Pregnancy Termination and Postnatal Major Congenital Heart Defect Prevalence After Introduction of Prenatal Cardiac Screening

Importance

Prenatal cardiac screening of the first and second trimesters has had a major impact on postnatal prevalence of congenital heart defects (CHDs), rates of termination of pregnancy (TOP), and outcomes among children born alive with CHDs.

Objective

To examine the prenatal and postnatal incidence of major CHDs (ie, necessitating intervention within the first year of life), detection rate trends, rates of TOP, and the association of cardiac screening with postnatal outcomes.

Design, Settings, and Participants

In this cross-sectional study, 3827 fetuses with antenatally diagnosed major CHDs in the Czech Republic (population 10.7 million) between 1991 and 2021 were prospectively evaluated with known outcomes and associated comorbidities. Prenatal and postnatal prevalence of CHD in an unselected population was assessed by comparison with a retrospective analysis of all children born alive with major CHDs in the same period (5454 children), using national data registry. Data analysis was conducted from January 1991 to December 2021.

Main Outcomes and Measures

Prenatal detection and postnatal prevalence of major CHDs and rate of TOPs in a setting with a centralized health care system over 31 years.

Results

A total of 3 300 068 children were born alive during the study period. Major CHD was diagnosed in 3827 fetuses, of whom 1646 (43.0%) were born, 2069 (54.1%) resulted in TOP, and 112 (2.9%) died prenatally. The prenatal detection rate increased from 6.2% in 1991 to 82.8% in 2021 (P < .001). Termination of pregnancy decreased from 70% in 1991 to 43% (P < .001) in 2021. Of 627 fetuses diagnosed in the first trimester (introduced in 2007), 460 were terminated (73.3%). Since 2007, of 2066 fetuses diagnosed in the second trimester, 880 (42.6%) were terminated, resulting in an odds ratio of 3.6 (95% CI, 2.8-4.6; P < .001) for TOP in the first trimester compared with the second trimester. Postnatal prevalence of major CHDs declined from 0.21% to 0.14% (P < .001). The total incidence (combining prenatal detection of terminated fetuses with postnatal prevalence) of major CHD remained at 0.23% during the study period.

Conclusions and Relevance

In this cross-sectional study, the total incidence of major CHD did not change significantly during the 31-year study period. The prenatal detection of major CHD approached 83% in the current era. Postnatal prevalence of major CHD decreased significantly due to early TOPs and intrauterine deaths. The introduction of first trimester screening resulted in a higher termination rate in the first trimester but did not revert the overall decreasing trend of termination for CHDs in general.

Early Vascular Aging in Children With Type 1 Diabetes and Ambulatory Normotension

Background: Preliminary data suggest that target organ damage (TOD) and early vascular aging (EVA) may occur in children with normal blood pressure (BP). Objectives: To analyze TOD and EVA in normotensive (BP <95th percentile on ambulatory BP monitoring) type 1 diabetes children (T1D) in comparison to healthy controls (C). Subjects: 25 T1D aged 13.9 ± 2.6 years and 22 C aged 14.0 ± 3.4 years. Methods: We analyzed age- and height-related pulse wave velocity (PWV) Z-scores and expected PWV based on age, height, and mean arterial pressure (MAP). Expected vascular age based on measured PWV was calculated from pooled pediatric and adult PWV norms. Left ventricular mass index (LVMI), estimated glomerular filtration rate (eGFR), and urinary albumin/creatinine ratio (ACR) were obtained as markers of TOD. Results: T1D and C groups did not differ in anthropometry, ambulatory, LVMI, and ACR. However, median age- and height-related PWV Z-scores were higher in T1D compared to C (1.08 vs. 0.57, p = 0.006; 0.78 vs. 0.36, p = 0.02, respectively). Mean (±SD) difference between measured and expected PWV was 0.58 ± 0.57 in T1D vs. 0.22 ± 0.59 in C, p = 0.02. The mean (±SD) difference between chronological and expected vascular age was 7.53 ± 7.74 years in T1D vs. 2.78 ± 7.01 years in C, p = 0.04. Conclusion: Increased arterial stiffness and increased intraindividual differences between expected and measured PWV as well as between chronological and expected vascular age indicate that EVA may develop in T1D children even at normal ambulatory BP levels.

