Accuracy of fetal echocardiography in the routine detection of congenital heart disease among unselected and low risk populations: a systematic review

[Formula: see text] Optimizing neurodevelopmental outcomes following fetal diagnosis of congenital heart disease: a call for primary prevention neuropsychology

Critical congenital heart disease (CHD) presents a lasting threat to quality of life through its adverse impact on neurodevelopmental and psychosocial outcomes. As recognition of this threat has increased, so too has an appreciation for the role of pediatric neuropsychologists in supporting families affected by CHD. But there is more to offer these families than traditional neuropsychological services, which tend to focus on secondary/tertiary forms of prevention. Now that many children with CHD are diagnosed prenatally, it may be possible to begin mitigating CHD-related risks and promoting positive outcomes earlier than ever before. Through primary prevention-oriented fetal neuropsychological consultation, as well as close collaboration with allied specialists, pediatric neuropsychology has an opportunity to re-envision its typical borders and more familiar practice models; to forge early and enduring partnerships with families; and to help promote the best possible neurodevelopmental trajectories, beginning before children are even born. In this conceptual review, we survey and integrate evidence from developmental science, developmental origins of health and disease, maternal-fetal medicine, and cardiac neurodevelopmental literatures, along with current practice norms, arriving ultimately at two central conclusions: 1) there is an important role to fill on multidisciplinary teams for the pediatric neuropsychologist in fetal cardiac care and 2) role expansion (e.g., through valuing broader-based training, flexing more generalist skills) can likely improve neuropsychological outcomes earlier than has been standard for pediatric neuropsychologists. Such a reimagining of our practice may be considered primary prevention neuropsychology. Implications for care in various settings and pragmatic barriers to implementation are discussed.

Artificial intelligence in perinatal diagnosis and management of congenital heart disease

Prenatal diagnosis and management of congenital heart disease (CHD) has progressed substantially in the past few decades. Fetal echocardiography can accurately detect and diagnose approximately 85% of cardiac anomalies. The prenatal diagnosis of CHD results in improved care, with improved risk stratification, perioperative status and survival. However, there is much work to be done. A minority of CHD is actually identified prenatally. This seemingly incongruous gap is due, in part, to diminished recognition of an anomaly even when present in the images and the need for increased training to obtain specialized cardiac views. Artificial intelligence (AI) is a field within computer science that focuses on the development of algorithms that "learn, reason, and self-correct" in a human-like fashion. When applied to fetal echocardiography, AI has the potential to improve image acquisition, image optimization, automated measurements, identification of outliers, classification of diagnoses, and prediction of outcomes. Adoption of AI in the field has been thus far limited by a paucity of data, limited resources to implement new technologies, and legal and ethical concerns. Despite these barriers, recognition of the potential benefits will push us to a future in which AI will become a routine part of clinical practice.

Cardiac axis evaluation as a screening method for detecting cardiac abnormalities in the first trimester of pregnancy

Congenital cardiac abnormalities refer to especially anatomic malformations of the heart that normally occur during fetal heart development, before eight weeks after conception. Aim: The aim is to investigate the association between cardiac axis and congenital heart abnormalities for a potential underline clinical application of cardiac axis evaluation during detection by abnormalities at the time of first trimester ultrasound. It is known that aneuploids can be associated in almost half of cases with cardiac abnormalities, so the angle of the cardiac axis could be a potential indirect marker for the detection of aneuploids in the first trimester of pregnancy. Being easy to obtain, from the cross-section at the chest level with the visualization of the four chambers, does not require additional sections to those provided in the current guides, we aim to prove its usefulness in diagnosing aneuploids and congenital cardiac abnormalities along with the translucent nuchal flow, at the level of the venous duct and the presence of tricuspid regurgitation. Conclusions: Cardiac axis has a higher value for the detection of congenital cardiac abnormalities with respect to the nuchal translucency, tricuspid regurgitation and inverted A wave at the level of the venous duct.

Prenatal diagnosis of congenital heart defects and voluntary termination of pregnancy

BACKGROUND

The prenatal diagnosis of an isolated congenital heart defect is a matter of concern for parents. The decision of whether to terminate the pregnancy according to the different types of congenital heart defects has not been investigated yet.

OBJECTIVE

This study aimed to evaluate the frequency of voluntary termination of pregnancy after the prenatal diagnosis of a congenital heart defect in a tertiary care center.

STUDY DESIGN

This was a retrospective study of patients who were referred to our center from January 2013 to December 2019, underwent fetal echocardiography, and were counseled by a perinatologist and a pediatric cardiologist. The following data were collected: prenatal diagnosis, including genetic testing; gestational age at diagnosis; and outcome of pregnancy. The diagnoses were stratified retrospectively according to the type of congenital heart defect and its severity (low complexity, moderate complexity, and high complexity) by a perinatologist and a pediatric cardiologist.

