The added value of screening fetal echocardiography after normal cardiac views on a detailed ultrasound

Utility of Screening Fetal Echocardiograms Following Normal Level II Ultrasounds in Fetuses with Siblings with Congenital Heart Disease

INTRODUCTION

In pregnancies when congenital heart disease (CHD) is present in siblings, fetal echocardiograms (F-echo) are recommended, regardless if there was a prior level II ultrasound (LII-US) that was normal. The goal of this study was to evaluate if any diagnosis of a critical congenital heart disease (CHD) was missed in a fetus who had a sibling with CHD, when a normal LII-US was documented.

METHODS

Retrospective chart review of all F-echo where the indication was sibling with CHD between January 1, 2019 and December 31, 2023 was performed. Fetuses were included if they had a LII-US that was read as normal and had a F-echo. Critical CHD was defined as CHD requiring catheterization or surgical intervention < 1 month of age.

RESULTS

A total of 187 F-echo on fetuses who had a sibling with CHD were evaluated, of which 113 met inclusion criteria. LII-US was performed at 21.1 ± 3.3 weeks gestational age and F-echo was performed at 25.4 ± 3.1 weeks gestational age. No patient with a normal LII-US had a diagnosis of a critical CHD by F-echo (negative predictive value = 100%). Six patients that had a negative LII-US were diagnosed with non-critical CHD or cardiac issues postnatally (negative predictive value = 94.7%). F-echo correctly diagnosed two of the six missed LII-US CHD.

CONCLUSION

Critical CHD was not missed with a normal LII-US in this at-risk population. F-echo also missed the majority of CHD when a LII-US was read as normal. The cost/benefit of screening F-echo in fetuses with siblings with CHD should be evaluated if a normal LII-US has been performed. Larger studies are needed to determine if these findings remain consistent.

Impact of COVID-19 on Prenatal Diagnosis and Surgical Outcomes of Congenital Heart Disease: Fetal Heart Society and Society of Thoracic Surgeons Collaborative Study

BACKGROUND

Fetal echocardiography is the mainstay of prenatal diagnosis of congenital heart disease. The COVID-19 pandemic led to shifts in triage of prenatal services. Our objective was to evaluate the impact of COVID-19 restrictions on prenatal diagnosis, surgical outcomes, and disparities in neonatal critical congenital heart disease (CCHD) management in the United States during the pandemic's first year.

METHODS AND RESULTS

A multi-institutional retrospective cohort study compared neonatal CCHD outcomes (requiring surgery within 60 days of birth) 1 year prior (prepandemic era) and during the peak pandemic era, supplemented by a Fetal Heart Society survey assessing regional practice changes. Data on prenatal diagnosis, demographics, outcomes, and 2020 state Area Deprivation Index were analyzed using Wilcoxon rank sum and χ2 tests. The survey, completed by 72 fetal cardiologists from 9 US census regions, showed 75% of institutions implemented restrictions by March 2020, affecting triage, referrals, and number of prenatal cardiology visits. Compared with CCHD neonates born prepandemic (n=4637), those born during the pandemic (n=1806) had a higher proportion of prenatal diagnosis (66% versus 63%, P<0.05). There were no significant differences in complications or mortality, but pandemic-era neonates had longer hospital stays. During the pandemic, CCHD neonates had a more disadvantaged Area Deprivation Index and had surgery at hospitals located in more advantaged regions.

CONCLUSIONS

Although pandemic-driven care delivery adjustments affected perinatal cardiology referrals and triage, prenatal diagnosis, perioperative outcomes, and survival remained robust. The management of CCHD demonstrates health care resilience, maintaining core prenatal and perioperative care. Regional variations highlight the need for targeted strategies to address disparities during health care crises.

