Fetal cardiac abnormalities identified prior to 14 weeks' gestation

Simplified First-Trimester Fetal Cardiac Screening Protocol for Low-Risk Pregnancies: Enhancing Efficiency and Accuracy

Introduction

Congenital heart defects (CHDs) are among the most prevalent congenital anomalies and are frequently detected in pregnancies classified as low-risk, rather than in high-risk groups. Advancements in ultrasound technology have heightened the emphasis on first-trimester fetal cardiac screening. However, due to the small size of the fetal heart at this stage, significant challenges persist, underscoring the need for simplified and reproducible protocols that can be effectively applied on a population-wide scale.

Methods

This paper describes a screening approach centred on the four-chamber view (4CV) and three-vessel tracheal view (3VTV) with colour Doppler imaging. This includes optimisation of ultrasound machine settings and the use of transabdominal and transvaginal approaches to enhance visualisation.

Results

Evidence demonstrates a CHD detection rate of 76% in low-risk populations, with a 95% success rate in obtaining the necessary views.

Discussion and Conclusion

Operator expertise and familiarity with cardiac anomalies are critical for accurate detection. The early identification of CHDs enables informed decision-making regarding pregnancy management. A simplified protocol for first-trimester cardiac screening offers a promising tool for the early identification of CHDs, enabling timely referral and intervention. To optimise detection rates and clinical outcomes, continuous professional education and systematic auditing processes are indispensable for practitioners performing early fetal cardiac screening.

Evaluation of first-trimester ultrasound screening strategy for fetal congenital heart disease

OBJECTIVE

To assess the performance of a standardized first-trimester ultrasound screening strategy for fetal congenital heart disease (CHD).

METHODS

This was a large retrospective study involving 74 839 consecutive mixed-risk pregnancies (77 396 fetuses). Routine ultrasound scans at 11 + 0 to 13 + 6 weeks' gestation were performed in a single center from January 2015 to June 2023. All fetuses were examined using a predefined standardized ultrasound scanning strategy with adjustment of imaging parameters, which included assessment of the fetal heart. The ultrasound results (e.g. extracardiac congenital malformations), ultrasound markers (e.g. nuchal translucency thickening, reversed a-wave in the ductus venosus and tricuspid regurgitation), follow-up, genetic tests and diagnostic results were recorded and analyzed.

RESULTS

In total, there were 831 cases of CHD, with an incidence of 1.07% (831/77 396). In the first-trimester scan, 590 fetuses were diagnosed with CHD, but four were confirmed as normal in later examinations. In addition, 245 cases were missed. The detection rate was 70.52%, with a sensitivity, specificity, false-positive rate and false-negative rate of 70.52%, 99.99%, 0.01% and 29.48%, respectively. In fetuses with negative ultrasound markers and no extracardiac malformations, the detection rate of CHD was 45.79% (185/404). There were 281 cases that underwent karyotyping and chromosomal microarray (245 fetuses) or whole-exome sequencing (36 fetuses). In total, 38.79% (109/281) had a positive genetic test result. There were 273/831 CHD cases associated with extracardiac malformations. The abnormal image patterns and abnormal features of each view in the scanning strategy were summarized.

CONCLUSIONS

Ultrasound screening for fetal CHD in the first trimester of pregnancy enables earlier prenatal diagnosis and consultation. The standardized ultrasound screening strategy used in this study had a high detection rate for fetal CHD in the first trimester. Our proposed fetal heart screening strategy shows promising effectiveness for early diagnosis of CHD and we recommend its use. It is important to note, however, that first-trimester ultrasound screening for fetal CHD should not replace fetal echocardiography in the second trimester. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

Advancements in prenatal diagnosis and management of hypoplastic left heart syndrome: A multidisciplinary approach and future directions

Hypoplastic left heart syndrome is a severe congenital defect involving underdeveloped left-sided cardiac structures, leading to significant mortality and morbidity. Prenatal diagnosis using fetal ultrasound and echocardiography enables early detection, family counseling, and improved clinical decision-making. Advanced prenatal interventions, such as fetal aortic valvuloplasty and atrial septostomy, show promise but require careful patient selection. A multidisciplinary approach involving obstetricians, neonatologists, and pediatric cardiologists is vital for effective management. Future directions include refining imaging techniques, such as three-dimensional ultrasound, cardiovascular magnetic resonance imaging, and exploring bioengineering solutions, stem cell therapies, and genetic research. These advancements aim to improve therapeutic options and address current limitations, including transplant scarcity and postoperative complications. Although surgical innovations have improved survival rates, challenges remain, including neurological risks and long-term hemodynamic issues. Ongoing research and technological advancements are essential to enhance outcomes and quality of life for hypoplastic left heart syndrome patients.

Referral pattern of pregnant mother for fetal echocardiography in Shiraz, South Iran

OBJECTIVE

To evaluate the referral patterns for fetal echocardiography at a tertiary care center in Shiraz, South Iran.

METHOD

This retrospective cohort study analyzed data from 22,600 pregnant women who underwent fetal echocardiography between January 1, 2016, and December 31, 2021. Information was extracted from a centralized electronic medical record system used by medical centers affiliated with Shiraz University of Medical Sciences.

RESULT

Congenital heart disease was detected in 14.5% of fetal echocardiograms. The mean gestational age at the time of examination was 21.8 ± 4.2 weeks (range: 13-40 weeks). Notably, 75.9% of pregnant women were referred after 19 weeks of gestation. The most common reason for referral was abnormal fetal laboratory screening (triple or quad test).

CONCLUSION

In our center, fetal echocardiography is optimally performed by 19 weeks of gestation. This timing allows for detailed anatomical assessment and aligns with the legal threshold for abortion, ensuring timely counseling and decision-making when necessary. However, in our study, the mean gestational age at the time of echocardiography was 21 weeks, indicating that a significant proportion of patients underwent the procedure later than the optimal timing.

Complete Transposition of the Great Arteries in the Pediatric Field: A Multimodality Imaging Approach

The complete transposition of the great arteries (C-TGA) is a congenital cardiac anomaly characterized by the reversal of the main arteries. Early detection and precise management are crucial for optimal outcomes. This review emphasizes the integral role of multimodal imaging, including fetal echocardiography, transthoracic echocardiography (TTE), cardiovascular magnetic resonance (CMR), and cardiac computed tomography (CCT) in the diagnosis, treatment planning, and long-term follow-up of C-TGA. Fetal echocardiography plays a pivotal role in prenatal detection, enabling early intervention strategies. Despite technological advances, the detection rate varies, highlighting the need for improved screening protocols. TTE remains the cornerstone for initial diagnosis, surgical preparation, and postoperative evaluation, providing essential information on cardiac anatomy, ventricular function, and the presence of associated defects. CMR and CCT offer additional value in C-TGA assessment. CMR, free from ionizing radiation, provides detailed anatomical and functional insights from fetal life into adulthood, becoming increasingly important in evaluating complex cardiac structures and post-surgical outcomes. CCT, with its high-resolution imaging, is indispensable in delineating coronary anatomy and vascular structures, particularly when CMR is contraindicated or inconclusive. This review advocates for a comprehensive imaging approach, integrating TTE, CMR, and CCT to enhance diagnostic accuracy, guide therapeutic interventions, and monitor postoperative conditions in C-TGA patients. Such a multimodal strategy is vital for advancing patient care and improving long-term prognoses in this complex congenital heart disease.

Cardiac Axis in Early Gestation and Congenital Heart Disease

Congenital heart defects represent the most common structural anomalies observed in the fetal population, and they are often associated with significant morbidity and mortality. The fetal cardiac axis, which indicates the orientation of the heart in relation to the chest wall, is formed by the angle between the anteroposterior axis of the chest and the interventricular septum of the heart. Studies conducted during the first trimester have demonstrated promising outcomes with respect to the applicability of cardiac axis measurement in fetuses with congenital heart defects as well as fetuses with extracardiac and chromosomal anomalies, which may result in improved health outcomes and reduced healthcare costs. The main aim of this review article was to highlight the cardiac axis as a reliable and powerful marker for the detection of congenital heart defects during early gestation, including defects that would otherwise remain undetectable through the conventional four-chamber view.

