that routine exams and advanced maternal age referrals were very frequent. Those exams were not associated to fetal echocardiography abnormalities. In this scenario, when the obstetric ultrasound suggests a fetal cardiac abnormality, the fetal echocardiography probably is abnormal. Therefore, obstetric ultrasound is a good screening method.

Sensitivity, specificity, and accuracy of fetal echocardiography for high-risk pregnancies in a tertiary center in Egypt

BACKGROUND

Advances in fetal echocardiography training among pediatric cardiologists have led to substantial improvements in prenatal detection of congenital heart diseases (CHDs). Nevertheless, diagnostic accuracy varies among centers. Moreover, this subspecialty continues to evolve in developing countries, with limited studies assessing fetal echocardiography sensitivity, specificity, and accuracy in developing countries such as Egypt.

SUBJECT AND METHODS

High-risk pregnancies referred for fetal echocardiography from January 2011 to January 2019 were analyzed retrospectively. All of the cases included had one of the high-risk indications for fetal echocardiography. Maternal age and gestational age at the prenatal diagnosis were determined, and detailed fetal and neonatal echocardiograms were documented. The results of fetal and postnatal echocardiography were compared to assess the sensitivity, specificity, and accuracy of fetal echocardiography. A minor lesion was defined when no postnatal intervention was needed and a major anomaly when postnatal cardiac therapy, surgery, or intervention was required.

RESULTS

Out of 615 pregnant patients referred, comparisons between fetal and neonatal echocardiography were possible in 458 fetuses, with 157 patients excluded from the study. The mean maternal age in the study was 26.97±5.871 years and the mean gestational age at referral was 27.24±5.407 weeks. The most common indication for prenatal echocardiography in this cohort was a family history of CHD (142; 31%) followed by nonimmune hydrops (97; 21.18%) and abnormal obstetrical ultrasound screening (64; 13.97%). We had three false-positive minor diagnoses and four false-negative cases with only one requiring intervention. Prenatal diagnosis in this study was accurate in 98.47% of cases. The sensitivity, specificity, and accuracy of fetal echocardiography in the current work were 97.03%, 99.07%, and 98.47, respectively.

CONCLUSION

Fetal echocardiography is considered a highly sensitive specific tool for prenatal detection of congenital heart diseases in high-risk pregnancies even in developing countries. However, minor fetal cardiac disorders are challenging to diagnose and family counseling should emphasize the difficulty of excluding or confirming such lesions.

Cardiac Findings in Fetal and Pediatric Autopsies: A 15-Year Retrospective Review

INTRODUCTION

Congenital heart defects (CHDs) carry significant morbidity and mortality in pediatric patients. This study determined the spectrum of CHDs based on fetal and pediatric autopsies.

METHODS

Autopsy reports over a 15-year period were reviewed. Postmortem findings were correlated with echocardiography records.

RESULTS

From 608 autopsies, 119 cases with CHDs were identified (11% of fetal, 53% of neonatal, 18% of infant, and 4.5% of childhood autopsies). Persistent left superior vena cava was the most common individual defect. 41% of cases had extracardiac malformations. 18.5% of cases had chromosomal abnormalities. Prenatal echocardiography was available in 52 cases, showing 85% correlation with autopsy findings. Defects missed by echocardiography were generally of mild severity.

CONCLUSION

Postmortem examination is important to delineate the anatomy of CHDs, and recognize extracardiac malformations for identification of possible genetic syndromes. This information can be used for parental counseling and for assessment of accuracy of pre-mortem imaging studies.

Can echocardiographic screening in the early days of life detect critical congenital heart disease among apparently healthy newborns?

BACKGROUND

Delayed diagnosis of critical congenital heart disease (CCHD) carries a serious risk of mortality, morbidity, and handicap. As echocardiography is commonly used to diagnose congenital heart disease (CHD), echocardiographic investigations in newborns may be helpful in detecting CCHD earlier and with higher sensitivity than when using other screening methods. The present study aimed to evaluate the effectiveness of echocardiographic screening for CCHD in a tertiary care center.

METHODS

A retrospective chart review was conducted among newborns delivered at Hamamatsu University Hospital between June 2009 and May 2016. The study included consecutive newborns who underwent early echocardiographic screening (within the first 5 days of life) performed by pediatric cardiologists, were born at ≥36 weeks of gestation, had a birthweight ≥2300 g, and were cared for in the well-baby nursery. Newborns admitted to the neonatal intensive care unit, as well as those with prenatal diagnosis of CHD and/or clinical symptoms or signs of CHD were excluded. Four CHD outcome categories were defined: critical, serious, clinically significant, and clinically non-significant.

RESULTS

A total of 4082 live newborns were delivered during the study period. Of 3434 newborns who met the inclusion criteria and had complete echocardiography data, 104 (3.0%) were diagnosed as having CHD. Among these, none was initially diagnosed as having critical or serious CHD. Of the 95 newborns who continued follow-up with a cardiologist, 61 (64%) were determined to have non-significant CHDs that resolved within 6 months of life. Review of excluded newborns revealed nine cases of critical or serious CHD; among these newborns, six were diagnosed prenatally and three had some clinical signs of CHD prior to hospital discharge.

CONCLUSIONS

In our tertiary care center, echocardiography screening within the first 5 days of life did not help improve CCHD detection rate in newborns without prenatal diagnosis or clinical signs of CHD. Echocardiographic screening may be associated with increased rate of false-positives (defects resulting in clinically non-significant CHDs) in newborns without prenatal diagnosis or suspicion of CHD.

