Antenatal Transabdominal Ultrasound Detection of Cleft Lip and Palate in Western Australia from 1996 to 2003

Diagnostic Potential of Complementation of MRI to Prenatal Ultrasound for Detecting Orofacial Clefts in High-Risk Fetuses: A Network Meta-Analysis

OBJECTIVE

To compare the complementation of magnetic resonance imaging (MRI) to prenatal ultrasound (US) with prenatal US alone in detecting orofacial clefts in high-risk fetuses.

DESIGN

A network meta-analysis.

SETTING

Literature retrieval in PubMed, EMBASE, and Cochrane library, and meta-analysis based on STATA 14.0.

PATIENTS

Fetuses were at high-risk for orofacial clefts.

INTERVENTIONS

Prenatal US and the complementation of MRI to prenatal US.

MAIN OUTCOME MEASURES

The pooled sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic odds ratio (DOR), and area under the curve (AUC).

RESULTS

Thirteen studies involving 776 patients were included. Direct meta-analysis showed that the complementation of MRI to prenatal US did not differ from prenatal US in detecting orofacial clefts if the type of orofacial clefts was not distinguished. Subgroup analysis showed that the specificity of prenatal US for the detection of isolated cleft palate (CP) was lower than that of the complementation of MRI to prenatal US. Furthermore, network meta-analysis consistently suggested a comparable diagnostic value between prenatal US and the complementation of MRI to prenatal US. Moreover, subgroup analysis showed that the specificity of prenatal US was significantly lower than that of complementation of MRI to prenatal US for the detection of isolated CP.

CONCLUSIONS

MRI is more accurate than ultrasound in detecting cleft palate. Therefore, MRI should be offered if there is a fetus with a possible or ultrasound diagnosis of cleft palate, especially if the evaluation of cleft palate is deemed unsatisfactory after careful evaluation of the images.

Updates in Cleft Care

Cleft lip and/or palate is a congenital malformation with a wide range of presentations, and its effective treatment necessitates sustained, comprehensive care across an affected child's life. Early diagnosis, ideally through prenatal imaging or immediately postbirth, is paramount. Access to longitudinal care and long-term follow-up with a multidisciplinary approach, led by the recommendations of the American Cleft Palate Association, is the best way to ensure optimal outcomes. Multiple specialties including plastic surgery, otolaryngology, speech therapy, orthodontists, psychologists, and audiologists all may be indicated in the care of the child. Primary repair of the lip, nose, and palate are generally conducted during infancy. Postoperative care demands meticulous oversight to detect potential complications. If necessary, revisional surgeries should be performed before the child begin primary school. As the child matures, secondary procedures like alveolar bone grafting and orthognathic surgery may be requisite. The landscape of cleft care has undergone significant transformation since early surgical correction, with treatment plans now tailored to the specific type and severity of the cleft. The purpose of this text is to outline the current standards of care in children born with cleft lip and/or palate and to highlight ongoing advancements in the field.

Diagnostic Accuracy of Prenatal Fetal Ultrasound to Detect Cleft Palate in High-Risk Fetuses: A Systematic Review and Meta-Analysis

OBJECTIVES

This systematic review and meta-analysis investigated the accuracy of prenatal fetal ultrasound (US) to detect cleft palate during the second and third trimester (12-36 weeks) of pregnancy in high-risk fetuses.

METHODS

Pubmed and Embase databases were searched for studies that performed prenatal fetal US (comparator) and postnatal examination (reference standard) in fetuses at high risk for orofacial clefts. Risk of bias among included studies was assessed using the QUADAS-2. Area under the summary receiver operating characteristic (SROC) curve and pooled sensitivity and specificity were calculated.

RESULTS

This meta-analysis included 7 studies involving 663 high-risk fetuses. The individual studies showed that prenatal fetal US accurately predicted the possibility of cleft palate in these fetuses. Pooled sensitivity was 87% (95% CI 71%-95%), pooled specificity was 98% (95%CI 90%-100%), and the area under the SROC curve was 0.98 (95% CI 0.97-0.99).

