The association between prenatal atrioventricular septal defects and chromosomal abnormalities

Congenital heart disease and arrhythmia disorders in newborns with congenital diaphragmatic hernia: a 23-year experience at a UK university pediatric surgical centre

PURPOSE

Congenital diaphragmatic hernia (CDH) is associated with congenital heart disease (CHD) and index newborns reportedly may experience cardiac arrhythmia disorders [Tella et al.-Pediatric Critical Care Medicine 2022]. This study analyses, details and reports contemporary outcome metrics of CHD and cardiac rhythm disease (CRD) in CDH babies attending a university surgical centre.

METHODS

Retrospective analysis of medical records of all newborns undergoing Bochdalek CDH repair between 1999 and 2021 at a university paediatric surgical centre. CDH newborns with CHD and neonatal arrythmias were identified from echocardiogram and electrocardiogram (ECG) investigative studies. Operative native diaphragm and / or use of patch repair(s) was documented. Outcome(s) measured-(i) mortality and (ii) cardiopulmonary interventions including ventilatory strategies-ECMO (%), inotropes and anti-arrhythmic therapy(s).

RESULTS

Of 173 CDH neonates, 95 (55%) had CHD of which 9 babies (10%) had cardiac arrhythmias. CDH and co-existing CHD was linked with (a) lower infant birth weights (3130 g vs 3357 g, p = 0.05), (b) increased use of inotrope agents (48.4% vs 39.3%, p = 0.03) and (c) greater use of high-frequency oscillatory ventilation (38.9% vs 23%, p = 0.004). CDH babies experiencing arrythmias were at higher risk (%) of developing pulmonary hypertension (66.7% vs 28.7%, p = 0.01). No significant differences were observed in ECMO utilisation (12% vs 6%, p = 0.46) or patch repair(s) (53% vs 46%, p = 0.06) in CDH patients with and without CHD. CHD was not associated with increased risk(s) of mortality (OR 2.58, 95% CI 0.81-8.24, p = 0.11). Of 9 index CDH patients with arrhythmias-4 babies (44%) required interventional treatments.

CONCLUSION

CHD was prevalent in a high percentage (%) of CDH newborns treated at this university centre and associated with increased use (%) of cardiovascular respiratory support including patch repair. A minority of patients (2.3%) had cardiac rhythm disorders requiring treatment(s). In those developing arrhythmias pulmonary hypertension may be a risk-linked event. Optimising outcomes to offset pulmonary hypertension requires further appraisal. Future large-scale population studies may help underscore the 'real apparent incidence' of cardiac rhythm disorders in CDH.

Revisiting Atrioventricular Septal Defects: Exploring Chromosomal Abnormalities, Cardiac and Extracardiac Anomalies in a Contemporary Prenatal Cohort

To estimate if there is an association between partial AVSD with chromosomal abnormalities, cardiac and extracardiac malformations, and to report the outcomes of prenatally diagnosed AVSD in a large, contemporary cohort. This is a retrospective cohort study of 190 prenatally diagnosed fetal AVSD between 2014 and 2023. Type of AVSD (complete vs partial), additional cardiac findings, extracardiac findings, presence of a heterotaxy, results of prenatal karyotype, and pregnancy outcomes were documented and analyzed. A total of 190 cases of fetal AVSD were analyzed. Complete AVSDs comprised 141 (74.2%) of the cohort, while partial AVSDs comprised 49 (25.7%). Karyotype was completed in 131 cases, and in 98 (74.8%) cases chromosomal abnormalities were identified, with trisomy 21 being the most common (53/131, 40.5%). Complete AVSDs were associated with trisomy 21 (45.5%, p = 0.04), Isolated cases of complete AVSDs (p = 0.03). Partial AVSDs were associated with trisomy 18 (53.1%, p < 0.001). In cases of partial AVSDs with aneuploidies, 7 (70%) had an ostium primum defect and 20 (90.9%) of AV canal type VSD. Isolated partial AVSD had no clear association with aneuploidies. There were additional cardiac anomalies in 96 (50.5%) and extracardiac anomalies in 134 (70.5%) of the cohort. There were no differences between partial and complete AVSD in rate of additional cardiac and extracardiac anomalies. AVSD was part of a heterotaxy in 47 (24.7%) of cases, and heterotaxy was associated with complete AVSD in the majority of cases (43/47, 91.4%, p = 0.003). Fetal partial AVSDs are associated with trisomy 18. Fetal complete AVSDs, even isolated, are associated with trisomy 21. There were no differences in association of other aneuploidies, additional cardiac findings, or extracardiac anomalies between prenatally diagnosed complete AVSDs and partial AVSDs.

