False positive morphologic diagnoses at the anomaly scan: marginal or real problem, a population-based cohort study

Predictive Ability of Ultrasound on Neonatal Diagnoses and Consequences on Prenatal Care Utilization

ABSTRACT

Fetal anomalies suspected on fetal ultrasound may cause significant stress for patients. Some findings resolve or have minimal clinical significance for the neonate. Our purpose is to evaluate fetal ultrasound accuracy and false-positive results and determine the clinical impact on maternal counseling. A retrospective review was performed on electronic medical records for women receiving prenatal care at Harbor-UCLA Medical Center who had abnormal findings on fetal ultrasounds between January 2015 and December 2018. Corresponding neonatal medical records were reviewed for the suspected condition(s). χ2 and Fisher exact tests were conducted to assess associations between fetal ultrasounds and neonatal outcomes. Two hundred eight mothers and 237 babies (including all 29 sets of twins) were included in the final analysis. Fetal ultrasounds were significantly associated with neonatal findings for the following conditions (sensitivity, specificity): anatomical disorder of extremities (0.72, 0.97), anatomical disorder of the face/skull/brain (0.67, 0.91), congenital anomaly of gastrointestinal tract (0.75, 0.98), congenital heart disease (0.75, 0.91), genetic disorder (0.72, 1.00), growth restriction (1.00, 0.85), kidney disorder (0.55, 0.98), and large for gestational age (0.80, 0.98). The highest false-positive rates occurred in congenital heart disease (65.4%), anatomical disorder of the face/skull/brain (64.3%), and growth restriction (54%). Fetal ultrasound highly correlates with neonatal findings for many congenital conditions. However, it can also be associated with a high false-positive rate for certain diagnoses; maternal counseling should include the limitations of ultrasound, including the potential for false-positive results.

Educational Potential of Three-Dimensional Volumes Based on Seriate Histological Slices of First Trimester Fetal Hearts

The advantages of earlier diagnosis give the family more time to adjust to the fetal cardiac and related extracardiac diagnoses and to make informed pregnancy decisions. If a severe fetal CHD is detected in the first trimester and pregnancy termination is selected, the intervention may have a lower risk for the mother's physical and mental health. Training medical staff is a crucial part of implementing obstetric ultrasonography services well, since effective patient care depends on their ability to use the equipment skillfully and interpret results properly. In many low-and middle-income nations, there is a scarcity of healthcare professionals trained to offer ultrasound services and one of the reasons for this issue is the lack of available lectures, simulations and instruments to explain how ultrasound sections are acquired. We propose an alternative method of visualizing the ultrasound planes of interest using three-dimensional volumes of fetal hearts reconstructed from seriate histological slices. This method may aid trainees in understanding echocardiography.

On the outside looking in: a phenomenological study of the lived experience of Australian adults with a disorder of the corpus callosum

Background

While classified as a rare condition, a congenital disorder of the corpus callosum (DCC) is one of the most commonly identified brain anomalies in newborns, occurring in 1:4000 live births. Advances in imaging techniques have improved early diagnosis for children, yet adults with a DCC—who may present with extreme heterogeneity in cause and impact—often experience challenges in receiving a definitive diagnosis and accessing appropriate services and supports. To date, the dearth of evidence documenting the lived experiences of adults with DCC has made it difficult to determine adequate policy and service responses. This exploratory research aims to address this gap by presenting the first qualitative examination of the experiences and impact of complete or partial agenesis of the corpus callosum among adults.

Results

Eight face-to-face interviews were conducted with Australian adults, aged 23–72 years, to explore their lived experience. Data was collected in four Australian states from June to August 2017. Thematic and interpretive analyses were employed to analyse data. Three emergent themes described difficulties related to: (1) reactions to the diagnosis; (2) access to supports and key life domains, and (3) identifying as an adult. Interview analysis described lived experiences typically outlining a lifetime of exclusion and misunderstanding from family, educators and disability and health support services.

Conclusions

This paper contributes to filling the knowledge gap around a rare congenital brain disorder affecting the lives of adults. Findings confirm a considerable lack of information and support for adults living with corpus callosum disorders. Greater professional and societal understanding is needed to improve access to the key life domains of education, employment and social inclusion for adults with a DCC. To instigate truly effective change, social research must tackle the issues of applicability and impact to alter the dominance of uninformed practices, hindered by prevailing myths. This research paves the way for further phenomenological studies in which participant narrative is vital. Further research will elicit stronger policy and service responses for all current and emerging adults with a DCC.