Prenatal detection of critical cardiac outflow tract anomalies remains suboptimal despite revised obstetrical imaging guidelines

BACKGROUND

Fetal echocardiography can accurately diagnose critical congenital heart disease prenatally, but relies on referrals from abnormalities identified on routine obstetrical ultrasounds. Critical congenital heart disease that is frequently missed due to inadequate outflow tract imaging includes anomalies such as truncus arteriosus, double outlet right ventricle, transposition of the great arteries, tetralogy of Fallot, pulmonary stenosis, and aortic stenosis.

OBJECTIVE

This study evaluated the prenatal detection rate of critical outflow tract anomalies in a single urban pediatric hospital before and after "AIUM Practice Guideline for the Performance of Obstetric Ultrasound Examinations," which incorporated outflow tract imaging.

DESIGN

Infants with outflow tract anomalies who required cardiac catheterization and/or surgical procedure(s) in the first 3 months of life were retrospectively identified. This study evaluated two time periods; pre-guidelines from June 2010 to May 2013 and post-guidelines from January 2015 to June 2016. June 2013-December 2014 was excluded as a theoretical period necessary for obstetrical practices to implement the revised guidelines.

RESULTS

Overall, prenatal diagnosis occurred in 55% of infants with critical outflow tract anomalies; of the three most common defects, prenatal diagnosis occurred in 53% of D-transposition of the great arteries, 63% of tetralogy of Fallot, and 80% of double outlet right ventricle patients. Pre-guidelines, prenatal diagnosis occurred in 52% (52 of 102) infants with critical outflow tract anomalies requiring early cardiac intervention. Post-guidelines, prenatal diagnosis occurred in 61% (33 of 54) infants, not significantly different than the prenatal detection rate pre-guidelines (P = .31).

CONCLUSIONS

Despite revised obstetrical guidelines highlighting the importance of outflow tract imaging, referrals and prenatal diagnosis of these types of critical congenital heart disease remain low. Education of obstetrical sonographers and practitioners who perform fetal anatomic screening is vital to increase referrals and prenatal detection of critical outflow tract anomalies.

Complexity of consenting for medical termination of pregnancy: prospective and longitudinal study in Paris

BACKGROUND

We analyzed the patients' perception of prenatal diagnosis of fetal cardiac pathology, and the reasons for choosing to continue with pregnancy despite being eligible to receive a medical termination of pregnancy. We also identified the challenges, the motives interfering in decision-making, and the consequences of the decisions on pregnancy, child and mother.

METHODS

This descriptive, prospective and longitudinal study was conducted in France, amongst pregnant women who wished to continue their pregnancy despite an unfavorable medical advice (incurable fetal cardiac pathologies). Socio-demographic data were collected through a questionnaire. Such questionnaire covered information assessing the parents/mother's perception of prenatal diagnosis, and medical termination of pregnancy, their interpretation of the established diagnosis and their motives for not considering pregnancy termination.

RESULTS

72 eligible patients were analyzed over one year: mean age 33 ± 6.89 years, 47 patients had already given birth to ≥1 healthy child. Mean gestational age at the detection of fetal cardiac pathologies was 30 ± 4.37 weeks of amenorrhea. Patients decided to keep the child after 3 ± 1.25 consultations. 56 (77.78%) patients made their decision with their husbands and 16 made their decision alone. Reasons for declining the medical termination were culpability and responsibility (n = 36), ideologies and convictions (n = 24), mistrust and hope (n = 12). Newborns of 67 patients died with a mean survival duration of 38 days.

CONCLUSIONS

Patient informed consent should be sought before any decision in neonatology, even if conflicting with the medical team's knowledge and the pregnant mother's benefits. Decisions to accept or decline pregnancy termination depend on the patients' psychological character, ideologies, convictions, and mistrust in the diagnosis/prognosis, or hope in the fetus survival.

Prenatal diagnosis of congenital heart defects: accuracy and discrepancies in a multicenter cohort

OBJECTIVE

To examine the accuracy of fetal echocardiography in diagnosing congenital heart disease (CHD) at the fetal medicine units of three tertiary care centers.

METHODS

This was a multicenter cohort study of tertiary echocardiography referrals between 2002 and 2012. Prenatal and postnatal diagnoses were compared and the degree of agreement was classified as 'correct' (anatomy correct and the postnatal diagnosis led to a similar outcome as expected), 'discrepant' (anatomical discrepancies present but the severity and prognosis of the defect were diagnosed correctly) or 'no similarity' (the pre- and postnatal diagnoses differed completely).

RESULTS

We included 708 cases with CHD for which both prenatal and postnatal data were available. The prenatal diagnosis was correct in 82.1% of cases and discrepancies present were present in 9.9%; however, these did not result in a different outcome. In 8.1% there was no similarity between prenatal and postnatal diagnoses. Disagreement between pre- and postnatal diagnoses occurred significantly more frequently in cases that presented with a normal four-chamber view than in those with an abnormal four-chamber view (5.5% vs 1.9%). Incorrect identification of the outflow tracts and incorrect differentiation between unbalanced atrioventricular septal defect and hypoplastic left heart syndrome were relatively commonly encountered. In many cases with disagreement, trisomy 21, extracardiac anomaly or a high maternal body mass index was present.

CONCLUSIONS

The prenatal diagnosis and estimated prognosis of fetal echocardiography in our tertiary referral centers were appropriate in 92% of cases. Some types of CHD remain difficult to diagnose or rule-out prenatally, therefore awareness and education are of considerable importance. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Comparing the accuracy of obstetric sonography and fetal echocardiography during pediatric cardiology consultation in the prenatal diagnosis of congenital heart disease

AIM

The diagnostic accuracy of fetal echocardiogram performed by an obstetrician alone and that performed jointly by an obstetrician and pediatric cardiologist for congenital heart disease were compared.