Increased risk of adverse gestational outcomes in pregnant women with primary Sjögren's syndrome

OBJECTIVES

This study aimed to identify risk factors contributing to diverse pregnancy outcomes in primary Sjögren's syndrome (pSS) cases.

METHODS

A retrospective analysis was conducted on pregnant individuals with pSS, who received outpatient or inpatient care across multiple hospitals in Anhui Province, China, from January 2015 to December 2022.

RESULTS

This study included 164 pregnant women with pSS and 328 control subjects, with no statistically significant difference in average age between the two groups. Analysis of pregnancy outcomes revealed that, compared with the control group, pregnant women in the pSS group were more likely to experience miscarriages, both spontaneous (12.80% vs 1.52%, p<0.001) and therapeutic (6.10% vs 0.91%, p<0.05). The proportion of placental abnormalities detected during prenatal ultrasound in women from the pSS group was higher (14.63% vs 6.40%, p<0.05). In the analysis of pregnancy outcomes for live-born neonates, a higher incidence of congenital heart abnormalities was observed in the pSS group (27.34% vs 12.03%, p<0.05). While there were no significant differences between the pSS pregnancies in terms of both normal and adverse pregnancy outcomes, a comparison of fetal survival and fetal loss in pSS pregnancies revealed a greater use of prophylactic anticoagulant therapy in the fetal survival group. Notably, the application of low molecular weight heparin (LMWH) emerged as an independent protective factor for fetal survival.

CONCLUSIONS

Compared with non-autoimmune controls, pregnancy in women with pSS presents more challenges. Importantly, we observed that the use of LMWH as anticoagulant therapy is an independent protective measure for fetal survival.

Efficacy of atrioventricular valve regurgitation in the first trimester for the diagnosis of atrioventricular septal defect

PURPOSE

To investigate the efficacy of atrioventricular valve regurgitation (AVVR) for predicting atrioventricular septal defect (AVSD) in the first trimester.

METHODS

We performed a prospective observational study, screening for complicated congenital heart diseases and AVVR in fetuses at 11 to 13+6 weeks of gestation by advanced dynamic flow in four-chamber view and three-vessel-trachea view.

RESULTS

43 549 fetuses at 11 to 13+6 weeks of gestation were screened by echocardiography, of which 37 cases were diagnosed with AVSD, including complete AVSD (31 cases), intermediate AVSD (3 cases) and partial AVSD (1 cases), undiagnosed intermediate AVSD (2 cases), and misdiagnosed case (2 cases). AVVR was observed in 34 cases (34/37) in the first trimester, 59. 46% (22/37) nuchal translucency greater than 95th percentile, 29. 73% (11/37) absence of nasal bone, 32. 43% (12/37) ductus venosus A wave inversion, and 40. 54% (15/37) had tricuspid regurgitation. The sensitivity of common AVVR in predicting AVSD is better than other ultrasonic indexes.

CONCLUSIONS

AVVR can be used as an ultrasonic indicator to predict AVSD in the first trimester, which is beneficial to detect AVSD.

The Value of Prenatal Systematic Ultrasonic Examination of Fetal Structural Abnormality in Diagnosing Fetal Structural Abnormality

In order to explore the value of prenatal systematic ultrasound examination of fetal structural abnormality in the diagnosis of fetal structural abnormality, this paper retrospectively analyzed 200 cases of fetal abnormality referrals from December 2017 to December 2019 in the prenatal systematic ultrasound examination of the designated hospital in this study of pregnant women. By sorting, summarizing and summarizing the actual conditions of the systematic ultrasound examination of each prenatal fetal abnormal section, this study calculated, recorded and analyzed the detection rate, missed diagnosis rate, sensitivity, and specificity of the systematic ultrasound examination of structural abnormality, and then discussed the value of prenatal systematic ultrasound in the diagnosis of fetal structural abnormality. The results showed that, 185 cases were detected out of 200 fetal abnormality with the detection rate of 92.5%; missed diagnosis rate is 7.3%; detection sensitivity is 87.43%; and specificity is 76.58%. Among them, the detection rate of malformations of different diseases from high to low is cardiovascular system (97.54%), nervous system (93.16%), respiratory system (90.62%), facial system (87.54%), and urinary system (85.47%). Therefore, the prenatal systematic ultrasound fetal structural abnormality examination for pregnant women can achieve good diagnostic results, can provide pregnant women with fetal structural abnormality the opportunity to terminate pregnancy early, and effectively reduce the birth of structural abnormal fetuses and the burden of family and society, having important clinical significance and reducing.