Screening for Structural Heart Defects: A Single-Center Retrospective Cost Analysis for Fetal Echocardiography in Adults with Congenital Heart Disease

Fetal echocardiography (FE) is recommended for parents with congenital heart disease (pCHD) due to a 3-6% recurrence risk of congenital heart disease (CHD). This study aimed to evaluate the cost of FE for detecting neonatal CHD in pCHD. FE data were collected between 12/2015 and 12/2022. Parents were stratified by CHD complexity: "simple" (class I) and "complex" (class II/III). Cost analysis compared universal FE with selective FE following a positive level II screening anatomical ultrasound (SAU). Primary outcomes included the cost and number needed to screen (NNT) to detect one case of neonatal CHD. Of 419 pCHD cases, 48 were analyzed separately due to additional FE indications. Among the remaining 371 cases (73% maternal, 27% paternal; mean maternal age: 31 years), 14 postnatal CHD cases were detected (3.8%). Recurrence rates were 1.9% for simple pCHD (n = 156) and 5.1% for complex pCHD (n = 215). Universal FE increased the cost of detecting neonatal CHD. The cost per detected case was $267,157 for simple CHD (NNT = 560) and $135,125 for complex CHD (NNT = 288). The lower sensitivity of SAU reduced the cost of universal FE. In this single-center cohort, the recurrence risk of CHD in pCHD is higher than in the general population, particularly in complex cases. Universal screening in simple pCHD is costlier with high-sensitivity SAU. Targeted screening in complex pCHD may offer a better cost-to-risk ratio, highlighting the need for early detection to improve outcomes. The cost effectiveness is dependent on local SAU sensitivity rates.

Learning Curve of First-Trimester Detailed Cardiovascular Ultrasound Screening by Moderately Experienced Obstetricians in 3509 Consecutive Unselected Pregnancies with Fetal Follow-Up

Our primary objective was to assess the effectiveness of detailed cardiovascular ultrasound screening during the first trimester, which was performed by obstetricians with intermediate experience. We collected first-trimester fetal cardiac screening data from an unselected pregnant population at RMC-Fetal Medicine Center during a study period spanning from 1 January 2010, to 31 January 2015, in order to analyze our learning curve. A pediatric cardiologist performed a follow-up assessment in cases where the examining obstetrician determined that the fetal cardiac screening results were abnormal or high-risk. Overall, 42 (0.88%) congenital heart abnormalities were discovered prenatally out of 4769 fetuses from 4602 pregnant women who had at least one first-trimester cardiac ultrasonography screening. In total, 89.2% of the major congenital heart abnormalities (27 of 28) in the following fetuses were discovered (or at least highly suspected) at the first-trimester screening and subsequent fetal echocardiography by the pediatric cardiology specialist. Of these, 96.4% were diagnosed prenatally. According to our results, the effectiveness of first-trimester fetal cardiovascular ultrasound screening conducted by moderately experienced obstetricians in an unselected ('routine') pregnant population may reach as high as 90% in terms of major congenital heart defects, provided that equipment, quality assurance, and motivation are appropriate.

Prenatal Detection of Congenital Heart Disease: Importance of Fetal Echocardiography Following Normal Fetal Cardiac Screening

Fetal echocardiography may be performed because of noncardiac indications (the pregnancy is identified as high risk for fetal cardiac disease), or because of fetal cardiac indications (abnormal fetal heart at the time of a screening ultrasound). Considering recent improvements in fetal cardiac screening over the past decade, the goal of this single institution study was to reconsider the importance of performing fetal echocardiography purely for screening (noncardiac) indications. We performed a retrospective analysis to review screening and fetal cardiac indications and fetal cardiac findings for fetal echocardiograms performed at UCLA between 2015 and 2019. Fetal heart disease was identified in 391 (15%) of 2592 pregnancies in this study. Among these 391 cases, 227 (58%) occurred in low-risk pregnancies (without screening indications). While 79% of the cases of fetal cardiac disease were referred with fetal cardiac indications, 21% of the cases were referred with exclusively screening indications. Fetal cardiac disease was discovered on fetal echocardiograms in 4% of pregnancies referred for exclusively screening indications, but the frequency of fetal cardiac disease following normal fetal cardiac screening has decreased from 6% in 2015 to 3% in 2019. In our population, we recommend continued referral for fetal echocardiography for pregnancies identified as high risk for CHD. However, as fetal cardiac screening continues to improve, referral for fetal echocardiography following normal fetal cardiac screening will have diminishing value and yield.

