Prenatal ultrasonography and Doppler sonography for the clinical investigation of isolated ventricular septal defects in a late second-trimester population

The Impact of Technology on the Diagnosis of Congenital Malformations

As technology improves and becomes more widely accessible, more subclinical congenital malformations are being detected. Using a cohort of 1,780,156 pregnant women and their offspring nested in the 2000-2013 US Medicaid Analytic eXtract, we contrasted time trends in malformations which do not necessarily present with overt clinical symptoms early in life and are more likely to be diagnosed via imaging (secundum atrial septal defect, patent ductus arteriosus, ventricular septal defect, pulmonary artery anomalies, pulmonary valve stenosis, hydrocephalus) with trends in malformations that are unlikely to escape clinical diagnosis (tetralogy of Fallot, coarctation of the aorta, transposition of the great vessels, hypoplastic left heart syndrome, oral cleft, abdominal wall defect). Logistic regression was used to account for trends in risk factors while assessing the impact of increased screening intensity. Prevalence of the diagnosis of secundum atrial septal defect rose from 2.3‰ in 2000-2001 to 7.5‰ in 2012-2013, of patent ductus arteriosus from 1.9‰ to 4.1‰, and of ventricular septal defect from 3.6‰ to 4.5‰. Trends were not explained by changes in the prevalence of risk factors but were attenuated when accounting for screening tests. The other malformations showed no temporal trends. Findings suggest that increased screening partially explains the observed increase in diagnosis of milder cases of select common malformations.

Characteristics of Isolated Ventricular Septal Defects Less Likely to Close In Utero

OBJECTIVES

To determine the characteristics of fetal ventricular septal defects (VSDs) that will be less likely to close prenatally.

METHODS

In this 4-year retrospective cohort study, 148 fetuses had a diagnosis of a VSD during a comprehensive fetal anatomy survey. The VSD diagnosis was confirmed by color and pulsed wave Doppler studies. These fetuses were followed monthly until their birth. They had postnatal echocardiography performed within 1 month of age to assess the persistence of a VSD. Fisher exact, Wilcoxon rank sum, and log rank tests and bivariate and multivariate logistic regressions were used to examine the association of each individual variable with prenatal VSD closure.

RESULTS

One hundred twenty-five of 148 fetuses (84%) had prenatal VSD closure at a mean gestational age ± SD of 26.9 ± 4.5 weeks. Fetuses with a persistent VSD more frequently had other cardiac defects than the closed VSD group (12 of 23 versus 5 of 125; P < .001). Fetuses having a persistent VSD more frequently had an abnormal karyotype (9 of 23 versus 5 of 125; P < .001). The persistent VSDs were larger in their initial size (5.9 ± 8.4 mm versus 2.7 ± 0.8 mm; P = .002) and in their maximal prenatal size (6.0 ± 9.1 mm versus 2.9 ± 0.9 mm; P < .001). The presence of associated cardiac defects (adjusted odds ratio = 0.071; P = .031) and an abnormal karyotype (adjusted odds ratio = 0.058; P = .021) were significantly associated with a lower likelihood of prenatal VSD closure. All VSDs with a maximal size of 2 mm or less closed prenatally.

CONCLUSIONS

Fetuses with a complex cardiac defect or an abnormal karyotype were less likely to have prenatal VSD closure.

The natural history of fetal diagnosed isolated ventricular septal defect

OBJECTIVE

This study was undertaken to clarify the natural course of ventricular septal defect, and to find an index that would help in prenatal counseling.

METHODS

Between January 2010 and December 2014, 18 188 fetuses underwent echocardiographic examinations. Of these, 228 isolated ventricular septal defect cases were retrospectively reviewed.