ACR Appropriateness Criteria® Second and Third Trimester Screening for Fetal Anomaly

The Appropriateness Criteria for the imaging screening of second and third trimester fetuses for anomalies are presented for fetuses that are low risk, high risk, have had soft markers detected on ultrasound, and have had major anomalies detected on ultrasound. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Fetal brain, head, and neck tumors: Prenatal imaging and management

Fetal tumors represent an infrequent pathology when compared to congenital malformations, although their true incidence may be underestimated. A variety of benign and malignant neoplasms may occur anywhere in the neural axis. Imaging plays an important role in the fetal tumor diagnosis and evaluation of their resultant complications. Discovery of a fetal mass on obstetric ultrasound necessitates further evaluation with prenatal magnetic resonance imaging (MRI). New MR sequences and new applications of existing techniques have been successfully implemented in prenatal imaging. A detailed assessment may be performed using a variety of MR. Fetal tumors may be histologically benign or malignant, but their prognosis generally remains poor, especially for intracranial lesions. Unfavorable tumor location or heightened metabolic demands on a developing fetus may result in severe complications and a fatal outcome, even in cases of benign lesions. Nowadays, prenatal treatment focuses mainly on alleviation of secondary complications caused by the tumors. In this article we review congenital tumors of the brain, face, and neck encountered in prenatal life, and discuss diagnostic clues for appropriate diagnosis.

The accuracy of prenatal diagnosis of major congenital heart disease is increasing

Regular audit of results of prenatal screening for congenital heart disease (CHD) is crucial to ensure reliable prenatal diagnosis. We aimed to assess the accuracy of prenatal diagnosis of major CHD between 1996 and 2013. During the study period, prenatal detection of major CHD improved from 4.5% to 71.0% (p<.001). Prenatal diagnoses on 628 live born children and terminated pregnancies were compared with postnatal findings or autopsy reports. The proportion of correct diagnoses increased throughout the study period from 42.9% in 1996 and reached 88.2% in 2013 (p<.001). A total of 32 foetuses with suspected major CHD were terminated though no major CHD was found at autopsy. In these pregnancies, termination was mainly performed due to other anomalies in the foetus.Along with improved detection of major CHD, the validity of a prenatal diagnosis is increasing. No cases of misinterpreted major CHD resulted in the termination of a healthy foetus in this study.Impact statementWhat is already known on this subject? Prenatal diagnosis of isolated congenital heart disease (CHD) correlates well with lesions found during autopsy performed in terminated foetuses. Few studies have assessed the accuracy of prenatal diagnosis of major CHD in live born children, cases with associated anomalies and the time trend in validity.What the results of this study add? This study illustrates that the validity of prenatal diagnosis of major CHD is increasing. Prenatal diagnoses in terminated pregnancies as well as in live born children is high except for coarctation of the aorta and atrioventricular septal defects. Chromosomal anomalies are associated with lower accuracy of prenatal diagnosis.What the implications are of these findings for clinical practice and/or further research? Prenatal diagnosis is an accurate tool for detecting major CHD. Misinterpretation has not led to the termination of a healthy foetus; however, this study illustrates that vigilant care should be placed on the cardiac evaluation when termination is considered due to the cardiac defect.

Perinatal post-mortem ultrasound (PMUS): radiological-pathological correlation

There has been an increasing demand and interest in post-mortem imaging techniques, either as an adjunct or replacement for the conventional invasive autopsy. Post-mortem ultrasound (PMUS) is easily accessible and more affordable than other cross-sectional imaging modalities and allows visualisation of normal anatomical structures of the brain, thorax and abdomen in perinatal cases. The lack of aeration of post-mortem foetal lungs provides a good sonographic window for assessment of the heart and normal pulmonary lobulation, in contrast to live neonates.In a previous article within this journal, we published a practical approach to conducting a comprehensive PMUS examination. This covered the basic principles behind why post-mortem imaging is performed, helpful techniques for obtaining optimal PMUS images, and the expected normal post-mortem changes seen in perinatal deaths. In this article, we build upon this by focusing on commonly encountered pathologies on PMUS and compare these to autopsy and other post-mortem imaging modalities.

Are there risk factors for false-positive malformation diagnoses on obstetric ultrasound? A nested case-control study

INTRODUCTION

In a population-based study, we found an overall false-positive rate of 8.8% for the second and third trimester ultrasounds. Although numerous studies have been performed to examine factors which lead to false negatives, the same is not true for the factors associated with false positives. The principal objective of this study was to look for risk factors for false-positive diagnoses of fetal malformations on obstetric ultrasound scans.

MATERIAL AND METHODS

In this nested case-control study, the case infants were those whose mother had a false-positive antenatal ultrasound diagnosis of a malformation during the second or third trimester (ultrasound false-positives) and who were live - or stillborn in Auvergne in 2006-2010. The control group comprised all children who were ultrasound true-negatives in 2005 and 2007. The study included 46 cases and 184 controls, matched according to the level of the maternity unit in which they were born.

RESULTS

Most false-positive diagnoses were minor malformations. The mean term at this false-positive diagnosis was 27.7±5.4 weeks; in 46.8% of cases, the diagnosis was made during the second-trimester ultrasound. A single malformation was suspected in 95.7% of the cases. In 97.9% of cases, only one anatomical system was affected. In all, 49 malformations were identified among the 46 cases and their distribution differed according to anatomical system. The only risk factor identified was a body mass index (BMI)<25 (ORa=1.7; 95%CI: 1.2-2.4).

DISCUSSION

A maternal BMI<25 was the only risk factor identified for a false-positive ultrasound diagnosis of a fetal malformation.