Prenatal diagnosis of interrupted aortic arch using high-definition flow render mode and spatiotemporal image correlation

OBJECTIVES

To evaluate the clinical utility of two dimensional (2D) ultrasound combined with spatiotemporal image correlation (STIC) in diagnosing interrupted aortic arch (IAA) in fetal life.

METHODS

A total of 53 cases of fetal IAA were diagnosed using 2D ultrasound combined with STIC, and 53 normal fetuses of the same gestational week were selected. These cases were retrospectively analyzed to assess the utility of employing 2D ultrasound combined with STIC in the diagnosis of IAA.

RESULTS

2D ultrasound combined with STIC detected 22 cases of type A IAA, 24 cases of type B IAA, and seven cases of type C IAA. Furthermore, combining 2D ultrasound with STIC enabled dynamic visualization of the IAA, aiding in prenatal diagnosis. The diagnostic coincidence rate of IAA was found to be higher in the HD-flow combined with STIC than that in the 2D combined with HD-flow.

CONCLUSION

HD-flow combined with STIC can assist in diagnosing fetal IAA, and this technique has important clinical value.

The Utility of Screening Fetal Echocardiograms Following Normal Level II Ultrasounds in Fetuses with Maternal Congenital Heart Disease

INTRODUCTION

Fetal echocardiograms (F-echo) are recommended in all pregnancies when maternal congenital heart disease (CHD) is present, even if there was a prior level II ultrasound (LII-US) that was normal. The goal of this study was to evaluate if any diagnosis of a critical CHD was missed in a fetus with maternal CHD who had a normal LII-US.

METHODS

A retrospective chart review of all F-echoes where the indication was maternal CHD between 1/1/2015 to 12/31/2022 was performed. Fetuses were included if they had a LII-US that was read as normal and had an F-echo. Critical CHD was defined as CHD requiring catheterization or surgical intervention < 1 month of age.

RESULTS

A total of 296 F-echoes on fetuses with maternal CHD were evaluated, of which 175 met inclusion criteria. LII-US was performed at 19.8 ± 2.9 weeks gestational age and F-echo was performed at 24.2 ± 2.8 weeks gestational age. No patient with a normal LII-US had a diagnosis of a critical CHD by F-echo (negative predictive value = 100%). Evaluating those patients that had a negative LII-US, ten patients were diagnosed with non-critical CHD postnatally (negative predictive value = 94.3%). F-echo correctly diagnosed two of the ten missed LII-US CHD.

CONCLUSIONS

Critical CHD was not missed with a normal LII-US in this at risk population. F-echo also missed the majority of CHD when a LII-US was read as normal. A cost-benefit analysis of screening F-echo in fetuses with maternal CHD should be conducted if a normal LII-US has been performed.

Utility of Screening Fetal Echocardiograms at a Single Institution Following Normal Obstetric Ultrasound in Fetuses with Down Syndrome

Fetal echocardiograms (F-echo) are recommended in all pregnancies when the fetus has Down syndrome (DS) even if there was a prior obstetric scan (OB-scan) that was normal. The utility of a screening F-echo in this high-risk population when an OB-scan is normal is unknown. Goal of this study was to evaluate if any diagnosis of a critical congenital heart disease (CHD) was missed in a fetus with DS who had a normal OB-scan. Secondary goal was to determine if any CHD was missed postnatally when an OB-scan was read as normal. Retrospective chart review of all fetuses that had a F-echo whose indication was DS between 1/1/2010 to 6/30/2022 was performed. Fetuses were included if they had an OB-scan that was read as normal and had a F-echo. Postnatal transthoracic echocardiogram (pTTE) was reviewed when available. Critical CHD was defined as CHD requiring catheterization or surgical intervention < 1 month of age. One hundred twenty-two F-echo on fetuses with DS were evaluated, of which 48 met inclusion criteria. OB-scan was performed at 20.4 ± 4.5 weeks gestational age and F-echo was performed at 24.0 ± 4.6 weeks gestational age. No patient with a normal OB-scan had a diagnosis of a critical CHD by F-echo (n = 48, negative predictive value = 100%). Evaluating those patients that had an OB-scan and a pTTE (n = 38), 14 patients were diagnosed with CHD (muscular ventricular septal defect (VSD) n = 5, perimembraneous VSD n = 3, secundum atrial septal defect (ASD) n = 2, primum ASD n = 1, transitional atrioventricular septal defect (AVSD) n = 2, and aortic valve abnormality n = 1; negative predictive value = 63.2%). F-echo correctly diagnosed 4 of the 14 missed OB-scan CHD (perimembraneous VSD n = 2, muscular VSD n = 1, and transitional AVSD n = 1). Critical CHD was not missed with a normal OB-scan in this high-risk population. F-echo also missed the majority of CHD when an OB-scan was read as normal. The cost/benefit of screening F-echo in fetuses with DS should be evaluated if a normal OB-scan has been performed, considering all these patients would have a pTTE performed per guidelines.