RESULTS

Of 704 women who received a diagnosis of fetal congenital heart defect, 531 (75.4%) were seen before 23 weeks' gestation, which is the upper limit imposed for the termination of pregnancy by the Italian legislation. Congenital heart defects were apparently isolated in 437 of 531 cases (82.3%). Overall, 108 of 531 patients (20.3%) requested a termination of pregnancy. The rate of termination of pregnancy was found to vary according to the severity of congenital heart defects: low complexity, 0%; moderate complexity, 12.1%, and high complexity, 33.2% (P<.001). The presence or absence of associated anomalies or the ethnicity of the couples was not found to have an influence on women's decisions.

CONCLUSION

In our population, the decision to terminate a pregnancy after the diagnosis of a fetal congenital heart defect is influenced by the surgical complexity of the congenital heart defect itself. However, most patients, including those with the most severe forms of congenital heart defect, decided to continue the pregnancy.

Maternal and cord blood homocysteine, vitamin B12, folate, and B-type natriuretic peptide levels at term for predicting congenital heart disease of the neonate: A case-control study

Objective: To investigate the effectiveness of the metabolic markers homocysteine, vitamin B12, folate, and B-type natriuretic peptide in maternal and cord blood for detecting congenital heart disease.Methods: Homocysteine, vitamin B12, folate, and B-type natriuretic peptide concentrations in maternal and cord blood samples at term were measured in the case (n = 42) and control (n = 43) groups with and without fetal congenital heart disease, respectively. Additionally, newborns with congenital heart disease were divided into two subgroups: those with (n = 30) and without (n = 8) 6-month infant survival. The case and control groups and case subgroups were compared with each other with respect to maternal age, gravidity, parity, gestational age at delivery, birth weight, maternal and cord blood levels of homocysteine, vitamin B12, folate, and B-type natriuretic peptide, and arterial cord blood pH and base excess values. Statistical analyses were performed using SPSS for Windows, version 22.0. The Student's t-test, the Mann-Whitney U test, and the χ² test were used where appropriate. A p value of < .05 was considered statistically significant.Results: Mean maternal age, birth weight and median gravidity, parity and gestational age at delivery were not significantly different between the case and control groups, as well as between the case subgroups (all p > .05). Concentrations of metabolic markers in maternal blood were not significantly different between the two groups (p > .05). Homocysteine and B-type natriuretic peptide levels in cord blood samples were significantly higher, whereas folate levels were significantly lower in the case group compared with the control group (all p < .05). Cord blood B-type natriuretic peptide levels were significantly higher (p < .05) and arterial cord blood pH values were significantly lower (p < .05) in the case subgroup without 6-month infant survival compared with the case subgroup with 6-month infant survival.Conclusion: High cord blood B-type natriuretic peptide and homocysteine levels and low cord blood folate levels at term may be useful for predicting congenital heart disease in the neonate. Neonates with congenital heart disease who have high cord blood B-type natriuretic peptide and low pH values may have adverse outcomes.

Contribution of the Fetal Cardiac Axis and V-Sign Angle in First-Trimester Screening for Major Cardiac Defects

OBJECTIVE

To estimate the potential value of fetal assessment for the cardiac axis (CAx) and V-sign angle (VSA) in the first trimester in the prediction of fetal major cardiac defects.

METHODS

A cohort study was conducted from December 2015 to June 2016. Patients with singleton pregnancies and crown-rump length from 45 to 84 mm were recruited to undergo nuchal translucency sonography. The CAx on the 4-chamber view and the VSA on the 3-vessel and trachea view with Doppler mapping were measured. The estimated performance of different combinations of increased fetal nuchal translucency, CAx, and VSA in screening for major cardiac defects was examined.

RESULTS

The study population of fetuses included 30 fetuses with major cardiac defects and 1538 normal fetuses. The CAx and VSA were 30° to 60° and 30° to 40°, respectively, according to the 2.5th and 97.5th percentiles in normal fetuses. When cases of isolated septal wall defects and an isolated right aortic arch were excluded, nuchal translucency above the 95th percentile, an abnormal CAx, and an abnormal VSA were observed in 63.3% (19 of 30), 63.3% (19 of 30), and 66.7% (20 of 30) of fetuses with major cardiac defects, respectively, and in 4.6% (71 of 1538), 2.0% (30 of 1538), and 5.6% (86 of 1538) of those without cardiac defects. Either an abnormal CAx or VSA was found in 93.3% (28 of 30) of the fetuses with cardiac defects and in 7.3% (113 of 1538) of those without cardiac defects.

CONCLUSION

Assessment of the CAx and VSA is helpful in defining a population at risk for major cardiac defects in the first trimester.

Training: improving antenatal detection and outcomes of congenital heart disease

Objectives

This study describes the design, delivery and efficacy of a regional fetal cardiac ultrasound training programme. This programme aimed to improve the antenatal detection of congenital heart disease (CHD) and its effect on fetal and postnatal outcomes.