Neonatal pneumonia caused by Trichomonas vaginalis

Neonatal pneumonia is mostly bacterial and other etiology is considered less frequently. We report a case of newborn whose neonatal pneumonia has not improved, despite the aggressive ventilation regime and empiric antibiotic therapy. A special sample from the respiratory tract was collected for PCR examination. The test confirmed the presence of Trichomonas vaginalis. Antibiotic therapy was extended to include metronidazole. Targeted antibiotic therapy, which lasted for 28 days, improved the condition and the patient was discharged in a stabilized condition to home care on the 44th day of life. We demonstrate the need to consider atypical pathogens in the case of infections that do not respond to conventional therapy. The multiplex real-time PCR technique was used to detect the DNA of the pathogen. Targeted antibiotic therapy is the result of pathogen identification.

Echogenic foci in fetal heart from a pediatric cardiologists point of view

OBJECTIVES

To evaluate the occurrence and the significance of echogenic foci in the fetal heart and to assess the prognosis of the fetus and child.

SETTING

Department of Pediatrics and Prenatal Cardiology, Department of Pediatrics, University Hospital, Faculty of Medicine, Ostrava.

DESIGN

Original article.

METHODS

A retrospective study was conducted between 2008-2017. Fetal echocardiography was performed in the second trimester of pregnancy in the study population. The identification of echogenic heart foci, and their follow up during and after the pregnancy were performed by a pediatric cardiologist.

RESULTS

In the monitored period, a total of 27,633 fetuses were examined. Isolated cardiac hyperechogenic foci were detected in 3% (829/27,633) of the fetuses. The foci was found in 93%, 5%, and 2% in the left ventricle, mainly in valvular apparatus of the mitral valve, in the both ventricles, and in the right ventricle, respectively. In 1% (11/829) of the fetuses with cardiac echogenic foci, the others concomitant pathologies (tricuspid regurgitation, extrasystoles, renal pathology) were found. No genetic abnormalities were detected in the fetuses with cardiac hyperechogenic foci.

CONCLUSION

The echogenic focus in fetal heart is a relatively common, mostly insignificant finding, with any serious consequences for the fetus and the child.

The effects of within stand disturbance in plantation forests indicate complex and contrasting responses among and within beetle families

Plantation forests with timber production as the major function are highly fragmented and disturbed regarding the tree species composition and stand area. Their closed canopies also have different microclimatic conditions compared with better studied conservation areas. We studied three beetle families (click, longhorn, and rove beetles) with different ecological demands in lowland plantation forests dominated by Sessile oak and Norway spruce in the Czech Republic. Our main interest was how their species richness, abundance, diversity, body length, rarity, red-list status, species composition and individual species were driven by the main tree species, stand area and canopy openness. We analyzed 3466 individuals from 198 beetle species and the results revealed complex and contrasting responses of the studied beetle families - click beetles mostly preferred sun-exposure and spruce as the dominant tree species, longhorn beetles mainly preferred large stands, whereas rove beetles were mostly influenced by oak as the dominant tree species and increasing area. We also observed that some species had different preferences in plantation forests than is known from the literature. The main conclusions of our results are that the dominance of non-natural spruce plantations and a large stand area (both originating from artificially replanted large clear-cuts) did not affect the majority of the studied taxa as we expected. On the other hand, our results might have been influenced by other factor, such as the current small total area of the former vegetation, which in the past might have led to extinction debt; or a large area of other conifers in the surroundings that might have promoted conifer-associated fauna.

[Development of prenatal diagnostics of congenital heart defects, profit of standardized scanning planes]

OBJECTIVE

To audit the development and success rate of prenatal detection of congenital heart defects (CHDs), and to evaluate the effectiveness of diagnostics performed in standardized scanning planes.

SETTING

Department of Pediatrics, University Hospital Ostrava.

DESIGN

Retrospective study.

METHODS

Ultrasound examination of fetal heart (fetal echocardiography) was performed in the second trimester pregnancy. The observed region was the Moravian-Silesian region; the assessment was performed in the retrospective study performed between 2000- 2016. The knowledge of all significant heart defects in the region, processing of data from genetic reporting, further examination of all prenatal pathologies by a pediatric cardiologist, presence of a pediatric cardiologist at all autopsies, with a precise description of the defect, birth of a pathological new-born at a specialized centre. Analysis of detected CHDs was performed in relation to the ultrasound scans used.

RESULTS

During the monitored 17-year period, a total of 748 (3.8 cases per 1,000 foetuses) of prenatally identified and postnatally significant CHDs were observed in the total population of 198,300 foetuses. There were 53% (393/748) CHDs detected prenatally and 47% (355/748) of cases were not prenatally recognized. The effectiveness of CHD screening has improved progressively, from the initial 10% up to the current 74%. The best results were obtained using the basic four-chamber (4CH) scan; the results in practice gradually decreased, from the basic 4CH projection to the aortic arch.