Maternal metabolomic profiling and congenital heart disease risk in offspring: A systematic review of observational studies

Aetiological understanding and screening methods for congenital heart disease (CHD) are limited. Maternal metabolomic assessment offers the potential to identify risk factors and biomarkers. We performed a systematic review (PROSPERO CRD42022308452) investigating the association between fetal/childhood CHD and endogenous maternal metabolites. Ovid-MEDLINE, Ovid-EMBASE and Cochrane Library were searched between inception and 06/09/2022. Case control studies included analysing maternal blood or urine metabolites in pregnancy or postpartum where there was foetal/childhood CHD. Risk of bias assessment utilised the Scottish Intercollegiate Guidelines Network methodology checklist and narrative synthesis was performed. A total of 134 records were screened with eight eligible studies (n = 3242 pregnancies, n = 842 CHD-affected offspring). Five studies performed metabolomic analysis in pregnancy. Metabolites distinguishing case and control groups spanned lipid, glucose and amino-acid pathways, with the development of sensitive risk prediction models. No single metabolite consistently distinguished cases and controls across studies. Three studies performed targeted analysis postnatally with altered lipid and amino acid metabolites and raised homocysteine and markers of oxidative stress identified in cases. Included studies reported small sample sizes, analysing different biosamples at variable time points using differing techniques. At present, there is not enough evidence to confidently associate maternal metabolomic profiles with offspring CHD risk. However, several identified pathways warrant further investigation.

Fetal echocardiography in a low-income setting: relying on local Maternal-fetal medicine experts for detection of fetal cardiac anomalies

OBJECTIVE

To describe the experience of performing fetal echocardiography (FE) to detect fetal cardiac anomalies prenatally in an Ethiopian setting.

METHODS

A cross-sectional study was conducted at St Paul's Hospital Millennium Medical College (Addis Ababa, Ethiopia), from October 1, 2019 to September 30, 2020. Data for FE cases (on a risk-factor indication basis) performed at 22-24 weeks at the hospital during the study period were collected prospectively and analyzed using SPSSS version 23. Simple descriptive statistics were used to analyze the data. Results were presented as percentages and frequencies.

RESULTS

A total of 142 women who had FE were analyzed in this study. Fetal structural defect in other systems and maternal diabetes mellitus were the commonest indications for FE, seen in 48.2% (67/142) and 25.7% (36/142) of the participants, respectively. There were 5 cases (3.5%) of fetal cardiac anomalies among which were hypoplastic left heart syndrome, pulmonary stenosis, and cardiac tumor.

CONCLUSION

The prevalence of fetal cardiac anomalies in this study was found to be 3.5%. Fetal structural defects and maternal diabetes mellitus were the commonest indications for FE which is consistent with findings from previous similar studies.