Design setting and participants

This was a prospective study that compared antenatal CHD detection rates by professionals from 13 hospitals in Wales before and after engaging in our 'skills development programme'. Existing fetal cardiac practice and perinatal outcomes were continuously audited and progressive targets were set. The work was undertaken by the Welsh Fetal Cardiovascular Network, Antenatal Screening Wales (ASW), a superintendent sonographer and a fetal cardiologist.

Interventions

A core professional network was established, engaging all stakeholders (including patients, health boards, specialist commissioners, ASW, ultrasonographers, radiologists, obstetricians, midwives and paediatricians). A cardiac educational lead (midwife, superintendent sonographer, radiologist, obstetrician, or a fetal medicine specialist) was established in each hospital. A new cardiac anomaly screening protocol ('outflow tract view') was created and training on the new protocol was systematically delivered at each centre. Data were prospectively collected and outcomes were continuously audited: locally by the lead fetal cardiologist; regionally by the Congenital Anomaly Register and Information Service in Wales; and nationally by the National Institute for Cardiac Outcomes and Research (NICOR) in the UK.

Main outcome measures

Patient satisfaction; improvements in individual sonographer skills, confidence and competency; true positive referral rate; local hospital detection rate; national detection rate of CHD; clinical outcomes of selected cardiac abnormalities; reduction of geographical health inequality; cost efficacy.

Results

High levels of patient satisfaction were demonstrated and the professional skill mix in each centre was improved. The confidence and competency of sonographers was enhanced. Each centre demonstrated a reduction in the false-positive referral rate and a significant increase in cardiac anomaly detection rate. According to the latest NICOR data, since implementing the new training programme Wales has sustained its status as UK lead for CHD detection. Health outcomes of children with CHD have improved, especially in cases of transposition of the great arteries (for which no perinatal mortality has been reported since 2008). Standardised care led to reduction of geographical health inequalities with substantial cost saving to the National Health Service due to reduced false-positive referral rates. Our successful model has been adopted by other fetal anomaly screening programmes in the UK.

Conclusions

Antenatal cardiac ultrasound mass training programmes can be delivered effectively with minimal impact on finite healthcare resources. Sustainably high CHD detection rates can only be achieved by empowering the regional screening workforce through continuous investment in lifelong learning activities. These should be underpinned by high quality service standards, effective care pathways, and robust clinical governance and audit practices.

Use of prostaglandins in duct-dependent congenital heart conditions

Congenital heart disease (CHD) remains a leading cause of infant mortality, which is even higher in infants with undiagnosed duct-dependent CHDs. Up to 39%-50% of infants with critical CHD are being discharged undiagnosed from the hospital. Infants with duct-dependent critical CHD remain well during the fetal period and may deteriorate when the ductus arteriosus (commonly called 'duct') closes after birth. It is critical to open or maintain ductus arteriosus patent in infants with duct-dependent CHDs. Prostaglandin E1 (alprostadil marketed as 'Prostin VR ') and prostaglandin E2 (dinoprostone) are used to maintain a patent ductus arteriosus and the dose of medication depends on the clinical presentation. Delay in starting prostaglandin infusion can have deleterious effects on infants and can even lead to death. These infants often present as an emergency, and professionals caring for these infants need to have a good understanding of these conditions and medications used for ductal patency.

Clinical yield of fetal echocardiography for suboptimal cardiac visualization on obstetric ultrasound

OBJECTIVE

Suboptimal cardiac imaging on obstetric ultrasound is a frequent referral indication for fetal echocardiography, even in the absence of typical risk factors for fetal cardiac disease. The clinical profile of patients and findings of examinations performed for such an indication are not well defined. Given the increased cost, time and resource utilization of fetal echocardiography, we sought to determine the clinical findings of such referrals.

STUDY DESIGN

We performed a single-center review of such referrals from January 2010 to June 2016. Patients with commonly accepted indications for fetal echocardiography were excluded. Demographic variables and echocardiogram findings were collected. Findings were classified as (1) "normal," (2) "probably normal," if minor pathology could not confidently be excluded, or if minor findings were noted that were expected to resolve, or (3) "abnormal." Rates of pathology were determined with comparison of nonobese and obese populations.

RESULTS

A total of 583 gestations in 562 women were included (median gestational age 23.3 weeks, range 19.0-38.4). The median body mass index (BMI) was 34.6 kg/m² (range 17.2-66.3 kg/m² ). The majority of women were obese (BMI ≥ 30 kg/m² in 74.6%). Overall, 574 of 583 examinations (98.5%) were normal or "probably normal." Pathology was noted in 9 fetuses (1.5%), 3 of whom required intervention (0.5%). No ductal dependent lesions were diagnosed. There was no significant difference in pathology rates between nonobese and obese mothers.

CONCLUSIONS

We found a low fetal cardiac anomaly rate in studies performed for suboptimal views on obstetric ultrasound. The majority of women referred for this indication were obese. The practice of routine referral for this indication deserves further evaluation.