CONCLUSION

Second and third trimester fetal US has excellent sensitivity and specificity for the detection of cleft palate in high-risk pregnancies.

"People look and ask lots of questions": caregivers' perceptions of healthcare provision and support for children born with cleft lip and palate

BACKGROUND

Clefting of the lip and/or palate (CL/P) is amongst the five most common birth defects reported in South Africa. The emotional impact on parents at the birth of their new-born with CL/P could affect parent-child relationships. In light of insufficient scholarly attention parental experiences and perceptions, this study reports on caregivers' perceptions of health service provision and support for children born with cleft lip and palate in South Africa.

METHODS

The study setting consisted of 11 academic hospital centres situated in six of South Africa's nine provinces. At each of the academic centres cleft clinic, five to ten parents or caregivers were selected purposively. Participants were interviewed, using a semi-structured interview schedule that elicited socio-demographic information, explored the family experiences of having a child with CL/P, and their perceptions of care provision and support services available. The interviews were analysed using thematic content analysis.

RESULTS

Seventy-nine participants were interviewed. Their mean age was 33.3 years (range 17-68 years). The majority of the parents were black African (72%), unemployed (72%), single (67%) and with only primary school education (58%). The majority of the children were male, with a mean age of 3.8 (SD = ±4.3) years. Five broad themes emerged from the interviews: emotional experiences following the birth of a child with cleft lip and palate; reactions from family, friends or the public; the burden of care provision; health system responsiveness; and social support services. Caregivers reported feelings of shock, anxiety, and sadness, exacerbated by the burden of care provision, health system deficiencies, lack of public awareness and insufficient social support services.

CONCLUSIONS

The findings have implications for the integrated management of children with cleft lip and/or palate, including information to parents, the education and training of healthcare providers, raising public awareness of birth defects, and social support.

Antenatal Ultrasound Detection of Cleft in Western Australia from 2003 to 2012: A Follow-Up Study

AIM

To investigate trends in the rate of antenatal detection of cleft lip and palate (CLP) patients referred to the CLP Unit at Princess Margaret Hospital for Children in Perth, Western Australia during the period 2003-2012 and compare data with a previously published report covering the years 1996-2003.

METHODS

This is a single-center, retrospective survey of antenatal transabdominal ultrasound screenings of mothers of infants born between July 1, 2003 and June 30, 2012 that were referred to the CLP Unit at Princess Margaret Hospital.

RESULTS

Detection rates of oral clefts increased significantly when compared with outcomes reported in the same population between 1996 and 2003 (P < .05). An overall detection rate of 71.7% (165/230) was achieved for clefts involving lip and palate. Detection of isolated cleft palate (1/99) and microform (0/8) remained elusive. Most detections (76.5%) were achieved at 15 to 20 weeks of gestational age, corresponding with routine anatomical screening. A further 16.8% were detected post-20 weeks of gestation. Scans were performed by specialist obstetricians, and sonography clinics reported a detection rate of 84.6% (55/65), whereas nonspecialist clinics reported a detection rate of only 67.1% (110/164).

CONCLUSION

The antenatal detection rates of oral clefts involving the lip have improved to the extent that the majority of mothers are now being referred to a cleft unit in Western Australia prior to the births of their children. As a result of this improvement, antenatal counseling is now a common facet of cleft management.

Detection of lip, alveolar ridge and hard palate abnormalities using two-dimensional ultrasound enhanced with the three-dimensional reverse-face view

OBJECTIVE

The aim of this study was to assess conventional two-dimensional (2D) ultrasound enhanced with a three-dimensional (3D) ultrasound technique, the 'reverse-face' view (3D-RF) in prenatal evaluation of the involvement of the lips, alveolar ridge and secondary palate in suspected isolated orofacial clefting.

METHODS

One hundred and twenty-four cases of suspected orofacial clefting diagnosed by a routine 2D ultrasound scan were referred for specialist ultrasound at 20-34 weeks' gestation for a detailed assessment of the lips and palate using both 2D and 3D ultrasound. For the 3D examination the lips and alveolar ridges were examined both in profile and in the frontal plane. The palate was then assessed in the reverse coronal view by rotating the face through 180° on the vertical axis to produce the 3D-RF view. Antenatal diagnoses were compared with postnatal findings. Left and right lip and alveolar ridge defects were counted separately according to the Kernohan 'striped Y' classification.