First-Trimester Ultrasound Imaging for Prenatal Assessment of the Extended Cardiovascular System Using the Cardiovascular System Sonographic Evaluation Algorithm (CASSEAL)

INTRODUCTION AND OBJECTIVES

To compare fetal images obtained at the first- and second-trimester ultrasound scan when applying the Cardiovascular System Sonographic Evaluation Algorithm (CASSEAL).

METHODS

Using the CASSEAL protocol, nine sequential axial views were acquired in B-mode and color Doppler at the first- and second-trimester ultrasound scans, visualizing the main components of the extended fetal cardiovascular system. Images were compared qualitatively between both trimesters.

RESULTS

We obtained comparable images for all the nine axial views described in the CASSEAL protocol, with few differences and limitations.

CONCLUSIONS

The CASSEAL protocol is reproducible in the first trimester, and could help in the early detection of fetal cardiovascular abnormalities. It represents a promising additional tool in order to increase the CHD detection rate.

Evaluation fetal heart in the first and second trimester: Results and limitations

Background

Cardiac heart defects affect nearly 6-12 per 1000 live births in the general population and are more frequent than common trisomies.

Aim

To assess the efficacy and technical limitations of first-trimester fetal heart evaluation in the 11-14^th-weeks' scan and comparison with the second-trimester anatomical exam by ultrasound.

Material and Method

Between April 2015 and July 2020, medical records and ultrasound data of 3295 pregnancies who underwent first-trimester fetal anatomy exams by ultrasound were reviewed retrospectively. All ultrasound exams were performed by the same two operators (TUKD, OP) with transabdominal transducers. Fetal situs, four-chamber view, outflow tracts, and three-vessel trachea view are the cornerstones of first-trimester fetal heart examination. Conventional grayscale mode and high-definition power Doppler mode were utilized. The same operators re-examined all cases between the 18 and 23 weeks of gestation by ISUOG guidelines.

Results

We performed a combined transvaginal and transabdominal approach for only 101 cases (3.06%). The mean maternal age was 31.28 ± 4.43, the median gestational age at the first-trimester ultrasound exam was 12.4 weeks, and the median CRL was 61.87 mm (range was 45.1-84 mm). Even combined approach situs, cardiac axis, and four-chamber view could not be visualized optimally in 28 cases (0.7%). Outflow tracts were visualized separately in 80% (2636 in 3295) cases. Three vessel-trachea views were obtained in 85.4% (2814 in 3295) cases by high-definition Doppler mode. There were 47 fetuses with cardiac defects in 3295 pregnancies with the known pregnancy outcome. Ten cases had abnormal karyotype results. Thirty-two fetuses with cardiac anomalies (9.7 in 1000 pregnancies) were detected in the first-trimester examination, and the remaining 15 (4.55 in 1000 pregnancies) cases were diagnosed in the second-trimester examination. The prevalence of congenital cardiac anomalies was 14.25 in 1000 pregnancies. Fifteen cases were missed in the first-trimester exam. Also, ten fetuses which had abnormal cardiac findings in the first-trimester exam were not confirmed in the second-trimester exam. Sensitivity, specificity, positive, and negative predictive values were calculated as 65.3%, 99.7%, 66.8%, and 99.67%, respectively.

Conclusion

Late first-trimester examination of the fetus is feasible and allows earlier detection of many structural abnormalities of the fetus, including congenital heart defects. Suspicious and isolated cardiac abnormal findings should be re-examined and confirmed in the second-trimester exam. Previous abdominal surgery, high BMI, and subtle cardiac defects can cause missed cardiac abnormalities.

Impact of prenatally diagnosed congenital heart defects on outcomes and management

Fetal echocardiogram aids in prenatal identification of neonates at high risk for congenital heart defects (CHD). Prenatal detection rates for CHD have increased with improved ultrasound technology, the use of the early fetal echocardiography, and standardization of the performance of the fetal echocardiogram. Accurate prenatal detection of CHD, particularly complex CHD, is an important contributor to improved survival rates for patients with CHD. Early detection allows for families to choose whether or not to continue with pregnancy, referral to pediatric cardiology specialists for patient education, and delivery planning. Better psychosocial supports are needed for families with CHD.

First-trimester ultrasound detection of fetal heart anomalies: systematic review and meta-analysis

OBJECTIVES

To determine the diagnostic accuracy of ultrasound at 11-14 weeks' gestation in the detection of fetal cardiac abnormalities and to evaluate factors that impact the detection rate.

METHODS

This was a systematic review of studies evaluating the diagnostic accuracy of ultrasound in the detection of fetal cardiac anomalies at 11-14 weeks' gestation, performed by two independent reviewers. An electronic search of four databases (MEDLINE, EMBASE, Web of Science Core Collection and The Cochrane Library) was conducted for studies published between January 1998 and July 2020. Prospective and retrospective studies evaluating pregnancies at any prior level of risk and in any healthcare setting were eligible for inclusion. The reference standard used was the detection of a cardiac abnormality on postnatal or postmortem examination. Data were extracted from the included studies to populate 2 × 2 tables. Meta-analysis was performed using a random-effects model in order to determine the performance of first-trimester ultrasound in the detection of major cardiac abnormalities overall and of individual types of cardiac abnormality. Data were analyzed separately for high-risk and non-high-risk populations. Preplanned secondary analyses were conducted in order to assess factors that may impact screening performance, including the imaging protocol used for cardiac assessment (including the use of color-flow Doppler), ultrasound modality, year of publication and the index of sonographer suspicion at the time of the scan. Risk of bias and quality assessment were undertaken for all included studies using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool.

RESULTS

The electronic search yielded 4108 citations. Following review of titles and abstracts, 223 publications underwent full-text review, of which 63 studies, reporting on 328 262 fetuses, were selected for inclusion in the meta-analysis. In the non-high-risk population (45 studies, 306 872 fetuses), 1445 major cardiac anomalies were identified (prevalence, 0.41% (95% CI, 0.39-0.43%)). Of these, 767 were detected on first-trimester ultrasound examination of the heart and 678 were not detected. First-trimester ultrasound had a pooled sensitivity of 55.80% (95% CI, 45.87-65.50%), specificity of 99.98% (95% CI, 99.97-99.99%) and positive predictive value of 94.85% (95% CI, 91.63-97.32%) in the non-high-risk population. The cases diagnosed in the first trimester represented 63.67% (95% CI, 54.35-72.49%) of all antenatally diagnosed major cardiac abnormalities in the non-high-risk population. In the high-risk population (18 studies, 21 390 fetuses), 480 major cardiac anomalies were identified (prevalence, 1.36% (95% CI, 1.20-1.52%)). Of these, 338 were detected on first-trimester ultrasound examination and 142 were not detected. First-trimester ultrasound had a pooled sensitivity of 67.74% (95% CI, 55.25-79.06%), specificity of 99.75% (95% CI, 99.47-99.92%) and positive predictive value of 94.22% (95% CI, 90.22-97.22%) in the high-risk population. The cases diagnosed in the first trimester represented 79.86% (95% CI, 69.89-88.25%) of all antenatally diagnosed major cardiac abnormalities in the high-risk population. The imaging protocol used for examination was found to have an important impact on screening performance in both populations (P < 0.0001), with a significantly higher detection rate observed in studies using at least one outflow-tract view or color-flow Doppler imaging (both P < 0.0001). Different types of cardiac anomaly were not equally amenable to detection on first-trimester ultrasound.

CONCLUSIONS

First-trimester ultrasound examination of the fetal heart allows identification of over half of fetuses affected by major cardiac pathology. Future first-trimester screening programs should follow structured anatomical assessment protocols and consider the introduction of outflow-tract views and color-flow Doppler imaging, as this would improve detection rates of fetal cardiac pathology. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Prenatal incidence of isolated right aortic arch and double aortic arch

OBJECTIVE

To define the incidence of variants of aortic arch sidedness in fetuses undergoing routine first trimester ultrasound examination.