Sonographer-Identified Barriers and Facilitators to Prenatal Screening for Congenital Heart Disease

Background: Fetal ultrasound screening for congenital heart disease has high detection rates in efficacy studies but not in practice. We investigated sonographers’ perspectives on barriers to screening and their association with intermediate measures of cardiac imaging. Methods: Barriers to fetal heart screening were identified in focus groups with obstetric sonographers. A web-based survey measured reported barriers and sonographers’ ability to interpret fetal heart screening images. Generalized linear random effect models assessed associations between barriers and image interpretation. Results: Four themes were identified: intrinsic barriers (self-efficacy), external barriers (time), informational needs, and provider and patient expectations. Among 224 sonographers surveyed, an average of 77.6% of fetal heart images were interpreted correctly. Perceptions about self-efficacy ( P = .03) and ease of performing imaging ( P = .01) were associated with accuracy of image interpretation. Conclusions: Several sonographer-identified barriers associated with image interpretation may be novel targets for improving prenatal detection of congenital heart disease.

Impact of changing indications and increased utilization of fetal echocardiography on prenatal detection of congenital heart disease

BACKGROUND

Antenatal diagnosis of congenital heart defects (CHD) can impact outcomes in neonates with severe CHD. Obstetric screening guidelines and the indications for fetal echocardiography (FE) have evolved in an attempt to improve the early prenatal detection of CHD. Analyzing yield for specific indications will help clinicians better stratify at-risk pregnancies.

METHODS

Retrospective cohort study of all FE performed between 2000 and 2010 at a single tertiary care academic medical center in New York City. A total of 9878 FE met inclusion criteria for our study. In cases of multiple gestations (MG), each fetus was counted as a separate study.

RESULTS

The number of new diagnosis of fetal CHD by FEs increased 200%. There was a statistically significant increase in those referred for suspected CHD, increased nuchal translucency (NT), MG, and suboptimal imaging (P < .001). The indication of "suboptimal imaging" (SO) not only accounted for 5.23% of all referrals from 2000 to 2002, compared to 22.26% of all referrals from 2008 to 2010 (P < .0001), but also had the lowest yield for diagnoses of CHD (P < .02).

CONCLUSIONS

Over the past decade, there has been an increase in utilization of FE with a proportional increase in prenatally diagnosed CHD. For indications such as suspected CHD, NT and MG increases in referrals have led to a proportionate increase in fetal diagnosis of CHD. SO as an indication has the lowest yield of fetal diagnosis of CHD. Antenatal detection of CHD may be improved by a change in obstetric imaging protocols to ensure appropriate referrals.

Feasibility Study on Prenatal Cardiac Screening Using Four-Dimensional Ultrasound with Spatiotemporal Image Correlation: A Multicenter Study

Objective

This study aimed at investigating the feasibility of using the spatiotemporal image correlation (STIC) technology for prenatal cardiac screening, finding factors that influence the offline evaluation of reconstructed fetal heart, and establishing an optimal acquisition scheme.

Methods

The study included 452 gravidae presenting for routine screening at 3 maternity centers at 20–38 gestational weeks. The factors influencing the quality of STIC volume data were evaluated using t test, chi-square test, and logistic regression analysis. The predictive power was evaluated using the receiver operating characteristic (ROC) curve.

Results

Among the 452 fetuses enrolled, 353 (78.1%) were identified as successful and 99 (21.9%) as failure of evaluation of the reconstructed fetal heart. The total success rate of qualified STIC images was 78.1%. The display rates of reconstructed cardiac views were 86.5% (four-chamber view), 92.5% (left ventricular outflow tract view), 92.7% (right ventricular outflow tract view), 89.9% (three-vessel trachea view), 63.9% (aortic arch view), 81.4% (ductal arch view), 81% (short-axis view of great vessels), 80.1% (long-cava view), and 86.9% (abdominal view). A logistic regression analysis showed that more than 28 gestational weeks [OR = 0.39 (CI 95% 0.16, 0.19), P = 0.035], frequent fetal movements [OR = 0.37 (CI 95% 0.16, 0.87), P = 0.022], shadowing [OR = 0.36 (CI 95% 0.19, 0.72), P = 0.004], spine location at 10–2 o’clock [OR = 0.08 (CI 95% 0.02, 0.27), P = 0.0], and original cardiac view [OR = 0.51 (0.25, 0.89), P = 0.019] had a significant impact on the quality of STIC. The area under the ROC curve was 0.775.

Conclusions

Fetal cardiac-STIC seems a feasible tool for prenatal screening of congenital heart diseases. The influence factors on the quality of STIC images included the intensity of training, gestational age, fetal conditions and parameter settings. The optimal acquisition scheme may improve the application and widespread use of cardiac STIC.

Simplifying ultrasound assessment of the fetal heart: Incorporating the complete Three Vessel View into routine screening

Introduction: As our experience and ultrasound resolution have improved significantly in last 30 years it is possible to detect most of the major cardiac abnormalities prenatally with high degree of accuracy.