MATERIALS AND METHODS

All cases of suspected fetal congenital heart disease (CHD) referred to the Prenatal Diagnostic Clinic at Tsan Yuk Hospital, Hong Kong during 2006-2011 were reviewed. Prenatal fetal echocardiogram findings were compared with postnatal diagnosis. Cases of incorrect prenatal diagnosis with significant difference in prognosis were analyzed qualitatively.

RESULTS

One hundred and eleven cases of fetal CHD were analyzed. Complete agreement between prenatal and postnatal diagnosis of CHD was observed in 69.4% of cases by fetal echocardiogram performed by obstetrician and 83.8% by fetal echocardiogram performed during pediatric cardiology consultation (P = 0.001). Collaboration with a pediatric cardiologist also improved detection of ductal-dependent cardiac lesions (77.4% vs. 86%, P = < 0.001). Five cases with an incorrect diagnosis were associated with a different prognosis. Three of the cases involved outflow tract abnormalities with incorrect identification of outflow vessels.

CONCLUSION

Collaboration with a pediatric cardiologist can significantly improve the accuracy of prenatal diagnosis of CHD. In particular, joint consultation is associated with significantly better detection of ductal-dependent lesions. Outflow tract abnormalities remain a diagnostic challenge in prenatal diagnosis. Incorrect identification of outflow tract vessels was the major cause of incorrect diagnosis in our series.

Second trimester cardiac diagnosis: screening standards and outcomes

Second trimester screening for congenital heart defects occurs during the routine 18-20 weeks' anomaly scan in many countries. Most congenital heart defects can be prenatally detected by experts in foetal echocardiography working in tertiary centres with high-risk pregnancies. Many studies, however, have shown that detection rates obtained by experts are not reproducible in the low-risk peripheral practices where most of the foetal screening takes place. As the majority of foetuses with congenital heart defects are born to mothers with no identifiable risk factors, it is important that widespread screening of the low-risk population occurs. To facilitate this, standard protocols have been introduced in several countries, but they are not universal and have differing sensitivities depending on the screening views advocated and the area studied. Initially, only performing the four-chamber view (basic scan) was advocated. By adding the outflow tract views (extended scan), three-vessel, and laterality views, the sensitivity of the examination can be significantly increased. Unfortunately, the sensitivity of these extended protocols still does not meet that obtainable in experienced hands, reflecting the additional skill required to obtain these extended views. Thus, close links are required between the tertiary centres and the screening centres to teach and maintain the skills required to obtain and interpret the required views, and to support the sonographer's commitment. Furthermore, an audit system is required to trace false-positive and -negative cases so that targeted interventions can be planned. This is important, as a missed case of prenatal congenital heart defect is potentially a missed opportunity to reduce postnatal morbidity and mortality.

Cost-effectiveness of prenatal screening strategies for congenital heart disease

OBJECTIVE

The economic implications of strategies to improve prenatal screening for congenital heart disease (CHD) in low-risk mothers have not been explored. The aim was to perform a cost-effectiveness analysis of different screening methods.

METHODS

We constructed a decision analytic model of CHD prenatal screening strategies (four-chamber screen (4C), 4C + outflow, nuchal translucency (NT) or fetal echocardiography) populated with probabilities from the literature. The model included whether initial screens were interpreted by a maternal-fetal medicine (MFM) specialist and different referral strategies if they were read by a non-MFM specialist. The primary outcome was the incremental cost per defect detected. Costs were obtained from Medicare National Fee estimates. A probabilistic sensitivity analysis was undertaken on model variables commensurate with their degree of uncertainty.

RESULTS

In base-case analysis, 4C + outflow referred to an MFM specialist was the least costly strategy per defect detected. The 4C screen and the NT screen were dominated by other strategies (i.e. were more costly and less effective). Fetal echocardiography was the most effective, but most costly. On simulation of 10 000 low-risk pregnancies, 4C + outflow screen referred to an MFM specialist remained the least costly per defect detected. For an additional $580 per defect detected, referral to cardiology after a 4C + outflow was the most cost-effective for the majority of iterations, increasing CHD detection by 13 percentage points.

CONCLUSIONS

The addition of examination of the outflow tracts to second-trimester ultrasound increases detection of CHD in the most cost-effective manner. Strategies to improve outflow-tract imaging and to refer with the most efficiency may be the best way to improve detection at a population level.

Prenatal detection of cardiac anomalies in fetuses with single umbilical artery: diagnostic accuracy comparison of maternal-fetal-medicine and pediatric cardiologist

AIM

To determine agreement of cardiac anomalies between maternal fetal medicine (MFM) physicians and pediatric cardiologists (PC) in fetuses with single umbilical artery (SUA).

METHODS

A retrospective review of all fetuses with SUA between 1999 and 2008. Subjects were studied by MFM and PC, delivered at our institution, and had confirmation of SUA and cardiac anomaly by antenatal and neonatal PC follow-up. Subjects were divided into four groups: isolated SUA, SUA and isolated cardiac anomaly, SUA and multiple anomalies without heart anomalies, and SUA and multiple malformations including cardiac anomaly.

RESULTS

39,942 cases were studied between 1999 and 2008. In 376 of 39,942 cases (0.94%), SUA was diagnosed. Only 182 (48.4%) met inclusion criteria. Cardiac anomalies were found in 21% (38/182). Agreement between MFM physicians and PC in all groups combined was 94% (171/182) (95% CI [89.2, 96.8]). MFM physicians overdiagnosed cardiac anomalies in 4.4% (8/182). MFM physicians and PC failed to antenatally diagnose cardiac anomaly in the same two cases.