METHODS

The data for this study were derived from prospective routine ultrasound examination at 11+0 to 13+6 weeks' gestation in singleton pregnancies examined in a local population between January 2014 and March 2018. We examined the incidence of isolated right aortic arch (RAA) and double aortic arch (DAA) in the local, screened population and compared the groups with and without these abnormalities.

RESULTS

The study population of 33,202 pregnancies included 18 (5.4 per 10,000) cases with isolated RAA and 5 (1.5 per 10,000) with DAA. In the group with isolated RAA or DAA, compared to those without, the median maternal age was higher and the incidence of conceptions from in vitro fertilization (IVF) was eight-fold higher. The prevalence of 22q11microdeletion was 5% in patients with RAA from this local population.

CONCLUSIONS

The incidence of isolated RAA and DAA in a local population undergoing routine first-trimester ultrasound examination is 2-3-fold higher than that reported in postnatal studies and the risk for these abnormalities is substantially increased in fetuses conceived by IVF.

Quantified growth of the human embryonic heart

The size and growth patterns of the components of the human embryonic heart have remained largely undefined. To provide these data, three-dimensional heart models were generated from immunohistochemically stained sections of ten human embryonic hearts ranging from Carnegie stage 10 to 23. Fifty-eight key structures were annotated and volumetrically assessed. Sizes of the septal foramina and atrioventricular canal opening were also measured. The heart grows exponentially throughout embryonic development. There was consistently less left than right atrial myocardium, and less right than left ventricular myocardium. We observed a later onset of trabeculation in the left atrium compared to the right. Morphometry showed that the rightward expansion of the atrioventricular canal starts in week 5. The septal foramina are less than 0.1 mm² and are, therefore, much smaller than postnatal septal defects. This chronological, graphical atlas of the growth patterns of cardiac components in the human embryo provides quantified references for normal heart development. Thereby, this atlas may support early detection of cardiac malformations in the foetus.This article has an associated First Person interview with the first author of the paper.

Feasibility and Accuracy of Early Fetal Echocardiography Performed at 13+0-13+6 Weeks in a Population with Low and High Body Mass Index: a Prospective Study

PURPOSE

The earlier the detection and diagnosis of congenital heart diseases (CHD), the greater the clinical benefit; however, early fetal cardiac examination can be a challenge. The aim of our study is to demonstrate that the fetal cardiac examination at 13⁺⁰-13⁺⁶ weeks can be as adequately assessed as the examination performed at 16 weeks in patients with low and high body mass index (BMI).

METHODS

The study was a prospective observational cohort study. One hundred pregnant women at low risk of congenital heart anomalies were divided into two groups: 49 women with low BMI (<25) and 51 women with high BMI (≥ 25). A complete fetal cardiac scan was performed on each patient at 13⁺⁰-13⁺⁶ weeks, via the transvaginal and transabdominal approaches, and at 16 weeks by the transabdominal approach.

RESULTS

The examination at 13⁺⁰-13⁺⁶ weeks was adequately assessed in at least one of the two routes in 97 patients, as opposed to 87 patients at 16 weeks. A significantly higher adequate assessment rate was obtained at 13⁺⁰-13⁺⁶ weeks than at 16 weeks (p=0.017). The transvaginal approach showed the best resolution of the three examinations in 42% of women with BMI ≥35. No CHD were overlooked.

CONCLUSIONS

Early fetal echocardiography is feasible and accurate at 13⁺⁰-13⁺⁶ weeks. Within patients with high BMI, early fetal echocardiography may be performed two weeks in advance, since it allows visualization of the fetal heart through the transvaginal route with a higher resolution in a large number of women, which is not feasible at 16 weeks.

Comparison of the 1-year survival rate in infants with congenital heart disease diagnosed by prenatal and postnatal ultrasound: A retrospective study

The impact of prenatal diagnosis on the survival outcome of infants with congenital heart disease (CHD) is still unclear. This study aimed to compare the 1-year survival rate between the prenatally and postnatally diagnosed infants with CHDs.A single-center population-based retrospective cohort study was performed on data from all infants diagnosed with CHD born between January 1998 and December 2017. Among infants with isolated CHDs, the 1-year Kaplan-Meier survival probabilities for prenatal and postnatal diagnosis were estimated. Cox proportional hazard ratios were adjusted for critical CHD (CCHD) status and gestational age.A total of 424 (40 prenatally and 384 postnatally) diagnosed infants with CHDs were analyzed. Compared with non-CCHDs, infants with CCHDs were more likely to be prenatally diagnosed (55.0% vs 18.0%; P < .001). Among the 312 infants with isolated CHDs, the 1-year survival rate for the prenatally diagnosed was significantly lower than postnatally diagnosed (77.1% vs 96.1%; P < .001). For isolated CCHDs, the 1-year survival rate for the prenatally diagnosed was significantly lower than postnatally diagnosed (73.4% vs 90.0%; P < .001). The 1-year survival rate was increased with the increase of age at diagnosis. Among infants with isolated CHDs and CCHDs, the adjusted hazard ratios for 1-year mortality rates for the prenatally versus postnatally diagnosed were 2.554 (95% confidence interval [CI], 1.790, 3.654; P < .001) and 2.538 (95% CI: 1.796, 3.699; P < .001), respectively.Prenatal diagnosis is associated with lower 1-year survival rate for infants with isolated CCHDs. This could probably due to variation in the disease severity among the CCHD subtypes.

Tetralogy of Fallot and Outlet Ventricular Septal Defect with Anterior Malalignment Detected at Early Fetal Echocardiography

OBJECTIVES

To examine the evolution of tetralogy of Fallot (TOF) and outlet ventricular septal defect (VSD) with anterior malalignment (am) from the initial diagnosis at early fetal echocardiography through the gestation and to evaluate the impact of the first-trimester scan on the outcome.

METHODS

We identified cases of TOF or outlet VSD with am diagnosed before 16 weeks' gestation. For all cases, prenatal data and pregnancy outcomes were evaluated. In continuing pregnancies, the evolution in severity of the disease was assessed.

RESULTS

Fifty-one fetuses with TOF or outlet VSD with am were diagnosed at early fetal echocardiography. Parents opted for termination of pregnancy in all 23 cases associated with additional anomalies. In 2 of 28 continuing pregnancies, there was an intrauterine death. In the remaining 26, there was progression in severity in 7 (by 20-22 weeks in 3 cases and during the third trimester in the remaining 4).

CONCLUSIONS

TOF and outlet VSD with am diagnosed before 16 weeks' gestation can progress in severity throughout pregnancy in over one-quarter of cases. In addition, a high proportion of cases diagnosed in the first trimester may have associated extracardiac anomalies, with a significant impact on clinical management and on the rate of early termination of pregnancy.

Diagnosis of major heart defects by routine first-trimester ultrasound examination: association with increased nuchal translucency, tricuspid regurgitation and abnormal flow in ductus venosus

OBJECTIVE

To examine the association between fetal major heart defects and increased nuchal translucency thickness (NT), tricuspid regurgitation and abnormal flow in the ductus venosus in a large population of singleton pregnancies undergoing routine ultrasound examination at 11-13 weeks' gestation.

METHODS

This was a retrospective study of prospectively collected data from singleton pregnancies attending for a routine ultrasound scan at 11-13 weeks' gestation, which included examination of fetal anatomy, measurement of NT and assessment of blood flow across the tricuspid valve and in the ductus venosus, according to a standardized protocol. The incidence of fetal NT ≥ 95^th and ≥ 99^th percentiles, tricuspid regurgitation and reversed a-wave in the ductus venosus in fetuses with and those without a major heart defect was determined and the performance of each marker and their combination in the detection of major heart defects was calculated.