Method: Current screening techniques have poor detection rate for congenital heart diseases (CHD) and nearly half of the major cardiac abnormalities mainly of Great Arteries goes unrecognised. A high detection rate for major CHDs can be achieved in a screening setting by improving techniques of routine screening in the low risk population.

Conclusion: This article summarises the alternative strategies to examine the outflow tracts and Great Arteries, its correct interpretation and examples of abnormal views.

Beyond Critical Congenital Heart Disease: Newborn Screening Using Pulse Oximetry for Neonatal Sepsis and Respiratory Diseases in a Middle-Income Country

BACKGROUND

Studies on pulse oximetry screening for neonatal sepsis and respiratory disease in a middle-income country are lacking. Newborn screening for critical congenital heart disease (CCHD) using pulse oximetry is an effective and life-saving strategy in developed countries. While most studies have reported false-positive results during CCHD screening, they have not elaborated on the detected disease types. We studied the effectiveness and outcomes of pulse oximetry newborn screening for non-cardiac hypoxemic diseases such as neonatal sepsis, respiratory diseases, and CCHD in a middle-income country.

METHODS AND FINDINGS

In a pilot study performed at the University Malaya Medical Centre (UMMC), Malaysia, all apparently healthy term newborns, delivered at UMMC were screened pre-discharge using pulse oximetry. Echocardiography was performed for newborns that had positive screening results on two separate occasions, 1-h apart. Newborns with normal echocardiograms were evaluated and treated for other non-cardiac diseases. Fifteen of 5247 term newborns had positive screening results. The median age at screening was 20 h. Thirteen newborns (0.24%) had significant non-cardiac diseases: sepsis (n = 2) and respiratory diseases (n = 11) that required hospitalization and treatment. The remaining two newborns with normal antenatal ultrasonograms had positive screening test and confirmed to have CCHD. Another 18 newborns with negative screening test were later admitted for treatment of sepsis (n = 16) and penumonia (n = 2). All newborns were treated and alive at the end of the study. The sensitivity and specificity of pulse oximetry screening for non-cardiac diseases were 42% and 99.9% respectively, and 100% and 99.7% for CCHD, respectively.

CONCLUSIONS

Routine pulse oximetry screening test was effective in identifying newborns with CCHD and other hypoxemia illnesses, which may led to potential life-threatening condition. This study showed that the expanded use of pulse oximetry has immediate implications for low- and middle-income countries contemplating strategies to reduce neonatal mortality and morbidity.

ABBREVIATIONS

ASD, atrial septal defect; CCHD, critical congenital heart disease; CRP, C-reactive protein; CXR, chest radiographs; NDI, neurodevelopment impairment; PPHN, persistent pulmonary hypertension of the newborn; PDA, patent ductus arteriosus; PFO, patent foramen ovale; TGA, transposition of great artery; TTN, transient tachypnoea of the newborn; VSD, ventricular septal defect.

Long-distance transport of neonates with transposition of the great arteries for the arterial switch operation: A 26-year Western Australian experience

AIM

There is evidence that outcomes of complex paediatric cardiac procedures including the arterial switch operation (ASO) for transposition of the great arteries (TGA) are improved when performed at higher volume centres. While in utero transport for surgery is considered ideal, antenatal detection rates of TGA are low. Long-distance transport of post-natally diagnosed neonates has the potential to destabilise the patient's clinical condition. Since 1986, many neonates with TGA have been transported interstate from Perth to Melbourne or Brisbane for ASO surgery. The aim of this study was to review the Western Australian experience of interstate transport of newborns with TGA for ASO, noting transport complications and comparing the early mortality of these patients with published outcomes of the ASO from Royal Children's Hospital (RCH), Melbourne.

METHOD

In this retrospective cohort study, we reviewed the neonatal and cardiology databases and medical records to identify infants with TGA born between 1986 and 2011 and requiring ASO surgery during the neonatal period.

RESULTS

Over 26 years, 80 neonates were transferred interstate for ASO surgery. Twelve infants required ventilation, 36 needed prostaglandin (prostaglandin E1) infusion and 3 inotropic support. There was no mortality during transport and there was a single early post-operative death. This early mortality of 1.2% compares favourably with the RCH mortality of 2.8% from a recently published review of early outcomes for ASO.

CONCLUSIONS

When in utero transport is not possible, long-distance transport of neonates with TGA can be safely undertaken, with no evidence of increased transport mortality/ major morbidity or higher early surgical mortality.

Preoperative Physiology, Imaging, and Management of Transposition of the Great Arteries

Transposition of the great arteries (TGA) refers to hearts with concordant atrioventricular connections but discordant ventriculoarterial connections. In this lesion, the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle. As such, the pulmonary and aortic circulations run in parallel as opposed to in series, and this lesion is not compatible with survival without adequate mixing of these circulations. The management and outcomes of TGA parallels the field of pediatric cardiac surgery itself. Uniformly fatal in childhood, palliative procedures from the 1950s to 1970s offered survival, albeit at a high early and late cost. In the 1970s, the arterial switch operation (ASO) provided an anatomical "cure," with survival to adulthood in the current era of around 90%. Detailed perioperative imaging, attention to associated lesions, and comprehension of the physiology are critical to medical and surgical management.