Aberrant right subclavian artery: the association with chromosomal defects and the related post-natal outcomes in a third level referral centre

Aberrant right subclavian artery (ARSA) is the most common embryologic abnormality of the aortic arch. The presence of ARSA has been previously associated with an increased risk of Down syndrome. ARSA at birth may be associated with dysphagia, respiratory distress and stridor and there is no clear evidence-based management. The aim of this study was to describe the associations with chromosomal abnormalities and the postnatal outcome of fetuses diagnosed with ARSA. We analysed fetuses diagnosed antenatally with ARSA between January 2013 and September 2019 in the fetal echocardiography unit of the Hospital Monaldi, University 'Vanvitelli' of Naples, Italy. The results showed fifty fetuses diagnosed with ARSA, all confirmed after birth. The ARSA was an isolated finding in 46 fetuses (92%), while in 4 fetuses the ARSA was associated with other cardiac and/or extra-cardiac anomalies. Only one fetus was diagnosed with trisomy 21 (2%). In this fetus the ARSA was the only ultrasound anomaly identified. There were no cases necessitating referral due to the presence of compression symptoms at birth. The presence of ARSA was associated with trisomy 21 in the 2% of cases in our series and there were no neonatal complications due to airway compression at birth.IMPACT STATEMENTWhat is already known on this subject? Aberrant right subclavian artery (ARSA) is the most common embryologic abnormality of the aortich arch. ARSA at birth could be associated with dysphagia, respiratory distress and stridor and no evidence-based management of these fetuses has been described yet. The presence of ARSA has been previously associated with an increased risk of Down syndrome.What do the results of this study add? This study confirms known data on association with chromosomal defects and provides some original data on the absence of symptomatology due to tracheal compression with a postnatal follow-up up to three years of age.What are the implications of these findings for clinical practice and/or further research? Our findings suggest that in cases with adequate prenatal assessment performed by experienced clinicians, delivery can safely take place at local hospitals, with no need of referral soon after birth. The use of transthoracic echocardiography to confirm the diagnoses of ARSA after birth and to plan the next follow-up appointments can be supported.

Trends in the prenatal diagnosis of trisomy 21 show younger maternal age and shift in the distribution of congenital heart disease over a 20-year period

Prenatal testing has changed greatly over the past two decades, which may affect the diagnosis of congenital heart disease (CHD) in Down syndrome. The present study aimed to analyze changes in the prevalence and distribution of CHD diagnosed via ultrasonography and fetopathology in 462 fetuses with trisomy 21 between two consecutive 10-year periods (1999-2018), as well as the associations between CHDs, ultrasound markers, and extracardiac malformations. Overall, the frequency of cardiovascular malformations in trisomy 21 was 27.7 and 26.5%, and ultrasound identified 70 and 62% of CHDs during these periods. A profound increase in first-trimester ultrasound findings and associated anomalies with CHDs (ventricular septal defect, Tetralogy of Fallot) since 2009 were observed. Second-trimester nonstructural heart abnormalities were associated with ultrasound anomalies (74%) and major extracardiac malformations (42.9%). During both study periods, mothers carrying fetuses with CHD were significantly younger than those without CHD (p = 0.038, p = 0.009, respectively). Comparing the two 10-year periods, there were no changes in the prevalence and detection of CHDs. Trend analysis revealed that, although the frequency of CHD remained stable, the diagnostic spectrum had shifted between the study periods. Detection of nonstructural heart abnormalities necessitates detailed follow-up for cardiac/extracardiac malformations and chromosomal disorders.

Spillover of Early Extubation Practices From the Pediatric Heart Network Collaborative Learning Study

OBJECTIVES

The Pediatric Heart Network Collaborative Learning Study used collaborative learning strategies to implement a clinical practice guideline that increased rates of early extubation after infant repair of tetralogy of Fallot and coarctation of the aorta. We assessed early extubation rates for infants undergoing cardiac surgeries not targeted by the clinical practice guideline to determine whether changes in extubation practices spilled over to care of other infants.

DESIGN

Observational analyses of site's local Society of Thoracic Surgeons Congenital Heart Surgery Database and Pediatric Cardiac Critical Care Consortium Registry.

SETTING

Four Pediatric Heart Network Collaborative Learning Study active-site hospitals.

PATIENTS

Infants undergoing ventricular septal defect repair, atrioventricular septal defect repair, or superior cavopulmonary anastomosis (lower complexity), and arterial switch operation or isolated aortopulmonary shunt (higher complexity).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Aggregate outcomes were compared between the 12 month pre-clinical practice guideline and 12 months after study completion (Follow Up). In infants undergoing lower complexity surgeries, early extubation increased during Follow Up compared with Pre-Clinical Practice Guideline (30.2% vs 18.8%, p = 0.006), and hours to initial postoperative extubation decreased. We observed variation in these outcomes by surgery type, with only ventricular septal defect repair associated with a significant increase in early extubation during Follow Up compared with Pre-Clinical Practice Guideline (47% vs 26%, p = 0.006). Variation by study site was also seen, with only one hospital showing an increase in early extubation. In patients undergoing higher complexity surgeries, there was no difference in early extubation or hours to initial extubation between the study eras.