RESULTS

Of 124 patients, 110 had isolated facial clefts and were available for follow-up; in 10, 3D-RF views were not successfully obtained, leaving 100 cases for assessment. The sensitivity of the 2D enhanced with 3D-RF technique for the diagnosis of cleft of the lip was 116/122 (95%), false-positive rate (FPR) 7.7%; for alveolar ridge was 87/103 (84.5%), FPR 7.2%; and for hard palate was 61/68 (89.7%), FPR 15.6%.

CONCLUSION

The data reported represent the largest series of orofacial abnormalities diagnosed by 2D ultrasound and enhanced with 3D imaging to refine the detection of clefts of the hard palate. The technique is feasible in 90% of patients in whom almost 90% have a correct classification of clefts of the lip, alveolar ridge and palate.

Cleft lip/palate: incidence of prenatal diagnosis in Glasgow, Scotland, and comparison with other centers in the United Kingdom

OBJECTIVES

To determine the proportion of children with cleft lip and/or cleft palate diagnosed prenatally between 1999 and 2008 in those referred for treatment to the Royal Hospital for Sick Children in Glasgow, Scotland (RHSC); and to compare the percentage prenatally diagnosed in 2008 versus other cleft treatment centers in the U.K.

METHOD

A retrospective study was performed using medical records of the 459 cleft patients born and referred to RHSC between 1999 and 2008. Comparable data for year 2008 were requested from other U.K. units.

RESULTS

For the period studied, the percentage of all clefts diagnosed prenatally was 15%. This rose to 28% when only the cases of cleft lip with or without cleft palate (CL ± P) were considered. An increase was seen in prenatal detection of CL ± P from 11% in 1999 to 50% in 2008 (p = .011). Two of the six U.K. units that responded had a significantly higher percentage of CL ± P cases diagnosed prenatally compared with RHSC in 2008 (p < .05).

CONCLUSIONS

The percentage of CL ± P cases diagnosed prenatally in this study is consistent with the literature and increased between 1999 and 2008. Routine ultrasound anomaly scanning is shown to significantly improve detection rates compared with scanning of high-risk pregnancies only. Cases of CL ± P where the alveolus or the palate is involved have significantly higher detection rates than those involving only the lip.

Diagnostic accuracy of transabdominal ultrasound in detecting prenatal cleft lip and palate: a systematic review

OBJECTIVES

To systematically review the diagnostic accuracy of second-trimester transabdominal ultrasound in detecting orofacial clefts in low- and high-risk populations and to compare two-dimensional (2D) with three-dimensional (3D) ultrasound techniques.

METHODS

MEDLINE and EMBASE were searched for articles published in English, Dutch, French or German using the keywords 'cleft' and 'ultrasound' or 'screening' or 'sonogram' and 'prenatal' or 'antenatal' or 'fetus' to identify cohort studies and randomized trials in order to assess the detection rate by prenatal ultrasound of cleft lip and palate in high-risk and low-risk pregnant women.

RESULTS

Of 451 citations identified, 27 met the criteria for the systematic review, 21 involving unselected low-risk populations and six involving high-risk populations. In the selected studies there was diversity in the gestational age at which the ultrasound examination was performed and there was considerable variety in the diagnostic accuracy of 2D ultrasound in the low-risk women, with prenatal detection rates ranging from 9% to 100% for cleft lip with or without cleft palate, 0% to 22% for cleft palate only and 0% to 73% for all types of cleft. 3D ultrasound in high-risk women resulted in a detection rate of 100% for cleft lip, 86% to 90% for cleft lip with palate and 0% to 89% for cleft palate only.

CONCLUSIONS

2D ultrasound screening for cleft lip and palate in a low-risk population has a relatively low detection rate but is associated with few false-positive results. 3D ultrasound can achieve a reliable diagnosis, but not of cleft palate only.