Diagnosis of congenital heart disease in an era of universal prenatal ultrasound screening in southwest Ohio

OBJECTIVES

Diagnostic ultrasound is widespread in obstetric practice, yet many babies with major congenital heart disease remain undiagnosed. Factors affecting prenatal diagnosis of major congenital heart disease are not well understood. This study aims to document prenatal detection rates for major congenital heart disease in the Greater Cincinnati area, and identify factors associated with lack of prenatal diagnosis.

METHODS

All living infants diagnosed with major congenital heart disease by 4 months of age at our centre were prospectively identified. Prenatal care data were obtained by parent interview. Neonatal records were reviewed for postnatal data. Obstetricians were contacted for diagnostic ultrasound data.

RESULTS

A total of 100 infants met the inclusion criteria. In all, 95 infants were analysed, of whom 94 were offered diagnostic ultrasound. In all, 41 had a prenatal diagnosis of major congenital heart disease. The rate of prenatal detection varied by cardiac lesion, with aortic arch abnormalities, semilunar valve abnormalities, and venous anomalies going undetected in this sample. Among subjects without prenatal detection, the highest proportion consisted of those having Level 1 diagnostic ultrasound only (66%). Prenatal detection was not significantly influenced by maternal race, education level, income, or insurance type.

CONCLUSIONS

Despite nearly universal diagnostic ultrasound, detection rates of major congenital heart disease remain low in southwest Ohio. An educational outreach programme including outflow tract sweeps for community-level obstetrical personnel may improve detection rates.

Role of ultrasound in the management of diabetes in pregnancy

The purpose of this review is to discuss the established role of ultrasound (US) in the management of pregnancy complicated by diabetes mellitus (DM), as well as new developments with regard to the use of US in this situation. We choose to explore the role of US in pregnancy complicated by DM in three areas: (1) Role of US in estimation of fetal weight. (2) Role of US in diagnosis of congenital malformation. (3) Role of US in monitoring diabetic pregnant patients.

Care-related factors associated with antepartal diagnosis of intrauterine growth restriction: a case-control study

Background

Antenatal care is of core importance for maternal and child health and is therefore a central aspect of mother and child health care. One of the main goals of effective screening in antenatal care is the detection of suboptimal fetal growth. However, the sensitivity of antenatal diagnostic of suboptimal fetal growth (i.e. intrauterine growth restriction; IUGR) through clinical routine fetal ultrasonography has been observed to be low. A study conducted in Germany found that only 30% of IUGR cases and 40% of congenital malformations were diagnosed antenatally. Reasons for this low detection rate remain unclear.

Methods/Design

In the first of two study components, all mothers who delivered or will deliver a small for gestational age (SGA) newborn in one of three hospitals in Bremen (Germany) during recruitment phase are eligible for inclusion in a hospital based case–control study. Cases are defined as neonates with an IUGR that was not detected antenatally, while controls are defined as neonates whose IUGR was identified or at least suspected antenatally. Data collection instruments include a newborn documentation sheet, a standardized, computer-assisted personal interview with mothers, and a copy of pregnancy record books. The second component is a survey among all private practice-based gynecologists in the federal states of Bremen and Lower Saxony. The aim of this survey was to obtain detailed information e.g. on quality of ultrasonography equipment and examiner’s ultrasonography experience and qualification level.

Discussion

To our knowledge, this is one of the few German studies explicitly addressing care-related as well as maternal-related factors influencing the (non-) detection of IUGR by conducting comprehensive interviews with mothers and private practice-based gynecologists. Over the last 15 years there have been substantial technological advances in ultrasonography equipment in gynecological practices; hence there is the need to evaluate whether the detection rates of IUGR in Germany are still as low as previously reported in the late 1990ies. Our study results will contribute to a better understanding of core risk factors for low early detection rates of intrauterine growth restrictions and may support quality development in this important health care sector.

Metabolomic prediction of fetal congenital heart defect in the first trimester

OBJECTIVE

The objective of the study was to identify metabolomic markers in maternal first-trimester serum for the detection of fetal congenital heart defects (CHDs).

STUDY DESIGN

Mass spectrometry (direct injection/liquid chromatography and tandem mass spectrometry) and nuclear magnetic resonance spectrometry-based metabolomic analyses were performed between 11 weeks' and 13 weeks 6 days' gestation on maternal serum. A total of 27 CHD cases and 59 controls were compared. There were no known or suspected chromosomal or syndromic abnormalities indicated.