RESULTS

The study population of 93 209 pregnancies with no apparent chromosomal abnormality included 211 (0.23%) with a fetal major heart defect and 92 998 morphologically normal neonates. In 113 (53.6%) cases with a major heart defect, the diagnosis was made at the 11-13-week scan, in 82 (38.9%) at the 18-24-week scan, in 10 (4.7%) at the third-trimester scan and in six (2.8%) postnatally. At the 11-13-week scan, we diagnosed all cases of tricuspid or pulmonary atresia and polyvalvular dysplasia, > 90% of cases of hypoplastic left heart syndrome or atrioventricular septal defect, about 60% of complex heart defects and cases of left atrial isomerism (interrupted inferior vena cava with normal intracardiac anatomy), 30-40% of cases of tetralogy of Fallot and arch abnormalities, 25% of tricuspid valve abnormalities and about 15% of cases of transposition of the great arteries, but none of aortic or pulmonary stenosis or common arterial trunk. Fetal NT ≥ 95^th or ≥ 99^th percentile, tricuspid regurgitation or abnormal ductus venosus flow was observed in 77 (36.5%), 45 (21.3%), 61 (28.9%) and 58 (27.5%) fetuses with a major heart defect, respectively, and in 5678 (6.1%), 857 (0.9%), 1136 (1.2%) and 1644 (1.8%) of those without a heart defect. Any one of NT ≥ 95^th percentile, tricuspid regurgitation or abnormal flow in the ductus venosus was found in 117 (55.5%; 95% CI, 48.5-62.3%) fetuses with a heart defect and in 8166 (8.8%; 95% CI, 8.6-9.0%) of those without a heart defect. Any one of NT ≥ 99^th percentile or the other two markers was found in 99 (46.9%; 95% CI, 40.0-53.9%) fetuses with a heart defect and in 3517 (3.8%; 95% CI, 3.7-3.9%) of those without a heart defect.

CONCLUSION

At 11-13 weeks' gestation, measurement of fetal NT and assessment of flow across the tricuspid valve and in the ductus venosus can lead to early diagnosis of major heart defect. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Performance of First-Trimester Fetal Echocardiography in Diagnosing Fetal Heart Defects: Meta-analysis and Systematic Review

OBJECTIVES

Early fetal echocardiography is becoming increasing common during the nuchal translucency scan period. The aim of this meta-analysis was to assess the accuracy of first-trimester fetal echocardiography in diagnosing congenital heart defects (CHDs).

METHODS

The databases of PubMed, Embase, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature were systematically searched for the candidate articles, and the references of included studies were also examined. We recorded the characteristics of the included studies and assessed the quality of each study by the Quality Assessment of Diagnostic Accuracy Studies tool. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the curve (AUC) were calculated with Meta-Disc version 1.4 software (Ramón y Cajal Hospital, Madrid, Spain). We also evaluated the publication bias by using Stata version 12.0 software (StataCorp, College Station, TX).

RESULTS

This meta-analysis included 18 studies with 26,201 fetal hearts. The overall pooled sensitivity, specificity, PLR, and NLR were 0.750, 0.999, 392.95, and 0.277, respectively. The DOR and AUC were 1736.0 and 0.9331. The pooled sensitivity, specificity, PLR, NLR, DOR, and AUC for major CHDs were 0.838, 1.000, 725.69, 0.203, 5084.8, and 0.9617.

CONCLUSIONS

First-trimester fetal echocardiography had high value in diagnosing CHDs, especially major CHDs.

Fetal heart examination at the time of 13 weeks scan: a 5 years' prospective study

Objective To evaluate our ability in classifying the fetal heart as normal or abnormal during the 1st trimester scan through fetal cardiac examination and determining the best time for this examination. Methods This was a prospective study performed on 3240 pregnant women to examine the fetal heart. Four chambers view and ventricular outflow tracts were mainly examined during the scan. We used grayscale and color mapping in the diagnosis. Color Doppler was used if additional information was needed, and all patients were rescanned during the 2nd trimester to confirm or negate our diagnosis. Results The cardiac findings were normal at both scans in 3108 pregnancies. The same cardiac abnormality was detected at both scans in 79 cases. In 36 cases there was false-positive diagnosis at the early scan; in 20 of these cases, there were mildly abnormal functional findings early in pregnancy with no abnormality found later. In 17 fetuses, there was discordance between the early and later diagnosis due to missed or incorrect diagnoses. The best time to do fetal heart examination during 1st trimester is between 13 and 13 + 6 weeks. Conclusion A high degree of accuracy in the identification of congenital heart disease (CHD) can be achieved by a 1st trimester fetal echocardiography.

Initial Experience of Superb Microvascular Imaging for Key Cardiac Views in Foetal Assessment before 15 Weeks Gestation

BACKGROUND

In the first trimester, ultrasound confirmation of normal or abnormal cardiac anatomy is difficult. B-mode and colour flow Doppler (CFD) are used to assess the foetal heart. Superb microvascular imaging (SMI) can visualise blood flow within the heart and vessels in early gestation.

OBJECTIVE

We report an initial experience of SMI for visualisation of normal and abnormal cardiac anatomy in the first trimester.

METHODS

Transabdominal foetal echocardiography was performed between 11 + 6 and 14 + 3 weeks (Aplio 500 US system, Toshiba Medical Systems, Tokyo, Japan) from January 2017 to December 2017. All scans were performed at a tertiary foetal cardiology unit. To assess the potential utility of the technique for early gestation screening, normal scans were reviewed by foetal medicine trainees with respect to the B-mode, CFD and SMI. Three key views were selected to compare modalities: the 4-chamber view, outflow tracts and the 3-vessel and trachea view (VTV). Visualisation rates of key echocardiographic features of significant cardiac abnormalities by SMI were reviewed.

RESULTS

Fifty-five normal echocardiograms and 34 cardiac abnormalities were included. In the normal heart, when B-mode, CFD and SMI were assessed separately, SMI had the highest rate of visualisation of 4-chamber, outflow tracts and 3-VTV (93, 85 and 83%, respectively). Intra-observer reliability was moderate for SMI of the 3 standard views (kappa 1, 0.64 and 0.64); inter-observer for 4-chamber and outflow tract views was moderate (kappa 0.64 and 0.77). In 29/34 abnormal cases, SMI showed key features, enhancing greyscale visualisation.

CONCLUSION

SMI has potential to become a useful, complementary modality for early foetal echocardiography. Further prospective studies are warranted to establish the place of the technique in assessment of the first trimester foetal heart.

First-Trimester Ultrasound

Since the 1980s, development of high-resolution transvaginal ultrasound transducers has significantly improved ultrasound evaluation at earlier gestational ages. Although many indications exist for first-trimester ultrasound in pregnancy, more emphasis has been placed on assessment of fetal anatomy recently. In turn, congenital diagnoses can also be made earlier in pregnancy, raising the question of whether anatomic assessment in the first trimester is one of choice or obligation. Combining transvaginal and transabdominal approach yields the highest detection rate overall. Some studies have shown that more than half of all anomalies and almost all severe anomalies can be detected on early scans.

Diagnosis of fetal non-chromosomal abnormalities on routine ultrasound examination at 11-13 weeks' gestation

OBJECTIVE

To examine the performance of the routine 11-13-week scan in detecting fetal non-chromosomal abnormalities.

METHODS

This was a retrospective study of prospectively collected data from 100 997 singleton pregnancies attending for a routine ultrasound examination of fetal anatomy, performed according to a standardized protocol, at 11-13 weeks' gestation. All continuing pregnancies had an additional scan at 18-24 weeks and 71 754 had a scan at either 30-34 or 35-37 weeks. The final diagnosis of fetal abnormality was based on the results of postnatal examination in cases of live birth and on the findings of the last ultrasound examination in cases of pregnancy termination, miscarriage or stillbirth. The performance of the 11-13-week scan in the detection of fetal abnormalities was determined.