Utility of Screening Fetal Echocardiogram Following Normal Anatomy Ultrasound for In Vitro Fertilization Pregnancies

In vitro fertilization (IVF) is associated with a higher incidence of congenital heart disease, resulting in universal screening fetal echocardiograms (F-echo) even when cardiac structures on obstetric scan (OB-scan) are normal. Recent studies suggest that when OB-scan is normal, F-echo may add little benefit and increases cost and anxiety. We aim to determine the utility of screening F-echo in IVF pregnancies with normal cardiac anatomy on prior OB-scan. We conducted a retrospective chart review of IVF pregnancies referred for F-echo at the Seattle Children's Hospital between 2014 and 2020. OB-scan results and subspecialty of interpreting physician (Obstetrics = OB; Maternal Fetal Medicine = MFM; Radiology = Rads), F-echoes, and postnatal outcomes were reviewed. Cardiac anatomy on OB-scans was classified as complete if 4-chamber and outflow-tract views were obtained. Supplemental views (three-vessel and sagittal aortic arch views) on OB-scan were also documented. Of 525 IVF referrals, OB-scan reports were available for review in 411. Normal anatomy was demonstrated in 304 (74%) interpreted by OB (128; 42%), MFM (80; 26%), and Rads (96; 32%). F-echo was normal in 278 (91%). Of the 26 abnormal F-echo, none required intervention (17 muscular and 5 perimembranous ventricular septal defects, and 4 minor valve abnormalities). There was no difference in OB-scan accuracy for identifying normal cardiac anatomy when comparing 4-chamber and outflow-tract views vs. addition of supplemental views (91% vs 92% normal F-echo; p > 0.1). Evaluation of OB-scan accuracy by interpreting physician subspecialty demonstrated normal F-echo in 95%, 85%, and 92% (p = 0.95) as read by OB, MFM, and Rads, respectively. A majority of IVF referrals with normal cardiac anatomy visualized on OB-scan using 4-chamber and outflow-tract views resulted in normal F-echo, regardless of interpreting physician subspecialty or addition of supplemental views. Of the minority with abnormal F-echo, none required intervention. Consideration should be given to the cost/benefit of screening F-echo for the indication of IVF if normal cardiac anatomy is demonstrated on OB-scan.

Concordance Between Obstetric Anatomic Ultrasound and Fetal Echocardiography in Detecting Congenital Heart Disease in High-risk Pregnancies

OBJECTIVES

To evaluate the concordance between second-trimester anatomic ultrasound and fetal echocardiography in detecting minor and critical congenital heart disease in pregnancies meeting American Heart Association criteria.

METHODS

We conducted a retrospective cohort study of pregnancies in which a second-trimester fetal anatomic ultrasound examination (18-26 weeks) and fetal echocardiography were performed between 2012 and 2018 at our institution based on American Heart Association recommendations. Anatomic ultrasound studies were interpreted by maternal-fetal medicine specialists and fetal echocardiographic studies by pediatric cardiologists. Our primary outcome was the proportion of critical congenital heart disease (CCHD) cases not detected by anatomic ultrasound but detected by fetal echocardiography. The secondary outcome was the proportion of total congenital heart disease cases missed by anatomic ultrasound but detected by fetal echocardiography. Neonatal medical records were reviewed for all pregnancies when obtained and available.

RESULTS

Overall, 722 studies met inclusion criteria. Anatomic ultrasound and fetal echocardiography were in agreement in detecting cardiac abnormalities in 681(96.1%) studies (κ = 0.803; P < .001). The most common diagnosis not identified by anatomic ultrasound was a ventricular septal defect, accounting for 9 of 12 (75%) missed congenital heart defects. Of 664 studies with normal cardiac findings on the anatomic ultrasound examinations, no additional instances of CCHD were detected by fetal echocardiography. No unanticipated instances of CCHD were diagnosed postnatally.

CONCLUSIONS

With current American Heart Association screening guidelines, automatic fetal echocardiography in the setting of normal detailed anatomic ultrasound findings provided limited benefit in detecting congenital heart defects that would warrant immediate postnatal interventions. More selective use of automatic fetal echocardiography in at-risk pregnancies should be explored.