RESULTS

A total of 174 metabolites were identified and quantified using the 2 analytical methods. There were 14 overlapping metabolites between platforms. We identified 123 metabolites that demonstrated significant differences on a univariate analysis in maternal first-trimester serum in CHD vs normal cases. There was a significant disturbance in acylcarnitine, sphingomyelin, and other metabolite levels in CHD pregnancies. Predictive algorithms were developed for CHD detection. High sensitivity (0.929; 95% confidence interval [CI], 0.92-1.00) and specificity (0.932; 95% CI, 0.78-1.00) for CHD detection were achieved (area under the curve, 0.992; 95% CI, 0.973-1.0).

CONCLUSION

In the first such report, we demonstrated the feasibility of the use of metabolomic developing biomarkers for the first-trimester prediction of CHD. Abnormal lipid metabolism appeared to be a significant feature of CHD pregnancies.

Impact of educational video on critical congenital heart disease screening

OBJECTIVE

To assess the status of pulse oximetry screening and barriers to implementing screening programs.

METHODS

This was a prospective pre-post intervention survey of nurse managers and medical directors of hospital-based birthing centers in Oregon, Idaho, and Southern Washington. The intervention was a 7-minute video demonstrating and discussing pulse oximetry screening for critical congenital heart disease.

RESULTS

Analysis of matched pairs showed a significant increase in the use of pulse oximetry screening during the study period from 52% to 73% (P < .0001). Following implementation of the video, the perception of all queried potential barriers decreased significantly among individuals from hospitals self-identified as nonscreening at baseline. Viewing the educational video was associated with an increase in the percentage of individuals from nonscreening hospitals that rated screening as "very beneficial" (45% vs 90%, P = .0001).

CONCLUSIONS

An educational video was associated with improved opinions of pulse oximetry screening among hospitals not currently screening.

The new 3D/4D based spatio-temporal imaging correlation (STIC) in fetal echocardiography: a promising tool for the future

Congenital heart disease is the commonest congenital anomaly. It is much more common than chromosomal malformations and spinal defects. Its estimated incidence is about 4-13 per 1000 live births. Congenital heart disease is a significant cause of fetal mortality and morbidity. Antenatal diagnosis of congenital heart disease is extremely difficult and requires extensive training and expertise. The detection rate of congenital heart disease is very variable and it ranged from 35 to 86% in most studies. In the light of the above, the introduction of the new 3D/4D based spatio-temporal Image Correlation (STIC) is highly welcomed to improve antenatal detection of congenital heart disease. STIC is an automated device incorporated into the ultrasound probe and has the capacity to perform slow sweep to acquire a single 3-dimensional (3D) volume. This acquired volume is composed of a great number of 2-dimension (2D) frames. This volume can be analyzed and reanalyzed as required to demonstrate all the required cardiac views. It also provides the examiner with the ability to review all images in a looped cine sequence. This technology has the ability to improve our ability to examine the fetal heart in the acquired volume and decrease examination time. Using this technique you can share the information and consult colleagues both at your clinical sitting or remotely using the internet.

Evaluation of the fetal heart at 14 to 18 weeks' gestation in fetuses with a screening nuchal translucency greater than or equal to the 95th percentile

OBJECTIVES

The purpose of this study was to determine whether normal fetal cardiac anatomy could be successfully demonstrated and congenital heart disease detected transabdominally at 14 to 18 weeks' gestation in fetuses with a nuchal translucency greater than or equal to the 95th percentile.

METHODS

In this retrospective chart review, grayscale images, Z scores, and Doppler evaluations, including pulsed, color, and spectral Doppler imaging, were reviewed to determine whether fetal heart evaluation findings at 14 to 18 weeks' gestation were normal or abnormal.

RESULTS

Normal cardiac anatomy was successfully evaluated in 32 of 33 normal cases; only an aortic arch and a ductal arch were not successfully visualized in 1 case. Major congenital heart disease was detected prenatally in 4 abnormal cases.

CONCLUSIONS

The fetal heart can be successfully evaluated at an earlier gestational age but may be dependent on the skill of the sonographer and reading physician. Maternal decisions can be made earlier in gestation, before the pregnancy is obvious, and can allow planning for a pregnancy that will need to be delivered at a medical center that has a level 3 nursery.

Performance of different scan protocols of fetal echocardiography in the diagnosis of fetal congenital heart disease: a systematic review and meta-analysis

OBJECTIVE

The rapid progress in fetal echocardiography has lead to early detection of congenital heart diseases. Increasing evidences have shown that prenatal diagnosis could be life saving in certain cases. However, there is no agreement on which protocol is most adaptive diagnostic one. Thus, we use meta-analysis to conduct a pooled performance test on 5 diagnostic protocols.

METHODS

We searched PUBMED, EMBASE, the Cochrane Central Register of Controlled Trials and WHO clinical trails registry center to identify relevant studies up to August, 2012. We performed meta-analysis in a fixed/random-effect model using Meta-disc 1.4. We used STATA 11.0 to estimate the publication bias and SPSS 17.0 to evaluate variance.