RESULTS

The study population contained 1720 (1.7%) pregnancies with a fetal abnormality, including 474 (27.6%) detected on the first-trimester scan, 926 (53.8%) detected on the second-trimester scan and 320 (18.6%) detected in the third trimester or postnatally. At 11-13 weeks' gestation, we diagnosed all cases of acrania, alobar holoprosencephaly, encephalocele, tricuspid or pulmonary atresia, pentalogy of Cantrell, ectopia cordis, exomphalos, gastroschisis and body-stalk anomaly and > 50% of cases of open spina bifida, hypoplastic left heart syndrome, atrioventricular septal defect, complex heart defect, left atrial isomerism (interrupted inferior vena cava with normal intracardiac anatomy), lower urinary tract obstruction, absence of extremities, fetal akinesia deformation sequence and lethal skeletal dysplasia. Common abnormalities that were detected in < 10% of cases at 11-13 weeks included ventriculomegaly, agenesis of the corpus callosum, isolated cleft lip, congenital pulmonary airway malformation, ventricular septal defect, abdominal cysts, unilateral renal agenesis or multicystic kidney, hydronephrosis, duplex kidney, hypospadias and talipes.

CONCLUSIONS

A routine 11-13-week scan, carried out according to a standardized protocol, can identify many severe non-chromosomal fetal abnormalities. A summary statistic of the performance of the first-trimester scan is futile because some abnormalities are always detectable, whereas others are either non-detectable or sometimes detectable. To maximize prenatal detection of abnormalities, additional scans in both the second and third trimesters are necessary. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Screening performance of congenital heart defects in first trimester using simple cardiac scan, nuchal translucency, abnormal ductus venosus blood flow and tricuspid regurgitation

OBJECTIVE

The objective of this study was to analyze if the addition of simple cardiac scan in cases with increased nuchal translucency (NT) and/or abnormal ductus venosus (DV) blood flow, and/or tricuspid regurgitation (TCR) can improve detection of congenital heart defects (CHD) in chromosomally normal fetuses without non-cardiac defects at 11-13 + 6 gestational weeks in a population of singleton pregnancies.

METHODS

During the 10 years period, all singleton pregnancies at 11-13 + 6 weeks were routinely scanned for NT, DV blood flow and TCR assessment and, if a single of these parameters was abnormal, simple cardiac scan with 2D gray scale and color and/or directional power Doppler in 4-chamber (4-CV) and 3 vessel and trachea views (3VTV) was performed.

RESULTS

The sensitivity and specificity of NT ≥ 95th + DV R/A a-wave + TCR in detecting CHD were 77% and 97%, respectively, and of simple cardiac scan, 67% and 98%, respectively. Area under the curve of receiver operating characteristic curve of NT ≥ 95th + DV R/A a-wave + TCR was 0.838, and of NT ≥ 95th + DV R/A a-wave + TCR + simple cardiac scan was 0.915.

CONCLUSIONS

In chromosomally normal fetuses without non-cardiac anomalies, addition of simple cardiac scan to the combined first trimester screening parameters improves detection of major CHD during first trimester.

Prenatal diagnosis and clinical implications of an apparently isolated right aortic arch

OBJECTIVE

To define the associations of a prenatally diagnosed, apparently isolated right aortic arch (RAA) with chromosomal or genetic abnormalities and tracheal compression.

METHODS

This was a retrospective study of apparently isolated RAA assessed by fetal cardiologists and fetal medicine specialists at Kings College Hospital, London between 2000 and 2017.

RESULTS

The search identified 138 cases of apparently isolated RAA. Invasive testing was performed in 75, and chromosomal or genetic anomalies were identified in 16 (22%), and the most common was 22q11 microdeletion. An aberrant left subclavian artery was seen in 51% of cases. Symptoms of a vascular ring were present in 24 of 97 (25%) children who were reviewed after birth. Bronchoscopy was performed in 33 children, and significant tracheal compression was diagnosed in 28, including 18 of 19 symptomatic and 10 of 14 asymptomatic children.

CONCLUSIONS

An apparently isolated RAA is associated with a high incidence of chromosomal or genetic abnormalities and a high incidence of tracheal compression in symptomatic and asymptomatic patients. Prenatal counselling for genetic associations and postnatal airway assessment in the context of the vascular anatomy is recommended.

Spinal Cord Stimulation in Pregnant Patients: Current Perspectives of Indications, Complications, and Results in Pain Control: A Systematic Review

Spinal cord stimulation (SCS) has been described as a valuable neuromodulator procedure in the management of chronic medically untreated neuropathic pain. Although the use of this technique has been published in many papers, a question still remains regarding its applicability in pregnant patients. The goal of this paper is to discuss the risks, complications, and results as well as the prognosis of SCS in pregnant patients. We performed a systematic review from 1967 to 2018 using the databases MEDLINE, LILACS, SciELO, PubMed, and BIREME, utilizing language as selection criteria. Eighteen studies that met our criteria were found and tabulated. SCS is a reversible and adjustable surgical procedure, which results in patients that demonstrated a significant effect in the reduction of pain intensity in pregnant patients. The etiologies most frequent were complex regional pain and failed back pain syndromes, which together represented 94% of analyzed cases. The technical complications most frequent were lead migration (3%, n = 1). Regarding the risks, the authors did not show significative factors among the categorical variables that can suggest a teratogenicity, while the maternal risks have been associated to the consequences of technical complications due to, among other factors, improvement of abdominal pressure during pregnancy and delivery. Finally, although there are not significative cohorts of pregnant patients, the procedure is still an effective surgical approach of neuropathic pain associated to lower rates of complications and significative improvement in the quality of life of patients during pregnancy.

First-Trimester Fetal Echocardiography: Identification of Cardiac Structures for Screening from 6 to 13 Weeks' Gestational Age

BACKGROUND

Early fetal echocardiography (FE), performed at 12 to 16 weeks' gestational age (GA), can be used to screen for fetal heart disease akin to that routinely performed in the second trimester. The efficacy of FE at earlier GAs has not been as well explored, particularly with recent advances in ultrasound technology. The aim of this study was to evaluate the efficacy of early FE in assessing fetal heart structure, and the added benefit of color Doppler (CD), from as early as 6 weeks through to 13⁺⁶ weeks' GA.

METHODS

Pregnant women were prospectively recruited for first-trimester FE. All underwent two-dimensional (2D) cardiac imaging combined with CD assessment, and all were offered second-trimester fetal echocardiographic evaluations. Fetal cardiac anatomy was assessed both in real time during FE and additionally offline by two separate reviewers.

RESULTS

Very early FE was performed in 202 pregnancies including a total of 261 fetuses, with 92% (n = 241) being reassessed at ≥18 weeks' GA. Mean GA at FE was 10⁺⁶ weeks (range, 6⁺¹ to 13⁺⁶ weeks). Transabdominal scanning was used in all cases, and transvaginal scanning was used additionally in most at <11 weeks' GA (n = 103 of 117 [88%]). There was stepwise improvement in image resolution of the fetal heart in those pregnancies that presented at later gestation for assessment. CD assisted with definition of cardiac anatomy at all GAs. A four-chambered heart could be identified in 52% of patients in the eighth week (n = 12 of 23), improving to 80% (n = 36 of 45) in the 10th week and 98% (n = 57 of 58) by the 11th week. The inferior vena cava was visualized by 2D imaging in only 4% (n = 1 of 23) in the eighth week, increasing to 13% (n = 6 of 45) by the 10th week and 80% (n = 25 of 31) by the 13th week. CD improved visualization of the inferior vena cava at earlier GAs to >80% (n = 37 of 45) from 10 weeks. Pulmonary veins were not visualized by either 2D imaging or CD until after the 11th week. Both cardiac outflow tracts could be visualized by 2D imaging in the minority from 8⁺⁰ to 10⁺⁶ weeks (n = 18 of 109 [16%]) but were imaged in most from 11⁺⁰ to 13⁺⁶ weeks (n = 114 of 144 [79%]). CD imaging improved visualization of both outflow tracts to 64% (n = 29 of 45) in the 10th week. On 2D imaging alone, both the aortic and ductal arches were seen in only 29% of patients in the 10th week (n = 13 of 45), increasing to 58% when CD was used (58% [n = 26 of 45]) and to >80% (n = 47 of 58) using CD in the 11th week.