Prenatal diagnosis of orofacial clefts, National Birth Defects Prevention Study, 1998-2004

OBJECTIVE

The aims of this study were to determine how frequently orofacial clefts were diagnosed prenatally and to investigate factors associated with prenatal diagnosis.

METHODS

We included 2298 mothers from the National Birth Defects Prevention Study, each of whom gave birth to a child with an orofacial cleft, and assessed associated factors using logistic regression.

RESULTS

The frequencies of prenatal diagnosis for cleft lip and palate, cleft lip only, and cleft palate only were 33.3%, 20.3%, and 0.3%, respectively. Among cases with cleft lip with or without cleft palate, cleft type, geographic location, maternal body mass index, household income, year of infant's birth, and presence of multiple birth defects were significantly associated with receiving a prenatal diagnosis.

CONCLUSION

In the majority of infants with orofacial clefts, a prenatal diagnosis was not made. Receiving a prenatal diagnosis was significantly associated with several infant and maternal characteristics.

Antenatal detection of cleft lip with or without cleft palate: incidence of associated chromosomal and structural anomalies

OBJECTIVE

To ascertain how many fetuses with prenatally diagnosed cleft lip with or without cleft palate have associated congenital structural and/or chromosomal abnormalities and whether there is an association with the anatomical type of cleft lip or palate.

METHODS

This was a retrospective review of infants referred to the North-West England Regional Cleft Lip and Palate (CLAP) team between January 2000 and January 2006. Referrals made to the Regional Fetal Management Unit (FMU) in the same time period were investigated to identify the corresponding antenatal ultrasound findings and data on termination of pregnancy and intrauterine fetal death.

RESULTS

Over the 6-year period investigated, 570 infants were referred to the FMU and/or CLAP team. Among these, there were 24 terminations of pregnancy, two intrauterine fetal deaths and one early neonatal death identified. Data on 69 of the 543 patients that survived were incomplete. Of 188 cases with unilateral and 34 cases with bilateral cleft lip +/- palate there were no karyotypical abnormalities without other structural abnormalities. The incidence of associated structural abnormalities varied with the anatomical type of cleft: that of unilateral cleft lip +/- palate was 9.8% (19/194), that of bilateral cleft lip and palate was 25% (11/44) and that of midline cleft lip and palate was 100% (11/11). None of 252 cases with isolated cleft palate was identified antenatally; of these, 5.6% (n = 14) had either karyotypical or associated structural abnormalities and 21.0% (n = 53) had a genetic syndrome as an underlying diagnosis.

CONCLUSIONS

It is essential to tailor the antenatal counseling of patients to the specific scan diagnosis, considering both the anatomical type of cleft and the presence or absence of associated abnormalities. It is inappropriate to offer invasive testing to all patients. The use of three-dimensional ultrasound as an adjunct should be considered in these patients to improve the accuracy of prenatal diagnosis.

Examination of the secondary palate on stored 3D ultrasound volumes of the fetal face

OBJECTIVES

To examine the use of oblique planes from stored three-dimensional (3D) ultrasound volumes of the fetal face for viewing the secondary palate at various gestational ages.

METHODS

3D ultrasound volumes of the fetal face acquired with surface rendering at 15-35 weeks' gestation in 31 fetuses with confirmed normal secondary palates were reviewed. The secondary palate was viewed in three oblique planes targeted at the uvula: the oblique axial, the oblique sagittal and the reverse face view. The detection and appearance of the secondary palate, including the soft palate, with these views at various gestational ages were compared.

RESULTS

The various surfaces of the secondary palate could be viewed in all 31 fetuses in the oblique axial and the reverse face views, and in all except two fetuses in the oblique sagittal view. Both of these were < 19 weeks' gestation, at which age the uvula could not be identified clearly in this plane.

CONCLUSIONS

The oblique axial, the oblique sagittal and the reverse face view targeted at the uvula allow visualization of the various aspects of the fetal secondary palate on 3D ultrasound in the second and third trimesters of pregnancy. The uvula could be used as a landmark for viewing the soft palate, but was not always easily identifiable before 19 weeks' gestation.