CONCLUSION

The effectiveness of prenatal detection of congenital heart defects gradually improves, namely in cases of hypoplasia and significant ventricular anomalies, with up to 100% prenatally detected cases in the past three years. The level of detection statistically decreases, from the four-chamber projection to out-flow tracts, great arteries and the aortic arch. Congenital heart defect is generally well detectable prenatally, and is usually observed as an isolated anomaly. The most important factors include a precise diagnosis, overall examination of the pregnancy and correct counselling provided for the affected family.

Can auscultatory blood pressure normative values be used for evaluation of oscillometric blood pressure in children?

The aim of the study was to analyze whether auscultatory normative values (Fourth Task Force [4TF]) can be applied to blood pressure (BP) obtained by oscillometric devices. The authors performed a retrospective analysis of oscillometric office BP and ambulatory BP monitoring in 229 children (116 boys), median age 15.31 years. Office systolic BP (SBP) and diastolic BP (DBP) values were converted into Z scores using 4TF and oscillometric (German Health Interview and Examination Survey for Children and Adolescent [KiGGS]) reference values. There was good correlation between the two normative methods (r=0.9773 for SBP, r=0.9627 for DBP). Results from Bland-Altman test revealed only minimal differences in Z scores between 4TF and KiGGS for SBP, but a significant proportional error for DBP. 4TF and KiGGS Z scores were equally predictive of ambulatory hypertension. In conclusion, auscultatory and oscillometric normative data are interchangeable for SBP but not for DBP.

Increased prevalence of bicuspid aortic valve in Turner syndrome links with karyotype: the crucial importance of detailed cardiovascular screening

BACKGROUND

Bicuspid aortic valve (BAV) represents one of the strongest risk factors for aortic dissection in Turner syndrome (TS). An exact relation between the occurrence of BAV and a particular karyotype has not been established yet. The aim of this study was to determine the association between karyotype and prevalence of BAV.

METHODS

Sixty-seven TS patients aged between 6.6 and 32.5 years underwent cardiac magnetic resonance imaging (MRI) study. They were divided into four cytogenetic subgroups-45,X karyotype (n=27); 45,X/46,XX mosaicism (n=17); structural abnormalities of the X chromosome (n=10); and 45,X/structural abnormality of the X chromosome mosaicism (n=13). Prevalence of BAV and odds ratio (OR) compared with the general population in the whole study group, and statistical comparison of prevalences of BAV among the individual subgroups were determined.

RESULTS

Prevalence of BAV in the whole study group was established as 28.4% [OR 208.3 (95% CI - 103.8-418.0); p-value<0.0001]. Individuals with 45,X karyotype had the highest prevalence of BAV - 40.7%, p-value<0.0001. Presence of any 45,X cell line in karyotype significantly predisposed to BAV (p-value=0.05).

CONCLUSIONS

The 45,X karyotype is associated with the highest prevalence of BAV. Also, the presence of the 45,X cell line in any mosaic karyotype increases the probability of BAV.

[Ectopia cordis - case report]

OBJECT

Case report of ectopia cordis in a fetus at 23 weeks gestation.

DESIGN

Case repor.

SETTING

Obstetrics and Gynecology Clinic, University of Ostrava and University Hospital in Ostrava.

METHODS AND RESULTS

We report a case of pentalogy of Cantrell variant in a 23-week fetus with an ultrasound finding of ectopia cordis, associated intracardial defects and omphalocele containing liver and guts. The patient opted for termination of pregnancy by using prostaglandins. Autopsy of the fetus revealed a cleft sternum and thoracic wall defect with nude ectopic heart-thoracic type and omphalocele containing liver and guts. Detailed examination of the heart revealed a double outlet right ventricle with a complete atrioventricular septal defect. Our study describes typical ultrasound findings in a correlation with autopsy findings.

CONCLUSION

Ectopia cordis is a rare congenital malformation with an estimated incidence of 1:100 000 live births in developed countries. It is characterized by abnormal heart placement outside the thorax, mostly on the thoracoabdominal side. This form is often associated with pentalogy of Cantrell.

Thermodynamic properties of pure hard sphere, spherocylinder and dumbell fluids

A universal equation of state for the fluid of hard bodies of an arbitrary shape is proposed. New Monte Carlo data of the hard sphere system are published and the existing pseudoexperimental data for hard spheres, spherocylindres and dumbells are critically reviewed.