CONCLUSIONS

Very early FE, from as early as 8 weeks, can be used to assess cardiac structures. The ability to image fetal heart structures between 6 and 8 weeks is currently nondiagnostic. The use of CD significantly increases the detection of cardiac structures on early FE. The ideal timing of complete early FE, excluding pulmonary vein assessment, appears to be after 11 weeks' GA.

Does First-Trimester Screening Modify the Natural History of Congenital Heart Disease?

Background:

The study analyzed the impact of first-trimester screening on the spectrum of congenital heart defects (CHDs) later in pregnancy and on the outcome of fetuses and children born alive with a CHD.

Methods:

The spectrum of CHDs, associated comorbidities, and outcome of fetuses, either diagnosed with a CHD in the first trimester (Group I, 127 fetuses) or only in the second-trimester screening (Group II, 344 fetuses), were analyzed retrospectively between 2007 and 2013. Second-trimester fetuses diagnosed with a CHD between 2007 and 2013 were also compared with Group III (532 fetuses diagnosed with a CHD in the second trimester from 1996 to 2001, the period before first-trimester screening was introduced).

Results:

The spectrum of CHDs diagnosed in the first and second trimesters in the same time period differed significantly, with a greater number of comorbidities ( P <0.0001), CHDs with univentricular outcome ( P <0.0001), intrauterine deaths ( P =0.01), and terminations of pregnancy ( P <0.0001) in Group I compared with Group II. In Group III, significantly more cases of CHDs with univentricular outcome ( P <0.0001), intrauterine demise ( P =0.036), and early termination ( P <0.0001) were identified compared with fetuses diagnosed with CHDs in the second trimester between 2007 and 2013. The spectrum of CHDs seen in the second-trimester groups differed after first-trimester screening was implemented.

Conclusions:

First-trimester screening had a significant impact on the spectrum of CHDs and the outcomes of pregnancies with CHDs diagnosed in the second trimester. Early detection of severe forms of CHDs and significant comorbidities resulted in an increased pregnancy termination rate in the first trimester.

Advances in ultrasound imaging for congenital malformations during early gestation

BACKGROUND

With refinement in ultrasound technology, detection of fetal structural abnormalities has improved and there have been detailed reports of the natural history and expected outcomes for many anomalies. The ability to either reassure a high-risk woman with normal intrauterine images or offer comprehensive counseling and offer options in cases of strongly suspected lethal or major malformations has shifted prenatal diagnoses to the earliest possible gestational age.

METHODS

When indicated, scans in early gestation are valuable in accurate gestational dating. Stricter sonographic criteria for early nonviability guard against unnecessary intervention. Most birth defects are without known risk factors, and detection of certain malformations is possible in the late first trimester.

RESULTS

The best time for a standard complete fetal and placental scan is 18 to 20 weeks. In addition, certain soft anatomic markers provide clues to chromosomal aneuploidy risk. Maternal obesity and multifetal pregnancies are now more common and further limit early gestation visibility.

CONCLUSION

Other advanced imaging techniques during early gestation in select cases of suspected malformations include fetal echocardiography and magnetic resonance imaging.

Acoustic output measured by thermal and mechanical indices during fetal echocardiography at the time of the first trimester scan

We measured acoustic output, expressed as the thermal index (TI) and mechanical index (MI), during fetal echocardiography at the time of the first trimester scan. TI and MI were retrieved from the saved displays during gray-mode, high-definition color flow Doppler and pulsed-wave Doppler (tricuspid flow) ultrasound examinations of the fetal heart and from the ductus venosus assessment. A total of 399 fetal cardiac examinations were evaluated. There was a significant increase in TI values from B-mode studies (0.07 ± 0.04 [mean ± SD]) to color flow mapping (0.2 ± 0.0) and pulsed-wave Doppler studies (0.36 ± 0.05). The TI from ductus venosus assessment (0.1 ± 0.01) was significantly lower than those from Doppler examinations of the heart. MI values from B-mode scans (0.65 ± 0.12) and color flow mapping (0.71 ± 0.11) were comparable, although different, and both values were higher than those from pulsed-wave Doppler tricuspid evaluation (0.39 ± 0.03). There were no differences in MI values from power Doppler assessment between the tricuspid flow and ductus venosus. Safety indices were remarkably stable and were largely constant, especially for color Doppler (TI), tricuspid flow (MI) and ductus venosus assessment (TI, MI). We acquired satisfactory Doppler images and/or signals at acoustic levels that were lower than the actual recommendations and never reached a TI of 0.5.

Factors affecting the feasibility of routine first-trimester fetal echocardiography

OBJECTIVES

The purpose of our study was to assess the factors that may improve the feasibility of routine fetal echocardiography at the time of the first-trimester scan.

METHODS

In this prospective study, we included 616 healthy singleton fetuses. Examinations were performed transabdominally by a single sonographer at the beginning of his training in first-trimester screening. The fetal heart was examined by high-definition color Doppler imaging to obtain the 4-chamber view, right and left ventricular outflow tracts, and 3-vessel and trachea view. Logistic regression was used to investigate the effect on the ability to visualize different cardiac structures.

RESULTS

The frequency of successful heart examinations increased significantly with the number of scans performed (P < .05). The sonographer needed 180 examinations before he could successfully examine the heart in at least 80% of cases. Significant factors that increased the probability of adequate echocardiography were the length of the heart examination and the experience of the sonographer (P< .05) but not transducer-heart distance, maternal body mass index, fetal crown-rump length, placenta interposition, or restrictive fetal position. Visualization of the left ventricular outflow tract could be improved by increasing the experience of the sonographer and decreasing the transducer-heart distance. Also, visualization of the 3-vessel and trachea view depended on the length of the heart examination, the experience of the sonographer, an anterior position of the placenta, and a restrictive fetal position.

CONCLUSIONS

Competence in color flow mapping assessment of the fetal heart at gestational ages of 11 weeks to 13 weeks 6 days is achieved only after extensive supervised training.

Imaging the first trimester heart: ultrasound correlation with morphology

First trimester sonography is a widely used technique to examine the foetus early in pregnancy. The desire to recognise complex anatomy already in early developmental stages stresses the need for a thorough knowledge of basic developmental processes as well as recognition of cardiac compartments based on their morphology. In this paper, we describe the possibilities and limitations of sonographic assessment of the foetal heart between 10 and 14 weeks of gestation and correlate this to morphology. Examples of the most commonly detected congenital anomalies are atrioventricular septal defects, transposition of the great arteries, and hypoplastic left heart, which are shown in this paper.

Collaborative study of 4-dimensional fetal echocardiography in the first trimester of pregnancy

OBJECTIVES

Accumulating evidence supports a role for 2-dimensional fetal echocardiography in the first trimester of pregnancy for the identification of congenital heart defects. Our objective was to investigate the role of 4-dimensional (4D) sonography in the identification of congenital heart defects between 11 and 15 weeks of pregnancy.

METHODS

This study included 4 centers with expertise in first-trimester 4D fetal echocardiography. Fetuses with and without confirmed heart defects were evaluated between 11 and 15 weeks and their volume data sets were uploaded onto a centralized file transfer protocol server.

RESULTS

Forty-eight volume data sets from fetuses with normal (n = 17) and abnormal (n = 16) hearts were evaluated. Overall, the median (range) accuracy, sensitivity, and specificity, as well as the positive and negative likelihood ratios, for the identification of fetuses with congenital heart defects were 79% (77%-83%), 90% (70%-96%), 59% (58%-93%), 2.35 (2.05-9.80), and 0.18 (0.08-0.32), respectively.

CONCLUSIONS

(1) Four-dimensional fetal echocardiography can be performed in the first and early second trimesters of pregnancy; and (2) 4D volume data sets obtained from fetuses between 11 and 15 weeks can be remotely acquired and accurately interpreted by different centers.

Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association

BACKGROUND

The goal of this statement is to review available literature and to put forth a scientific statement on the current practice of fetal cardiac medicine, including the diagnosis and management of fetal cardiovascular disease.

METHODS AND RESULTS

A writing group appointed by the American Heart Association reviewed the available literature pertaining to topics relevant to fetal cardiac medicine, including the diagnosis of congenital heart disease and arrhythmias, assessment of cardiac function and the cardiovascular system, and available treatment options. The American College of Cardiology/American Heart Association classification of recommendations and level of evidence for practice guidelines were applied to the current practice of fetal cardiac medicine. Recommendations relating to the specifics of fetal diagnosis, including the timing of referral for study, indications for referral, and experience suggested for performance and interpretation of studies, are presented. The components of a fetal echocardiogram are described in detail, including descriptions of the assessment of cardiac anatomy, cardiac function, and rhythm. Complementary modalities for fetal cardiac assessment are reviewed, including the use of advanced ultrasound techniques, fetal magnetic resonance imaging, and fetal magnetocardiography and electrocardiography for rhythm assessment. Models for parental counseling and a discussion of parental stress and depression assessments are reviewed. Available fetal therapies, including medical management for arrhythmias or heart failure and closed or open intervention for diseases affecting the cardiovascular system such as twin-twin transfusion syndrome, lung masses, and vascular tumors, are highlighted. Catheter-based intervention strategies to prevent the progression of disease in utero are also discussed. Recommendations for delivery planning strategies for fetuses with congenital heart disease including models based on classification of disease severity and delivery room treatment will be highlighted. Outcome assessment is reviewed to show the benefit of prenatal diagnosis and management as they affect outcome for babies with congenital heart disease.

CONCLUSIONS

Fetal cardiac medicine has evolved considerably over the past 2 decades, predominantly in response to advances in imaging technology and innovations in therapies. The diagnosis of cardiac disease in the fetus is mostly made with ultrasound; however, new technologies, including 3- and 4-dimensional echocardiography, magnetic resonance imaging, and fetal electrocardiography and magnetocardiography, are available. Medical and interventional treatments for select diseases and strategies for delivery room care enable stabilization of high-risk fetuses and contribute to improved outcomes. This statement highlights what is currently known and recommended on the basis of evidence and experience in the rapidly advancing and highly specialized field of fetal cardiac care.

Simplified first-trimester fetal cardiac screening (four chamber view and ventricular outflow tracts) in a low-risk population

OBJECTIVES

Our aim was to assess the accuracy of a simplified fetal cardiac study, inclusive of four-chamber view (4CV) and ventricular outflow tracts, performed during the 11-14 week screening by well-trained obstetricians to detect congenital heart diseases (CHDs).

METHODS

A transabdominal ultrasound was performed on 4820 singleton pregnant women at 11-14 weeks to visualize the visceral site, the 4CV, and the outflow tracts. Neonatal outcomes were recorded 6 and 12 months after birth.

RESULTS

Among the 4820 patients reviewed, 790 were excluded because of loss at prenatal or postnatal follow-up (649 cases), or inability to obtain adequate first-trimester sonographic cardiac evaluation (141 cases). Among the 4030 included cases, 32 CHD cases were detected (20 major and 12 minor); 18 of the major (90%) and five of the minor (42%) were detected or suspected in the first trimester, one major and six minor in the second trimester, and one major and one minor only after birth.

CONCLUSIONS

A simplified protocol is an effective tool to screen for CHD at 11-14 weeks.

Transposition of the great arteries: factors influencing prenatal diagnosis

OBJECTIVE

The objective of this study is to highlight the factors that may affect prenatal diagnosis of transposition of the great arteries (TGA) in order to improve it.

METHODS

This is a retrospective study performed between 2004 and 2009 in the maternity units from North of France. We identified a total of 68 cases of TGA (isolated or associated with only VSD or coarctation of aorta), of which 32 (47.1%) had prenatal diagnosis (PND+) and 36 did not (PND-). Maternal characteristics and ultrasound factors were studied in relation to PND.

RESULTS

Maternal weight and body mass index were significantly higher in the PND- group (70.4 kg and 26.5 kg/m(2) vs 63.6 kg and 23.6 kg/m(2) , respectively). Maternal obesity (body mass index >30) was significantly more frequent in the PND- group (27.8% vs 12.5%). More than a quarter of TGA (28.1%) were diagnosed during the third trimester.

CONCLUSION

Obesity is the main cause of missed PND of TGA. Obese patients with suboptimal prenatal scans may benefit from reassessment of fetal cardiac anatomy and/or from referral for fetal echocardiography.

Accuracy of ultrasonography at 11-14 weeks of gestation for detection of fetal structural anomalies: a systematic review

OBJECTIVE

To review the literature concerning the efficacy of early ultrasonography (at 11-14 weeks of gestation) to identify fetal malformations.

DATA SOURCES

A search in PubMed, MEDLINE, Embase, Cochrane Library, and ClinicalTrials.gov was performed (January 2000 to December 2012). Keywords were: fetal anatomy, fetal echocardiography, nuchal translucency, fetal structural anomalies, fetal malformations, prenatal diagnosis, prenatal screening, and first-trimester ultrasonography.

METHODS OF STUDY SELECTION

Inclusion criteria were: fetal anatomy examination at early ultrasonography and diagnosis of fetal malformations confirmed by postnatal or postmortem examination. Data abstracted were: sample size, location of structural defect, ultrasound modality, presence of multiple defects, and study population. Pooled detection rate was calculated for each malformation and compared with χ. Differences were considered statistically significant if P<.05.

TABULATION, INTEGRATION, AND RESULTS

From 1,203 articles, 19 were included. Overall, we pooled 78,002 fetuses undergoing ultrasonography at 11-14 weeks, of which 996 were malformed, leading to prevalence of malformation of 12 per 1,000. The overall detection rate was 472 of 957 (51%). The highest detection rate was achieved for neck anomalies (92%), whereas limbs (34%), face (34%), and genitourinary anomalies (34%) were associated with the lowest detection rate. At 14 weeks of gestation or less, fetal echocardiography detected 53% of congenital heart disease compared with 43% by complete scan (P=.040). The use of Doppler did not improve the detection rate for congenital heart defects (52% compared with 44%, respectively; P=.11). Multiple defects were identified more frequently than isolated malformations (60% compared with 44%; P=.005). The detection rate was higher combining transabdominal and transvaginal techniques (62%) than either abdominal (51%) or transvaginal (34%; P<.001). Detection rate was higher in women at high risk (65%) than unselected population (50% P=.001).

CONCLUSION

Because of the natural history of fetal defects and the late development of some organ systems, a number of fetal malformations remain undetected by early ultrasonography.

Comparison of echocardiographic findings in fetuses at less than 15 weeks' gestation with later cardiac evaluation

OBJECTIVE

To compare the echocardiographic findings in fetuses at < 15 weeks' gestation with a later follow-up scan, and determine both the accuracy of early diagnosis and the frequency of findings that change between scans.

METHODS

For the period 2002 to the end of 2009, we searched our database for all patients who had had a detailed fetal echocardiogram at less than 15 completed weeks' gestation and a repeat scan at least 6 weeks later.

RESULTS

Of 1200 patients fulfilling our selection criteria, the cardiac findings were normal at both scans in 1069. In 46 cases the same cardiac abnormality was seen at both scans. There was a false-positive diagnosis at early scan in seven cases. In 50 cases, there were mildly abnormal functional findings early in pregnancy with no abnormality found later. In 29 fetuses, there was discordance between the early and later morphological diagnosis, 15/29 being considered significant differences, with 10/15 representing true progression of findings between the early and later scans, rather than missed or incorrect diagnoses.

CONCLUSIONS

A high degree of accuracy in the identification of congenital heart disease can be achieved by early fetal echocardiography (sensitivity 84.8 (95% CI, 75.0-91.9)%, specificity 95.3 (95% CI, 93.9-96.4)%), although the identification of every case of tetralogy of Fallot and small atrioventricular septal defects presents particular diagnostic challenges at this gestational age. A small but significant group showed progression of findings during this stage of rapid fetal heart growth, particularly in obstructive lesions.