CONCLUSIONS

We observed spillover of extubation practices promoted by the Collaborative Learning Study clinical practice guideline to lower complexity operations not included in the original study that was sustainable 1 year after study completion, though this effect differed across sites and operation subtypes. No changes in postoperative extubation outcomes following higher complexity surgeries were seen. The significant variation in outcomes by site suggests that center-specific factors may have influenced spillover of clinical practice guideline practices.

Coding and Legal Issues in Obstetric and Gynecologic Ultrasound

This article addresses coding and liability related to obstetric and gynecologic ultrasound examinations. The coding section includes an overview of general concepts, highlighting the differences between coding in hospital-owned facilities and provider-owned clinics. It also addresses the importance of correct International Classification of Diseases, 10th edition, coding, emphasizing the use of the most specific applicable codes. This section discusses proper coding and applicable parameters for early pregnancy and gynecologic ultrasound examination. The liability section addresses common errors leading to litigation in obstetric and gynecologic ultrasound practice. Examples are given demonstrating how such errors lead to liability actions.

First trimester screening for major cardiac defects based on the ductus venosus flow in fetuses with trisomy 21

OBJECTIVE

To examine whether in fetuses with trisomy 21 (T21), the ductus venosus (DV) flow differs in presence of a major cardiac defect (congenital cardiac defect [CHD]) and whether this affects the risk distribution in first trimester screening for T21.

METHODS

This retrospective study included pregnant women who underwent first trimester screening. This involves an examination of the crown-rump length, the nuchal translucency, the ductus venosus (DV) flow, and the heart. Three groups of fetuses were examined: euploid without CHD, T21 with CHD, and T21 without CHD. We examined the DV pulsatility index for veins, the direction of the a-wave, and ratios of velocities: v/S, v/D, a/S, a/D, and S/D.

RESULTS

The study population consisted of 410 euploid fetuses and 136 with T21 (51 with CHD and 85 without CHD). In the 3 groups, the a-wave was reversed in 3.2%, 66.7%, and 57.6%. The DV flow ratios in T21 with and without CDH were significantly different compared with normal fetuses. When comparing the ratios between the 2 T21 groups, only the a/S and a/D ratio were significantly different. The risk distributions in screening for T21 with and without CDH were similar.

CONCLUSION

There are some small differences in the DV flow of T21 fetuses with and without CHD, but they are not clinically useful.

Pregnancy Outcomes Following In Utero Exposure to Lamotrigine: A Systematic Review and Meta-Analysis

INTRODUCTION

Lamotrigine is used in pregnancy to control epilepsy and mood disorders. The reproductive safety of this widely used drug remains undefined and may represent a significant public health concern.

OBJECTIVE

We aimed to perform a systematic review and meta-analysis of existing knowledge related to malformation rates and maternal-neonatal outcomes after in utero exposure to monotherapy with lamotrigine.

METHODS

Relevant studies were identified through systematic searches conducted in MEDLINE (Ovid), Embase (Ovid), CENTRAL (Ovid), and Web of Science (Thomson Reuters) from database inception to July 2016; no language or date restrictions were applied. All publications of clinically relevant outcomes of pregnancies following in utero exposure to lamotrigine were included in this systematic review and meta-analysis.

RESULTS

A total of 21 studies describing immediate pregnancy outcomes and rates of congenital malformations fulfilled the inclusion criteria. Compared with disease-matched controls (n = 1412, total number of patients) and healthy controls (n = 774,571, total number of patients), in utero exposure to lamotrigine monotherapy was found to be associated with significantly decreased rates of inborn defects (odds ratio [OR] 1.15; 95% confidence interval [CI] 0.62-2.16 and OR 1.25; 95% CI 0.89-1.74, respectively). Rates of miscarriages, stillbirths, preterm deliveries, and small for gestational age (SGA) neonates were not found to have been increased after in-utero exposure to LTG compared to the general population. Similarly, in utero exposure to lamotrigine monotherapy was not found to be associated with increased rates of inborn defects compared with in utero exposure to carbamazepine, and lamotrigine was found to be statistically significantly less teratogenic than valproic acid (n = 12,958 and 10,748; OR 0.84; 95% CI 0.68-1.03 and OR 0.32; 95% CI 0.26-0.39, respectively).

CONCLUSION

No association was found between prenatal lamotrigine monotherapy and increased rates of birth defects and other explored variables related to adverse pregnancy outcomes.