RESULTS

In this retrospective study, the incidence of isolated ventricular septal defect was 1.25% (228/18 188). There were 146 patients who underwent echocardiography after delivery in order to confirm the natural course of patients with isolated ventricular septal defect. Of the 146 cases, 64 cases (43.84%) had the ventricular septal defect naturally closed in the fetal period. Of the 82 patients with ventricular septal defect at birth, 25 patients showed natural closure during follow-up. However, four patients (2.74%) required surgical treatment for ventricular septal defect. In case of perimembranous defects, natural closure is more frequent in the fetal period than in the postnatal period.

CONCLUSION

Our results indicate that 60.96% (89/146) of isolated ventricular septal defects diagnosed during the fetal life are closed naturally. Perimembranous type defect, small defect (<2 mm) and maternal age less than 35 years are the good prognostic factors for the natural closure during fetal life. © 2017 John Wiley & Sons, Ltd.

Factors controlling fetal echocardiography determine the diagnostic accuracy of isolated ventricular septal defect

BACKGROUND

Fetal echocardiography (FECG) is a key screening tool for prenatal cardiac abnormalities. Herein, we examined the ultrasonic factors determining prenatal ultrasonic diagnosis of isolated ventricular septal defect (IVSD).

METHODS

The diagnostic role of ultrasonic factors was investigated in patients in middle or late pregnancy, diagnosed with IVSD by FECG and confirmed using postnatal echocardiography.

RESULTS

One hundred and six patients with IVSD were enrolled; the majority had perimembranous VSD. The combined imaging mode of 2 dimentional-echocardiography (2DE) and color doppler flow imaging (CDFI) showed the highest rate (56.6%) of IVSD detection, while CDFIwas more efficient than 2DE (32.1% vs. 11.3%). The single-view mode was more efficient than multiple-view mode (75.5% vs. 24.5%). The highest efficient mode to detect IVSD was achieved using combined imaging mode on the single view of the left ventricular outflow tract view (LVOTV) (28.3%). FECG correctly classified 71.7% of fetal IVSD. There was a significant difference of accuracy rate in classifying IVSD among the three different imaging modes (χ ²=7.141, P<0.05). The single imaging mode of CDFIand the mode of CDFIcombined with 2DE correctly classified 75.9% and 75.0% of fetal IVSD, respectively. LVOTV was the most accurate view of fetal IVSD classification (85.2%; χ ²=15.782, P<0.05). There was no difference in accuracies of IVSD classification among multiple-view modes (χ ²=2.343, P>0.05) or between single-view mode and multiple-view mode (χ ²=0.32, P>0.05).

CONCLUSION

Single LVOTV in CDFIor CDFIcombined with 2DE of FECG were the most effective diagnostic modes for fetal IVSD diagnosis.

Early pregnancy exposure to selective serotonin reuptake inhibitors, risks of major structural malformations, and hypothesized teratogenic mechanisms

INTRODUCTION

Selective serotonin reuptake inhibitors (SSRIs) are commonly used to manage antenatal depression. Hence, the aim of this systematic review is to assess the prevalence of birth defects associated with pregnancy exposure to such agents and summarize the hypothesized teratogenic mechanisms.

AREAS COVERED

Medical literature published in English (1980 - June 2015) was electronically searched to identify all articles reporting an increased prevalence of birth defects associated with prenatal SSRI exposure and hypothesizing teratogenic mechanisms.

EXPERT OPINION

The only recurrent pattern of congenital anomalies associated with antenatal SSRI exposure is heart defects. SSRIs may alter the function of serotonin and related receptors which are involved in the development of the monoamine-dependent cardiac structures. Nevertheless, the magnitude of this increase and, thus, its clinical significance are unclear. Therefore, a cautious approach of using SSRI during pregnancy only in the case of major depressive episodes should be applied. However, this risk should be balanced against the risks associated with the worsening of depressive symptoms, and take into consideration the large number of studies that found no associations between transplacental SSRI exposure and cardiac anomalies. Prenatal ultrasonography and Doppler sonography to detect early cardiac defects are also advisable. Non-pharmacological approaches are preferred for less severe psychiatric disorders.