CONCLUSIONS

Good agreement was noted between MFM physicians and PC in our institution. Studies performed antenatally by MFM physicians and PC are less likely to uncover the entire spectrum of cardiac abnormalities and thus neonatal follow-up is suggested.

Sonographic markers for early diagnosis of fetal malformations

Fetal malformations are very frequent in industrialized countries. Although advanced maternal age may affect pregnancy outcome adversely, 80%-90% of fetal malformations occur in the absence of a specific risk factor for parents. The only effective approach for prenatal screening is currently represented by an ultrasound scan. However, ultrasound methods present two important limitations: the substantial absence of quantitative parameters and the dependence on the sonographer experience. In recent years, together with the improvement in transducer technology, quantitative and objective sonographic markers highly predictive of fetal malformations have been developed. These markers can be detected at early gestation (11-14 wk) and generally are not pathological in themselves but have an increased incidence in abnormal fetuses. Thus, prenatal ultrasonography during the second trimester of gestation provides a “genetic sonogram”, including, for instance, nuchal translucency, short humeral length, echogenic bowel, echogenic intracardiac focus and choroid plexus cyst, that is used to identify morphological features of fetal Down’s syndrome with a potential sensitivity of more than 90%. Other specific and sensitive markers can be seen in the case of cardiac defects and skeletal anomalies. In the future, sonographic markers could limit even more the use of invasive and dangerous techniques of prenatal diagnosis (amniocentesis, etc.).

Performance of different scan protocols of fetal echocardiography in the diagnosis of fetal congenital heart disease: a systematic review and meta-analysis

OBJECTIVE

The rapid progress in fetal echocardiography has lead to early detection of congenital heart diseases. Increasing evidences have shown that prenatal diagnosis could be life saving in certain cases. However, there is no agreement on which protocol is most adaptive diagnostic one. Thus, we use meta-analysis to conduct a pooled performance test on 5 diagnostic protocols.

METHODS

We searched PUBMED, EMBASE, the Cochrane Central Register of Controlled Trials and WHO clinical trails registry center to identify relevant studies up to August, 2012. We performed meta-analysis in a fixed/random-effect model using Meta-disc 1.4. We used STATA 11.0 to estimate the publication bias and SPSS 17.0 to evaluate variance.

RESULTS

We use results from 81 studies in 63 articles to analyze the pooled accuracy. The overall performance of pooled sensitivities of spatiotemporal image correlation (STIC), extend cardiac echography examination (ECEE) and 4 chambers view + outflow tract view + 3 vessels and trachea view (4 CV+OTV+3 VTV) were around 0.90, which was significant higher than that of 4 chambers view + outflow tract view or 3 vessels and trachea view (4 CV+OTV/3 VTV) and 4 chambers view (4 CV). Unfortunately the pooled specificity of STIC was 0.92, which was significant lower than that of other 4 protocols which reached at 1.00. The area under the summary receiver operating characteristic curves value of STIC, ECEE, 4 CV+OTV+3 VTV, 4 CV+OTV/3 VTV and 4 CV were 0.9700, 0.9971, 0.9983, 0.9929 and 0.9928 respectively.

CONCLUSION

These results suggest a great diagnostic potential for fetal echocardiography detection as a reliable method of fetal congenital heart disease. But at least 3 sections view (4 CV, OTV and 3 VTV) should be included in scan protocol, while the STIC can be used to provide more information for local details of defects, and can not be used to make a definite diagnosis alone with its low specificity.

'I-shaped' sign in the upper mediastinum: a novel potential marker for antenatal diagnosis of d-transposition of the great arteries

OBJECTIVES

To investigate the 'I-shaped' sign as a novel echocardiographic marker for antenatal diagnosis of d-transposition of the great arteries (dTGA) in routine cardiac examination, and to compare its prevalence in fetuses with dTGA, those with other congenital heart diseases (CHDs) and those with normal structural hearts.

METHODS

This retrospective evaluation involved 1134 fetuses undergoing echocardiography to screen for CHD over a 4-year period. I-shaped sign was defined as the characteristic appearance of the aortic arch, resembling the letter 'I', from the most anterior to the most posterior point of the descending aorta visible in the three vessels and trachea view. The frequency of this sign was evaluated in cases with dTGA, those with other cardiac defects and those with normal cardiac structures.

RESULTS

CHD was diagnosed in 671 (59.1%) cases, of which 31 (4.6%) had dTGA. I-shaped sign was observed in 30/31 (96.8%) cases of dTGA, compared with 31/640 (4.8%) cases with other cardiac anomalies, which included single ventricle with pulmonary atresia or severe pulmonary stenosis, hypoplastic left heart syndrome with aortic atresia, corrected transposition of the great arteries, and double outlet right ventricle with malposition of the great arteries. I-shaped sign was detected significantly more frequently in the dTGA group compared with the normal group and with the other CHDs group (both P < 0.001) and had 96.8% sensitivity and 97.1% specificity for diagnosis of dTGA. Importantly, I-shaped sign was never observed in fetuses with structurally normal hearts.

CONCLUSIONS

Detection on echocardiography of an extremely long vessel with a marked I-shape should raise suspicion of cardiac anomaly, especially dTGA. This marker may therefore aid in the prenatal diagnosis of dTGA during routine ultrasound examination.

Ultrasound and echocardiographic findings obtained in the second and third trimesters of gestation in fetuses with normal karyotype and increased nuchal translucency

Introduction

Numerous papers have proven that an increased nuchal translucency is connected with a raised risk of chromosomal aberrations, but few analyses are related to the further state of fetuses with a normal karyotype.