Prenatal diagnosis of congenital heart defects: echocardiography

Congenital heart defects (CHD) are the most common congenital anomaly, and the majority can be diagnosed during prenatal life. Prenatal detection rates remain highly variable, as most CHD occur in low risk pregnancies and therefore depend on the maternal obstetric provider to recognize fetal cardiac abnormality on obstetric screening anatomic ultrasound. Fetuses with abnormal findings on obstetric screening anatomic ultrasound and/or risk factors for cardiac disease should be referred for evaluation with fetal echocardiography. Fetal echocardiography should be performed by specialized sonographers and interpreted by physicians with knowledge of evolving fetal cardiac anatomy and physiology throughout gestation. A fetal echocardiography examination, which can be done from the late first trimester onward, utilizes a standardized and systemic approach to diagnose fetuses with CHD or other forms of primary or secondary cardiac disease. The field of fetal cardiology has advanced past the accurate prenatal diagnosis of simple and complex CHD, as fetal echocardiography enables understanding of dynamic fetal cardiac physiology and consideration of potential fetal/neonatal treatment. The greatest impact of fetal echocardiography remains identification of critical CHD before birth to allow immediate cardiac management after delivery to decrease neonatal morbidity and mortality. Analyzing the severity of abnormal cardiac physiology in various forms of CHD before birth allows the fetal cardiologist to prognosticate effects on the developing fetus, predict risk of postnatal hemodynamic instability, guide delivery planning through multidisciplinary collaboration, and anticipate how the disease will impact the neonate after delivery.

Cost-effectiveness of prenatal screening methods for congenital heart defects in pregnancies conceived by in-vitro fertilization

OBJECTIVES

To determine if a policy of universal fetal echocardiography (echo) in pregnancies conceived by in-vitro fertilization (IVF) is cost-effective as a screening strategy for congenital heart defects (CHDs) and to examine the cost-effectiveness of various other CHD screening strategies in IVF pregnancies.

METHODS

A decision-analysis model was designed from a societal perspective with respect to the obstetric patient, to compare the cost-effectiveness of three screening strategies: (1) anatomic ultrasound (US): selective fetal echo following abnormal cardiac findings on detailed anatomic survey; (2) intracytoplasmic sperm injection (ICSI) only: fetal echo for all pregnancies following IVF with ICSI; (3) all IVF: fetal echo for all IVF pregnancies. The model initiated at conception and had a time horizon of 1 year post-delivery. The sensitivities and specificities for each strategy, the probabilities of major and minor CHDs and all other clinical estimates were derived from the literature. Costs, including imaging, consults, surgeries and caregiver productivity losses, were derived from the literature and Medicare databases, and are expressed in USA dollars ($). Effectiveness was quantified as quality-adjusted life years (QALYs), based on how the strategies would affect the quality of life of the obstetric patient. Secondary effectiveness was quantified as number of cases of CHD and, specifically, cases of major CHD, detected.

RESULTS

The average base-case cost of each strategy was as follows: anatomic US, $8119; ICSI only, $8408; and all IVF, $8560. The effectiveness of each strategy was as follows: anatomic US, 1.74487 QALYs; ICSI only, 1.74497 QALYs; and all IVF, 1.74499 QALYs. The ICSI-only strategy had an incremental cost-effectiveness ratio (ICER) of $2 840 494 per additional QALY gained when compared to the anatomic-US strategy, and the all-IVF strategy had an ICER of $5 692 457 per additional QALY when compared with the ICSI-only strategy. Both ICERs exceeded considerably the standard willingness-to-pay threshold of $50 000-$100 000 per QALY. In a secondary analysis, the ICSI-only strategy had an ICER of $527 562 per additional case of major CHD detected when compared to the anatomic-US strategy. All IVF had an ICER of $790 510 per case of major CHD detected when compared with ICSI only. It was determined that it would cost society five times more to detect one additional major CHD through intensive screening of all IVF pregnancies than it would cost to pay for the neonate's first year of care.

CONCLUSION

The most cost-effective method of screening for CHDs in pregnancies following IVF, either with or without ICSI, is to perform a fetal echo only when abnormal cardiac findings are noted on the detailed anatomy scan. Performing routine fetal echo for all IVF pregnancies is not cost-effective. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Omphalocele-What should we tell the prospective parents?