Prenatal assessment of the normal fetal soft palate by three-dimensional ultrasound examination: is there an objective technique?

OBJECTIVES

To describe a three-dimensional (3D) ultrasound technique for assessing the fetal soft palate.

METHODS

A prospective study conducted from April to December 2006 included 87 fetuses in a low-risk population. Fetal ultrasound scans were performed between 21 and 25 weeks of gestation to determine the normal 3D ultrasound view of the fetal soft tissues of the palate. The sonographers used a 30 degrees-inclined axial 3D view of the fetal palate. Ultrasound images obtained in this view were compared with fetopathological specimens of the same gestational age by two observers, both pediatric surgeons. Each observer indicated whether they thought that the uvula or the velum could be detected, and the differences in responses between the observers were assessed.

RESULTS

The frequencies of detection of the uvula and velum of each observer varied between 80% and 90%. The observers showed a significant difference in judging the visualization of the uvula, but not in judging the velum.

CONCLUSIONS

A 30 degrees -inclined axial 3D ultrasound view seems to be effective in assessing the integrity of the fetal soft palate.

A Population-Based Evaluation of Antenatal Diagnosis of Orofacial Clefts

Objectives:

To evaluate the changes in prevalence and antenatal detection of cleft lip with or without cleft palate and isolated cleft palate and to describe the association between anomalies and rates of antenatal diagnosis in Nova Scotia from 1992 to 2002.

Design:

This population-based cohort study employed the Nova Scotia Atlee Perinatal Database, the Fetal Anomaly Database, and IWK Cleft Palate Database in Halifax, Nova Scotia, Canada.

Outcome Measures:

Cleft type, mode of diagnosis, and associated abnormalities of orofacial clefts for liveborn infants, stillbirths, and second trimester terminations of pregnancy between 1992 and 2002 were determined.

Results:

There were 225 fetuses identified as having orofacial clefts. The overall prevalence of clefts was 2.1 in 1000 live births, and this prevalence did not change with time. The overall antenatal detection of cleft lip with or without cleft palate was 23%; however, there was improvement in detection of cleft lip with or without cleft palate from the years 1992 to 1996 (14%) to the years 1997 to 2002 (30%, p  =  .02). No isolated cleft palates were detected antenatally. Associated structural anomalies were seen in 34.2% of cases with orofacial clefts, and chromosomal abnormalities were associated with 9.8%.

Conclusions:

The prevalence of orofacial clefts in Nova Scotia has not changed from 1992 to 2002. The proportion of antenatally diagnosed cleft lip with or without cleft palate in Nova Scotia is consistent with rates reported in the literature and has increased from 1992 to 2002.

Improving cleft palate/cleft lip antenatal diagnosis by 3-dimensional sonography: the "flipped face" view

OBJECTIVE

Three-dimensional sonography has enhanced the diagnosis of congenital anomalies in the early stages of pregnancy. Both cleft lip and palate remain a diagnostic challenge for the sonographer because of the variable size of the defects as well as their location. Recently, a technique described by Campbell et al (Ultrasound Obstet Gynecol 2003; 22:552-554, 2005; 25:12-18) demonstrated an improved method called the "reverse face" view, which appears to assist in the diagnosis of clefts involving the palate.

METHODS

The fetal face was initially examined with the fetus in the supine position. Using 3-dimensional sonography, a static volume was acquired. Following acquisition of the volume, it was rotated 90 degrees so that the cut plane was directed in a plane from the chin to the nose. The volume cut plane was then scrolled from the chin to the nose to examine in sequential order the lower lip, mandible, and alveolar ridge; tongue; upper lip, maxilla, and alveolar ridge; and hard and soft palates.

RESULTS

This approach identified the full length and width of the structures of the mouth and palates and allows the examiner to identify normal anatomy as well as clefts of the hard and soft palates.

CONCLUSIONS

The fetal hard and soft palates of the mouth can be accessed using a new technique, which we call the "flipped face" maneuver, when an adequate volume of the face can be obtained.