The aim of the study

The aim of the study was to estimate the risk of cardiac defects and other developmental disorders in fetuses with increased nuchal translucency and normal findings of a standard cytogenetic examination.

Methods

The authors carried out a retrospective analysis of 5183 examinations of 3376 patients who reported to the Department of Diagnosis and Prophylaxis of Congenital Malformations in the Polish Mother's Memorial Hospital in Łódź in the period from January 2008 to March 2011 for prenatal ultrasound and echocardiographic examinations. The authors analyzed the results of the examinations performed in the second and third trimesters of gestation in fetuses with an increased nuchal translucency of ≥3 mm in the first trimester and with a normal karyotype.

Results

Fifty-seven patients (1.7% of the examined group) fulfilled the criteria necessary to be included in the study. In 31 pregnant women (54%) structural defects or anomalies of the fetus were found. Cardiac anomalies were detected in 17 fetuses (29.8%). The authors detected various types of cardiac defects such as tetralogy of Fallot, ventricular septal defect, atrioventricular septal defect, transposition of the great arteries and hypoplastic left heart syndrome.

Conclusions

In more than half of the fetuses with an increased nuchal translucency (NT ≥ 3 mm) and a normal karyotype, developmental defects of various organs appeared in the further course of pregnancy: mainly heart defects that were either isolated, or accompanied other anomalies.

Recent trends in indications of fetal echocardiography and postnatal outcomes in fetuses diagnosed as congenital heart disease

Background and Objectives

We hypothesized that fetal echocardiography (echoCG) is an accurate diagnostic tool reflecting well postnatal echoCG findings and outcomes.

Subjects and Methods

We reviewed the medical records of 290 pregnant women, including 313 fetuses, who were examined by fetal echoCG at the Seoul National University Children's Hospital from January 2008 through April 2011.

Results

The mean gestational age at diagnosis was 26.2±5.2 weeks. The mean age of mothers at diagnosis was 31.7±3.8 years. We identified indications for fetal echoCG in 279 cases. The most common indication was abnormal cardiac findings in obstetrical screening sonography (52.0%). Among the 313 echoCG results, 127 (40.6%) were normal, 13 (4.2%) were minor abnormalities, 35 (11.2%) were simple cardiac anomalies, 50 (16.0%) were moderate cardiac anomalies, 60 (19.2%) were complex cardiac anomalies, 16 (5.1%) were arrhythmias, and 12 (3.8%) were twin-to-twin transfusion syndrome. The most common congenital heart disease was tetralogy of Fallot (23 fetuses, 15.9%). One hundred forty-eight neonates were examined by echoCG. We analyzed differences between fetal echoCG and postnatal echoCG. In 131 (88.5%) cases, there was no difference; in 15 (10.1%), there were minor differences; and in only 2 (1.4%) cases, there were major differences.

Conclusion

There is a recent increase in abnormal cardiac findings of obstetric ultrasonography screenings that indicate fetal echoCG. Fetal echoCG is still a good, accurate diagnostic method for congenital heart disease.

Should clinicians advise terminating a pregnancy following the diagnosis of a serious fetal cardiac abnormality?

An 18-year-old single mother presented for counseling following the diagnosis of a hypoplastic left heart syndrome in the fetus. Despite being encouraged by her family members to terminate the pregnancy, the clinicians involved endeavored to provide information in a non-directive manner in accordance with widely accepted norms for antenatal counseling. Following the consultation, however, the clinicians wondered whether they should have provided more directive advice. In this report, we review the ethics of counseling following the diagnosis of a severe fetal cardiac abnormality. We assess the general and specific arguments in favor of providing directive advice, at least in some circumstances. There may be legitimate concerns about harms to the fetus, to the mother, or to the wider community from continuing a pregnancy. While these arguments yield rare exceptions to the generally accepted practice that antenatal counseling should not be directive, they may still not apply to the more severe forms of congenital cardiac abnormalities.

Barriers to prenatal detection of congenital heart disease: a population-based study

OBJECTIVE

To evaluate the extent and determinants of missed prenatal detection of congenital heart disease (CHD) in a population-based setting.

METHODS

This was a retrospective cohort study of cases with CHD, excluding minor defects, identified between 1997 and 2007 by a statewide surveillance program. We examined a comprehensive list of potential risk factors for which data were available in the surveillance database from abstracted medical charts. We analyzed the association of fetal, maternal and encounter factors with 1) whether a prenatal ultrasound was performed and 2) prenatal detection of CHD.

RESULTS

CHD was detected prenatally in only 39% of 1474 cases, with no improvement in detection rate over the 10-year period. Among the 97% (n = 1431) of mothers who underwent one or more ultrasound examinations, 35% were interpreted as abnormal; fetal echocardiography was performed in 27% of the entire cohort. Maternal and encounter factors increasing the adjusted odds of prenatal detection included: family history of CHD (OR, 4.3 (95% CI, 1.9-9.9)), presence of extracardiac defects (OR, 2.7 (95% CI, 1.9-3.9)) and ultrasound location i.e. high risk clinic vs clinic (OR, 2.1 (95% CI, 1.3-3.1)). Defects that would be expected to have an abnormal outflow-tract view were missed more often (64%) than were those that would be expected to have an abnormal four-chamber view (42%).

CONCLUSION

The majority of CHD cases over the 10-year study period were missed prenatally and detection rates did not increase materially during that time. The failure to detect CHD prenatally was related to encounter characteristics, specifically involving screening ultrasound examinations, which may be targeted for improvement.