Use of spatiotemporal image correlation at 11-14 weeks' gestation

OBJECTIVE

To assess prospectively the use of four-dimensional (4D) spatiotemporal image correlation (STIC) in the evaluation of the fetal heart at 11-14 weeks' gestation.

METHODS

The study involved offline analysis of 4D-STIC volumes of the fetal heart acquired at 11-14 weeks' gestation in a population at high risk for congenital heart disease (CHD). Regression analysis was used to investigate the effect of gestational age, maternal body mass index, quality of the 4D-STIC volume, use of a transvaginal vs transabdominal probe and use of color Doppler ultrasonography on the ability to visualize separately different heart structures. The accuracy in diagnosing CHD based on early fetal echocardiography (EFE) using 4D-STIC vs conventional two-dimensional (2D) ultrasound was also evaluated.

RESULTS

One hundred and thirty-nine fetuses with a total of 243 STIC volumes were included in this study. Regression analysis showed that the ability to visualize different heart structures was correlated with the quality of the acquired 4D-STIC volumes. Independently, the use of a transvaginal approach improved visualization of the four-chamber view, and the use of Doppler improved visualization of the outflow tracts, aortic arch and interventricular septum. Follow-up was available in 121 of the 139 fetuses, of which 27 had a confirmed CHD. A diagnosis based on EFE using 4D-STIC was possible in 130 (93.5%) of the 139 fetuses. Accuracy in diagnosing CHD using 4D-STIC was 88.7%, and the results of 45% of the cases were fully concordant with those of 2D ultrasound or the final follow-up diagnosis. EFE using 2D ultrasound was possible in all fetuses, and accuracy in diagnosing CHD was 94.2%. Five of the seven false-positive or false-negative cases were minor CHD.

CONCLUSIONS

In fetuses at 11-14 weeks' gestation, the heart can be evaluated offline using 4D-STIC in a large number of cases, and this evaluation is more successful the higher the quality of the acquired volume. 2D ultrasound remains superior to 4D-STIC at 11-14 weeks, unless volumes of good to high quality can be obtained.

First trimester two- and four-dimensional cardiac scan: intra- and interobserver agreement, comparison between methods and benefits of color Doppler technique

OBJECTIVE

To evaluate intra- and interobserver agreement for first-trimester fetal cardiac structural assessment, using two-dimensional (2D) ultrasound (2D-US) and 4D-US (4D spatiotemporal image correlation (STIC) technology), to compare the methods and to assess the advantages of adding color Doppler to each technique.

METHODS

Digital videoclips (B-mode and color Doppler) and 4D-STIC volumes (gray-scale and color Doppler) from 632 pregnancies with normal fetal hearts were acquired and stored at the time of detailed first-trimester ultrasound examination. Later analysis on a randomized sample of 100 cases was performed, targeting 11 cardiac structures and features. We compared visualization of fetal heart parameters using 2D-US vs 4D-US and gray-scale vs color Doppler imaging.

RESULTS

STIC volumes were considered satisfactory (adequate visualization of at least 8/11 parameters) in 78% of cases and 2D-US acquisitions in 89% of cases. The intra- and interobserver agreement was good for both 2D and 4D methods (kappa > 0.6), and the percentage overall agreement was very high using both methods (95%). 2D- and 4D-US identification of the fetal cardiac parameters did not differ significantly. The differences between gray-scale and color Doppler imaging were statistically significant in identifying similar key cardiac parameters, for both 2D- and 4D-US (P < 0.05).

CONCLUSION

Both 2D and 4D methods for assessing first-trimester heart parameters are feasible and repeatable within and between observers. Color Doppler adds valuable information to both methods.

Sonographic markers for early diagnosis of fetal malformations

Fetal malformations are very frequent in industrialized countries. Although advanced maternal age may affect pregnancy outcome adversely, 80%-90% of fetal malformations occur in the absence of a specific risk factor for parents. The only effective approach for prenatal screening is currently represented by an ultrasound scan. However, ultrasound methods present two important limitations: the substantial absence of quantitative parameters and the dependence on the sonographer experience. In recent years, together with the improvement in transducer technology, quantitative and objective sonographic markers highly predictive of fetal malformations have been developed. These markers can be detected at early gestation (11-14 wk) and generally are not pathological in themselves but have an increased incidence in abnormal fetuses. Thus, prenatal ultrasonography during the second trimester of gestation provides a “genetic sonogram”, including, for instance, nuchal translucency, short humeral length, echogenic bowel, echogenic intracardiac focus and choroid plexus cyst, that is used to identify morphological features of fetal Down’s syndrome with a potential sensitivity of more than 90%. Other specific and sensitive markers can be seen in the case of cardiac defects and skeletal anomalies. In the future, sonographic markers could limit even more the use of invasive and dangerous techniques of prenatal diagnosis (amniocentesis, etc.).

Should the first trimester ultrasound include anatomy survey?

First trimester scanning has become routine since the introduction of nuchal translucency screening. While most scans have included dating and gross anatomical structures, recent reports have shown that with improvement of ultrasound technology, especially high-frequency transvaginal transducers, detailed analysis of the early fetal anatomy is now possible. Studies included in this manuscript demonstrate the ability to now being able to identify many fetal malformations including some very subtle ones. The literature presented has carefully conducted many prospective studies presenting timelines that show optimal periods to review the anatomical structures by a given gestational age especially noting when these anatomical structures are not optimally seen.

Fetal diagnosis and imaging in cardiology

BACKGROUND

Fetal echocardiography plays a critical role in the diagnosis and management of structural, functional and rhythm-related fetal cardiovascular disease.

OBJECTIVES/METHODS

This article reviews the history of fetal echocardiography and the prenatal diagnosis of fetal cardiovascular disease as well as the evolution of the field of fetal cardiology. The clinical application of fetal echocardiography, including indications for referral, timing of referral and considerations in the diagnosis and serial assessment of fetal cardiovascular disease, is presented.

CONCLUSIONS

Newer directions in the field of fetal cardiology, including first trimester diagnoses and fetal intervention, will continue to expand its role in the evaluation and treatment of affected pregnancies in the future; however, equally as important are efforts to continue to improve prenatal detection rates.

Ultrasound and echocardiographic findings obtained in the second and third trimesters of gestation in fetuses with normal karyotype and increased nuchal translucency

Introduction

Numerous papers have proven that an increased nuchal translucency is connected with a raised risk of chromosomal aberrations, but few analyses are related to the further state of fetuses with a normal karyotype.

The aim of the study

The aim of the study was to estimate the risk of cardiac defects and other developmental disorders in fetuses with increased nuchal translucency and normal findings of a standard cytogenetic examination.

Methods

The authors carried out a retrospective analysis of 5183 examinations of 3376 patients who reported to the Department of Diagnosis and Prophylaxis of Congenital Malformations in the Polish Mother's Memorial Hospital in Łódź in the period from January 2008 to March 2011 for prenatal ultrasound and echocardiographic examinations. The authors analyzed the results of the examinations performed in the second and third trimesters of gestation in fetuses with an increased nuchal translucency of ≥3 mm in the first trimester and with a normal karyotype.

Results

Fifty-seven patients (1.7% of the examined group) fulfilled the criteria necessary to be included in the study. In 31 pregnant women (54%) structural defects or anomalies of the fetus were found. Cardiac anomalies were detected in 17 fetuses (29.8%). The authors detected various types of cardiac defects such as tetralogy of Fallot, ventricular septal defect, atrioventricular septal defect, transposition of the great arteries and hypoplastic left heart syndrome.

Conclusions

In more than half of the fetuses with an increased nuchal translucency (NT ≥ 3 mm) and a normal karyotype, developmental defects of various organs appeared in the further course of pregnancy: mainly heart defects that were either isolated, or accompanied other anomalies.