An omphalocele is a congenital defect in the abdominal wall characterized by absent abdominal muscles, fascia, and skin. The characteristic ultrasound appearance includes a midline defect with herniation of abdominal contents into the base of the umbilical cord. Other anatomic abnormalities are seen in approximately 50% of cases, most notably cardiac defects (19%-32%). Approximately, 50% of cases are associated with genetic and multiple malformation syndromes including trisomy 13/18, pentalogy of Cantrell and Beckwith-Wiedemann syndrome. Therefore, a thorough evaluation is recommended, including detailed anatomic survey, fetal echocardiogram, genetic counseling, and prenatal diagnostic testing. Overall prognosis depends on the size of the omphalocele, genetic studies, and associated anomalies. Early prenatal diagnosis remains important in order to provide parental counseling and assist in pregnancy management. Delivery should occur at a tertiary care center. Timing and mode of delivery should be based on standard obstetric indications with cesarean delivery reserved for large omphalocele (>5 cm) or those that involve the fetal liver. Neonatal management involves either primary or staged reduction, both of which can be associated with a prolonged neonatal hospitalization.

Role of routine fetal echocardiography in an unselected group of pregnant women for prenatal detection of cardiac malformations

Objectives

We investigated the potential for improvement in prenatal detection of congenital heart disease (CHD) by routinely performing detailed fetal echocardiography (FE) in all pregnant women.

Methods

Following routine obstetric sonography, 1445 unselected pregnant women were prospectively subjected to FE at gestational ages between 16 and 24 weeks, or at first visit, if they presented later. Maternal or fetal factors, conventionally known to be associated with risk of CHD, were noted.

The prevalence and detection rates of cardiac abnormalities were determined, and confirmation of findings by postnatal follow-up was done to ensure accuracy of FE. Prevalence of CHD was compared in pregnancies with or without conventional risk factors.

Results

The overall prevalence of CHD was 8.3 per 1000; only 2 CHD cases belonged to the high maternal risk group, while 10 cases were observed without maternal risk factors. Cardiac malformations were suspected in 14 fetuses during obstetric scan; but, only 5 of them had CHD, remaining 9 had structurally normal hearts. 50% of CHD cases occurred in pregnancies not associate with any (fetal or maternal) risk factor. The sensitivity, and specificity for prenatal CHD detection were 91.7% and 100% respectively.

Conclusions

Our study indicates that a substantial proportion of CHD cases occur in women not having high risk of giving birth to children with CHD. FE is a highly sensitive and specific test with strong predictive values. We recommend that FE should be done in every pregnancy.

Audit of level II scans in a tertiary center of a middle-income country (MIC)

CONTEXT

Significant anomalies are those that are lethal or those that require prolonged follow-up and unaffordable treatments. Detection of these anomalies allows early termination or the support systems necessary for pregnancies with these diagnoses. Anxiety associated with overdiagnosis makes the woman a victim of modern imaging technology. However, accurate detection of significant anomalies in a busy scan room of a developing country with the need to cater to large numbers is particularly challenging.

AIMS

The aim was to audit the diagnostic accuracy in a busy scan room.

SETTINGS AND DESIGN

Retrospective cohort in a tertiary center.

METHODS AND MATERIALS

Audit of significant anomalies identified at the 20-week scan was performed after the expected date of confinement. Anomalies that were missed or overdiagnosed were noted.

STATISTICAL ANALYSIS USED

All the categorical variables in this research were summarized using counts and percentages.

RESULTS

Twenty-eight thousand women underwent morphology ultrasound during the study period. 963 (3.4%) women were detected to have anomalies at birth. Multiple anomalies were seen in 285 (30%) cases and isolated ones in 678 (70%) cases. Anomalies of the genitourinary system were the commonest followed by the anomalies of central nervous system. Only 53 (0.2%) anomalies were missed. They were mainly syndromes and anomalies of the cardiovascular system. The most significant anomalies that were identified could be diagnosed with a basic ultrasound machine.

CONCLUSIONS

910/963 (95%) of significant anomalies can be identified even in busy centers if a systematic assessment approach is ensured.