Audit of 10 years of referrals for fetal echocardiography

OBJECTIVES

To evaluate trends over time, indications, diagnoses, noncardiac defects and outcome of fetuses referred for tertiary level echocardiography.

METHODS

Retrospective study of fetal echocardiograms performed between April 1999 and 2009.

RESULTS

Of the 623 fetuses included, 301 (48%) had cardiac pathology. Congenital heart defects (CHDs) were found in 243/301 (81%), mostly in the severe spectrum. Of the fetuses with CHDs, 26% (63/243) had chromosomal anomalies. The chromosomally normal fetuses with CHDs had a mortality rate of 43% (77/180) and 23% (41/180) had extra-cardiac anomalies. The termination of pregnancy (TOP) rate for all cardiac pathology was 24.9% (75/301) and for CHDs 29.6% (72/243). The TOP rates for CHDs diagnosed before 19 and 24 weeks gestation were 61% (28/46) and 44% (68/155), respectively. An increase in referrals followed the introduction of a national screening program, (nuchal translucency (NT) and routine structural ultrasound screening). The main referral indication was an increased NT (>95th percentile; 32% of cases). CHDs were found in 81/239 (34%) fetuses with an increased NT.

CONCLUSIONS

Referral indications for fetal echocardiography were appropriate (almost 50% had cardiac pathology). The mortality was high. Fetal outcome and TOP decisions correlated with CHD severity and presence of noncardiac defects. An increased NT is a strong marker for CHDs.

Screening fetal echocardiography in diabetic mothers with normal findings on detailed anatomic survey

OBJECTIVES

To evaluate the benefit of second-trimester fetal echocardiography for women with diabetes whose fetuses had no obvious heart disease on a detailed anatomic survey performed at skilled, high-volume obstetric centers, and to investigate the technical limitations of fetal echocardiography in this patient population.

METHODS

This was a retrospective descriptive review of fetal echocardiograms performed at Children's Hospital Boston from 2000 to 2005. All women referred during the second trimester for fetal echocardiography because of maternal diabetes were included. Those with severe heart disease suspected on obstetric ultrasound examination were excluded.

RESULTS

There were 584 initial fetal echocardiograms. No patients were diagnosed with severe heart disease prenatally. Nineteen were diagnosed with suspected mild heart disease (such as small ventricular septal defect), five of whom had normal follow-up fetal evaluation and five of whom had normal postnatal evaluation. Most of these pregnancies did not have a postnatal cardiac evaluation. Forty-seven fetuses had benign cardiac findings. Nearly one third of patients had imaging that was felt to be limited or incomplete, mostly due to poor acoustic windows. Forty-eight patients were asked to return for at least one follow-up visit, most due to the inability to complete the exam at the initial visit.

CONCLUSIONS

In an environment with access to high-volume, skilled comprehensive ultrasound services, fetal echocardiography by a pediatric cardiology program adds little to the care of women with diabetes and no suspected heart disease on a detailed anatomic survey. Poor acoustic windows frequently necessitate multiple visits.

Utility of fetal echocardiography in postnatal management of infants with prenatally diagnosed congenital heart disease

OBJECTIVE

Congenital heart disease (CHD) remains a significant cause of neonatal morbidity and mortality. This study evaluates the success of fetal echocardiography (FECHO) in guiding delivery management in pregnancies complicated by CHD.

METHODS

Cases with CHD diagnosed by prenatal FECHO performed at a single institution from January 2000 to June 2005 were retrospectively reviewed. The accuracy of prenatal diagnosis and the appropriateness of proposed care plans based on FECHO were compared to postnatal care plans based on neonatal echocardiograms (NECHOs).

RESULTS

Of the 72 mother-infant pairs with prenatally diagnosed CHD, 53 underwent NECHO. Overall, the FECHO diagnosis matched the NECHO diagnosis in 50 out of 53 cases (94.3%). The NECHO added diagnostic or functional information in 6 of the 53 FECHO cases. Three of these were minor and would not have resulted in a significant change of delivery plans. The other three were major findings and would have resulted in a revision of delivery planning. Overall, 96% of the delivery plans based on FECHO agreed with the delivery plans based on NECHO.

CONCLUSION

Fetal echocardiography has a high correlation with postnatal and neonatal echocardiographic findings. Delivery management plans may be based on fetal echocardiogram diagnoses.

Cardiac findings in fetal and pediatric autopsies: a five-year retrospective review

This review aims to determine the spectrum of cardiac findings in our fetal and pediatric postmortem population and provide an analysis of associated extracardiac malformations and genetic abnormalities. Pediatric autopsy reports from 2003 to 2007 inclusive were reviewed and cases with cardiac pathology selected for analysis. Over the 5-year period, 119 cases (10.8%) with abnormal cardiac findings were identified from a total of 1102 postmortem examinations. Of these cardiac cases, 42% were after termination of pregnancy for fetal anomaly, 29% after fetal demise, 14% after neonatal unit death, 3% after hospital inpatient death, and 11% after sudden unexpected death. Structural abnormality cases numbered 107 (90%), with ventricular septal defect as the most common individual defect. Nonstructural abnormality cases, such as myocarditis, numbered 12 (10%). Extracardiac malformations were identified in 78%. Chromosome or gene aberrations were detected in 37%. This review highlights the potential benefit of introducing routine fetal anomaly scanning, the need for cardiac pathology training for pediatric pathologists, and the importance of examination of the heart and associated vessels in all cases to provide parents with as much information as possible and aid identification of the etiology and associations of cardiac pathology.

