As technology evolves, so should its application: shortcomings of the "18-week anatomy scan"

Should an Early Anatomy Ultrasound Scan Be Offered Routinely to Obese Pregnant Women?

OBJECTIVE

The primary objective of this study was to determine whether an early anatomic scan (EAS), either on its own or in combination with the routine transabdominal scan (R-TAS), would improve overall completion rates of the fetal anatomic survey in the obese pregnant woman. The study's secondary objectives were to compare patients' and sonographers' satisfaction with EAS versus R-TAS.

METHODS

A prospective observational study was carried out over a 2.5-year period including consecutive pregnant women with a pre-pregnancy BMI ≥30 kg/m² who consented at a dating ultrasound appointment to undergo EAS at 15 ± 1 GA in addition to the second trimester R-TAS. Anatomic structures were categorized as normal, not well seen, or abnormal by using the institutional 26-item anatomic standardized reporting template. Examination completion and study duration were recorded. Neonatal follow-up was performed to evaluate for any missed diagnoses. Patients' and sonographers' satisfaction questionnaires were completed.

RESULTS

A total of 120 pregnant women completed the study. Visualization of all anatomic components was complete in 14% at EAS and in 61% at R-TAS (combined completion rate, 90%). Mean scan time was 30.4 minutes at EAS and 51 minutes at R-TAS. No missed diagnoses of structural anomalies were identified at neonatal follow-up. EAS and R-TAS differed in terms of sonographers' reports of difficult or suboptimal scans (9% vs. 58%), well-seen anatomy (85% vs. 78%), and good visibility (44% vs. 12%). Most sonographers expressed a preference for performing EAS in future pregnancies, rather than the R-TAS (96% vs. 6%). Although patients reported greater satisfaction with EAS (93% vs. 74%), for reasons that could not be determined, they expressed a preference for R-TAS in a subsequent pregnancy (23% vs. 63%).

CONCLUSION

Performing EAS along with R-TAS improves completion rates for anatomic evaluation in the obese gravida and is associated with greater patient and sonographer satisfaction.

Role of pulse oximetry in examining newborns for congenital heart disease: a scientific statement from the AHA and AAP

BACKGROUND

The purpose of this statement is to address the state of evidence on the routine use of pulse oximetry in newborns to detect critical congenital heart disease (CCHD).

METHODS AND RESULTS

A writing group appointed by the American Heart Association and the American Academy of Pediatrics reviewed the available literature addressing current detection methods for CCHD, burden of missed and/or delayed diagnosis of CCHD, rationale of oximetry screening, and clinical studies of oximetry in otherwise asymptomatic newborns. MEDLINE database searches from 1966 to 2008 were done for English-language papers using the following search terms: congenital heart disease, pulse oximetry, physical examination, murmur, echocardiography, fetal echocardiography, and newborn screening. The reference lists of identified papers were also searched. Published abstracts from major pediatric scientific meetings in 2006 to 2008 were also reviewed. The American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. In an analysis of pooled studies of oximetry assessment performed after 24 hours of life, the estimated sensitivity for detecting CCHD was 69.6%, and the positive predictive value was 47.0%; however, sensitivity varied dramatically among studies from 0% to 100%. False-positive screens that required further evaluation occurred in only 0.035% of infants screened after 24 hours.

CONCLUSIONS

Currently, CCHD is not detected in some newborns until after their hospital discharge, which results in significant morbidity and occasional mortality. Furthermore, routine pulse oximetry performed on asymptomatic newborns after 24 hours of life, but before hospital discharge, may detect CCHD. Routine pulse oximetry performed after 24 hours in hospitals that have on-site pediatric cardiovascular services incurs very low cost and risk of harm. Future studies in larger populations and across a broad range of newborn delivery systems are needed to determine whether this practice should become standard of care in the routine assessment of the neonate.

Role of pulse oximetry in examining newborns for congenital heart disease: a scientific statement from the American Heart Association and American Academy of Pediatrics

BACKGROUND

The purpose of this statement is to address the state of evidence on the routine use of pulse oximetry in newborns to detect critical congenital heart disease (CCHD).

METHODS AND RESULTS

A writing group appointed by the American Heart Association and the American Academy of Pediatrics reviewed the available literature addressing current detection methods for CCHD, burden of missed and/or delayed diagnosis of CCHD, rationale of oximetry screening, and clinical studies of oximetry in otherwise asymptomatic newborns. MEDLINE database searches from 1966 to 2008 were done for English-language papers using the following search terms: congenital heart disease, pulse oximetry, physical examination, murmur, echocardiography, fetal echocardiography, and newborn screening. The reference lists of identified papers were also searched. Published abstracts from major pediatric scientific meetings in 2006 to 2008 were also reviewed. The American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. In an analysis of pooled studies of oximetry assessment performed after 24 hours of life, the estimated sensitivity for detecting CCHD was 69.6%, and the positive predictive value was 47.0%; however, sensitivity varied dramatically among studies from 0% to 100%. False-positive screens that required further evaluation occurred in only 0.035% of infants screened after 24 hours.

CONCLUSIONS

Currently, CCHD is not detected in some newborns until after their hospital discharge, which results in significant morbidity and occasional mortality. Furthermore, routine pulse oximetry performed on asymptomatic newborns after 24 hours of life, but before hospital discharge, may detect CCHD. Routine pulse oximetry performed after 24 hours in hospitals that have on-site pediatric cardiovascular services incurs very low cost and risk of harm. Future studies in larger populations and across a broad range of newborn delivery systems are needed to determine whether this practice should become standard of care in the routine assessment of the neonate.