Prenatal diagnosis and treatment planning of congenital heart defects-possibilities and limits

BACKGROUND

Newborns with hypoplastic left heart syndrome (HLHS) or right heart syndrome or other malformations with a single ventricle physiology and associated hypoplasia of the great arteries continue to be a challenge in terms of survival. The vast majority of these forms of congenital heart defects relate to abnormal morphogenesis during early intrauterine development and can be diagnosed accurately by fetal echocardiography. Early knowledge of these conditions not only permits a better understanding of the progression of these malformations but encourages some researchers to explore new minimally invasive therapeutic options with a view to early pre- and postnatal cardiac palliation.

DATA SOURCES

PubMed database was searched with terms of "congenital heart defects", "fetal echocardiography" and "neonatal cardiac surgery".

RESULTS

At present, early prenatal detection has been applied for monitoring pregnancy to avoid intrauterine cardiac decompensation. In principle, the majority of congenital heart defects can be diagnosed by prenatal echocardiography and the detection rate is 85%-95% at tertiary perinatal centers. The majority, particularly of complex congenital lesions, show a steadily progressive course including subsequent secondary phenomena such as arrhythmias or myocardial insufficiency. So prenatal treatment of an abnormal fetus is an area of perinatal medicine that is undergoing a very dynamic development. Early postnatal treatment is established for some time, and prenatal intervention or palliation is at its best experimental stage in individual cases.

CONCLUSION

The upcoming expansion of fetal cardiac intervention to ameliorate critically progressive fetal lesions intensifies the need to address issues about the adequacy of technological assessment and patient selection as well as the morbidity of those who undergo these procedures.

Changing spectrum and outcome of 705 fetal congenital heart disease cases: 12 years, experience in a third-level center

INTRODUCTION

Congenital heart diseases are the most common prenatal and postnatal malformations. Nowadays, fetal echocardiography is a widely practiced technique; however, the impact of prenatal diagnosis on prognosis of the newborns affected by congenital heart disease remains uncertain.

OBJECTIVE

To assess the outcome and the changes in the spectrum of prenatally detected congenital heart disease in our tertiary care centre in 12 years of activity (1995-2006).

METHODS AND RESULTS

We detected 705 congenital heart diseases: 32% (223) were associated with extracardiac or chromosomal anomalies or both, and 68% (482) were isolated. Termination of pregnancy was chosen in 81% for associated anomalies and 37% for isolated anomalies (P<0.001). Of these, more than one-third occurred in hypoplasic left heart cases. The general survival rate was 72%; it was significantly lower in the group with associated heart diseases (46 vs. 80%, P<0.001). Over 12 years we noticed a reduction in the number of multimalformed fetuses and of the hypoplasic left heart cases, and a higher number of aortic arch anomalies detected. During the past 6 years of activity the survival rate obtained has significantly increased (55 to 84%, P<0.05), the termination rate has significantly decreased (35 to 14%, P<0.001) and the number of neonatal deaths has significantly decreased (39 to 10%, P<0.001).

CONCLUSION

The survival and the voluntary termination of fetuses with prenatally detected congenital heart diseases are strongly influenced by disease severity and by associated extracardiac or chromosomal anomalies, or both. Over 12 years, the spectrum of fetal congenital heart disease has changed and their outcome has significantly improved.

'Big-eyed frog' sign on spatiotemporal image correlation (STIC) in the antenatal diagnosis of transposition of the great arteries

OBJECTIVE

To determine the value of simultaneous visualization of the cross-sectional view of both atrioventricular (AV) valves, the pulmonary artery and the aorta (en-face view of the AV valves and great vessels) in the identification of fetuses with transposition of the great arteries (TGA).

METHODS

This was a retrospective analysis of volume datasets obtained with the spatiotemporal image correlation (STIC) technique from 56 fetuses with and 30 fetuses without congenital heart defects. Volume datasets were reviewed offline to compare the en-face view of the AV valves and great vessels between fetuses with normal echocardiography and those with TGA.

RESULTS

The en-face view of both AV valves and great vessels in fetuses with TGA displayed the main pulmonary artery situated side-by-side with the aorta ('big-eyed frog' sign). In contrast, fetuses with normal hearts did not have this characteristic sonographic sign. This novel sonographic sign also helped to identify additional cases of TGA in 17 fetuses with complex heart defects.

CONCLUSION

The big-eyed frog sign may prove helpful in the prenatal diagnosis of TGA.

Correlation between ultrasound and autopsy findings after 2nd trimester terminations of pregnancy

OBJECTIVE

To compare ultrasound (US) and fetal autopsy findings in 2(nd) trimester termination of pregnancy because of structural fetal anomalies.

METHODS

A total of 112 terminations of pregnancy (TOP) between 1999-2003 were reviewed retrospectively. The cases originated from a secondary and a tertiary Fetal Medicine unit in the south Stockholm area, using a common specialized perinatal pathology service. Karyotype was not known at the time of US examination. The findings were compared and classified into four groups according to the degree of agreement between US and autopsy.

RESULTS

In 45% of cases there was total agreement between US and autopsy. In 40%, autopsy confirmed all US findings but provided additional information of clinical importance. Partial or total lack of agreement was noted in 11% and 4% of the cases, respectively. Areas of discrepancy involved mainly CNS- and cardiovascular abnormalities and, to a lesser extent, renal anomalies, abdominal wall defects and hydrops/hygroma. Regarding CNS abnormalities the overall rate of agreement was 62%; it was highest in acrania/anencephaly (92%) and lowest in hydrocephaly (39%).

CONCLUSION

We find an overall high degree of agreement between US and autopsy findings. Autopsy often provided additional information of clinical value and it should always follow US examination and TOP. Fixation of CNS is crucial for optimal results. Specific limitations of autopsy, i.e., detection of CNS abnormalities, may be reduced by complementary imaging techniques, such as MRI. The ability of US to detect cardiac anomalies is enhanced with the close contact to specialized fetal cardiology.

Management of the sick neonate with suspected heart disease

A proportion of symptomatic neonates with congenital heart disease have lesions requiring urgent stabilisation. Despite increasing antenatal diagnoses, the importance of early recognition of symptomatic neonates is highlighted by the fact that up to 10% of all deaths in congenital heart disease continue to occur in children undiagnosed at the time of death. Specific anatomical knowledge of the many complex lesions is not required for good early management. The focus of this article is the specific symptom complexes in critically ill neonates with congenital heart disease, initial management strategies for stabilization and transfer to specialist centres, and issues in the ongoing preoperative care.

Importance of timely diagnosis of congenital heart disease

Most important types of congenital heart disease can be recognized early during prenatal or neonatal screening. However, a substantial proportion of cardiac defects are not diagnosed in due time. Such delay may lead to serious complications or even death. This article reviews the impact of screening strategies upon the outcome in pediatric cardiac patients.

Pregnancy: Maternal and Fetal Heart Disease

Cardiac disorders complicate less than 1% of all pregnancies. Physiologic changes in pregnancy may mimic heart disease. In order to differentiate these adaptations from pathologic conditions, an in-depth knowledge of cardiovascular physiology is mandatory. A comprehensive history, physical examination, electrocardiogram, chest radiograph, and echocardiogram are sufficient in most cases to confirm the diagnosis. Care of women with cardiac disease begins with preconception counseling. Severe lesions should be taken care of prior to contemplating pregnancy. Management principles for pregnant women are similar to those for the non-pregnant state. A team approach comprised of a maternal fetal medicine specialist, cardiologist, neonatologist, and anesthesiologist is essential to assure optimal outcome for both the mother and the fetus. Although fetal heart disease complicates only a small percentage of pregnancies, congenital heart disease causes more neonatal morbidity and mortality than any other congenital malformation. Unfortunately, screening approaches for fetal heart disease continue to miss a large percentage of cases. This weakness in fetal screening has important clinical implications, because the prenatal detection and diagnosis of congenital heart disease may improve the outcome for many of these fetal patients. In fact, simply the detection of major heart disease prenatally can improve neonatal outcome by avoiding discharge to home of neonates with ductal-dependent congenital heart disease. Fortunately, recent advances in screening techniques, an increased ability to change the prenatal natural history of many forms of fetal heart disease, and an increasing recognition of the importance of a multidisciplinary, team approach to the management of pregnancies complicated with fetal heart disease, together promise to improve the outcome of the fetus with congenital heart disease.

Fetal Diagnosis – Obligations of the Clinician

Fetal echocardiography allows for accurate diagnosis of major heart abnormalities by 16-18 weeks. The parents have up to 22 weeks to consider possible termination. What are the obligations of the clinician once an abnormality is found? Should only information be provided or is there a role in influencing the parents' decision? Two diverse examples are provided to discuss these questions. Mrs A., aged 40 years was noted at the 18-week and then the 20-week scan to have a fetus with a complete atrio-ventricular septal defect. In addition, the fetus had a Danny-Walker cyst. There was thickened nuchal folds and echogenic bowel all suggestive of a chromosomal abnormality. Amniocentesis was refused and the pregnancy continued. Mrs B., aged 34 years was noted at 19 weeks and again at 20 weeks to have a fetus with mild thickening of the walls of both the right and left ventricles. The flow patterns appeared normal. Despite a probable good outlook, the parents asked for a repeat scan at 22 weeks to allow them to consider possible termination. Despite a probable chromosomal abnormality, definite major cardiac and neurological abnormalities, Mrs A. refused karotyping and planned to proceed with the pregnancy. Mrs B., despite a probable good outcome for the fetus asserted pressure for us to prognosticate by 22 weeks. While non-directive counselling is the accepted norm, is that appropriate for all situations? Should one strongly influence Mrs A. to have an amniocentesis to confirm a probable Trisomy thereby allowing her to make a more informed decision? How reassuring can the clinician be to Mrs B. and if termination is sought should one counsel against that? Arguments for these positions are described, highlighting the difficulties faced by clinicians as they counsel parents often with incomplete information and in a setting of acute emotional distress.

The impact of prenatal diagnosis of congenital heart disease on pediatric cardiology and cardiac surgery

Since the early 1980s prenatal diagnosis of congenital heart disease (CHD) has progressively impacted on the practice of pediatric cardiology and cardiac surgery. Fetal cardiology today raises special needs in screening programs, training of the involved staff, and allocations of services. Due to the increased detection rate and to the substantial number of terminations, the reduced incidence of CHD at birth can affect the workload of centers of pediatric cardiology and surgery. In utero transportation and competition among centers may change the area of referral in favor of the best centers. Echocardiography is a powerful means to diagnose and to guide lifesaving medical treatment of sustained tachyarrhythmias in the fetus. Prenatal diagnosis not only improves the preoperative conditions in most cases but also postoperative morbidity and mortality in selected types of CHD. Intrauterine transcatheter valvuloplasty in severe outflow obstructive lesions has been disappointing so far and this technique remains investigational, until its benefits are determined by controlled trials. Prenatal diagnosis allows counselling of families which are better prepared for the foreseeable management and outcome of the fetus. These benefits can reduce the risks of litigation for missed ultrasound diagnosis. As increased costs can be expected in institutions dealing with a large number of fetal CHD, the administrators of these institutions should receive protected funds, proportional to their needs.