RESULTS

We use results from 81 studies in 63 articles to analyze the pooled accuracy. The overall performance of pooled sensitivities of spatiotemporal image correlation (STIC), extend cardiac echography examination (ECEE) and 4 chambers view + outflow tract view + 3 vessels and trachea view (4 CV+OTV+3 VTV) were around 0.90, which was significant higher than that of 4 chambers view + outflow tract view or 3 vessels and trachea view (4 CV+OTV/3 VTV) and 4 chambers view (4 CV). Unfortunately the pooled specificity of STIC was 0.92, which was significant lower than that of other 4 protocols which reached at 1.00. The area under the summary receiver operating characteristic curves value of STIC, ECEE, 4 CV+OTV+3 VTV, 4 CV+OTV/3 VTV and 4 CV were 0.9700, 0.9971, 0.9983, 0.9929 and 0.9928 respectively.

CONCLUSION

These results suggest a great diagnostic potential for fetal echocardiography detection as a reliable method of fetal congenital heart disease. But at least 3 sections view (4 CV, OTV and 3 VTV) should be included in scan protocol, while the STIC can be used to provide more information for local details of defects, and can not be used to make a definite diagnosis alone with its low specificity.

Effectiveness of prenatal screening for congenital heart disease: assessment in a jurisdiction with universal access to health care

BACKGROUND

Neonates with certain forms of severe congenital heart disease (CHD) diagnosed prenatally might have better outcomes in comparison with those diagnosed after birth. The proportion of prenatally detected neonates with severe CHD and the effect of prenatal diagnosis on clinical outcomes have not been previously investigated in Canada.

METHODS

We retrospectively studied infants in Alberta, Canada, who required surgical or catheter intervention for CHD at younger than 1 year of age, between January 2007 and December 2010, and pregnancy terminations affected by CHD.

RESULTS

Of the 374 subjects identified (327 infants, 47 pregnancies with termination), 188 (50%) were detected prenatally. Failure of prenatal diagnosis was associated with anomalies not involving the 4-chamber view on ultrasound (odds ratio, 1.86; 95% confidence interval, 1.48-2.35; P < 0.001) and region of residence (P = 0.04). Prenatal detection was associated with fewer days to hospital admission (P < 0.001), fewer days to surgery (P = 0.003), and greater use of prostaglandins (P = 0.001). Infants diagnosed prenatally who underwent surgery within 15 days of age had higher preductal O2 saturations (P = 0.04), fewer days to admission (P = 0.03), and less frequently required preoperative intubation (P = 0.004), and inotropes (P = 0.001). Pregnancy termination occurred among 49% of fetuses detected before 24 weeks' gestation.

CONCLUSIONS

Only 50% of fetuses and/or neonates with severe CHD managed in Alberta have a prenatal diagnosis. The likelihood of prenatal detection is influenced by the status of the 4-chamber view on ultrasound and the region of maternal residence indicating heterogeneous access to fetal echocardiography within Alberta. Prenatal detection might improve clinical outcomes for neonates with severe CHD.

Transporting newborns with transposition of the great arteries

AIMS

The aim of the study was to examine the prevalence and management of outborn babies with a post-natally confirmed diagnosis of transposition of the great arteries (TGA) requiring transport by the Newborn and Paediatric Emergency Transport Service (NETS), New South Wales during the epoch 1991-2010.

METHOD

A retrospective audit of NETS database and case notes. The physiological status, interventions and any complications encountered from the point of referral to NETS (pre-transport), stabilisation (transport) and subsequent admission to the receiving hospital (post-transport) were evaluated.

RESULTS

One hundred fifty-seven infants with TGA were transported, with an average of eight per year (1:11,598 births). Seven (4%) had an antenatal diagnosis, and 72 (46%) had a post-natal diagnosis prior to referral. Physiological and clinical parameters demonstrated overall clinical stability; however, 47% of the babies had a PaO(2) <30 mmHg, and approximately one-fifth had oxygen saturations <70%. Rates of mechanical ventilation and prostaglandin E(1) administration were approximately 50%. A quarter of transported babies encountered a transport-related event, including one death and two babies for which a decision was reached to forego life-sustaining treatment at the referring hospital.

CONCLUSIONS

Most newborns with TGA remain stable or improve during transport. There is a rate of adverse events; however, this reinforces the need to facilitate delivery where there is ready access to interventional paediatric cardiology services.

Barriers to prenatal detection of congenital heart disease: a population-based study

OBJECTIVE

To evaluate the extent and determinants of missed prenatal detection of congenital heart disease (CHD) in a population-based setting.

METHODS

This was a retrospective cohort study of cases with CHD, excluding minor defects, identified between 1997 and 2007 by a statewide surveillance program. We examined a comprehensive list of potential risk factors for which data were available in the surveillance database from abstracted medical charts. We analyzed the association of fetal, maternal and encounter factors with 1) whether a prenatal ultrasound was performed and 2) prenatal detection of CHD.

RESULTS

CHD was detected prenatally in only 39% of 1474 cases, with no improvement in detection rate over the 10-year period. Among the 97% (n = 1431) of mothers who underwent one or more ultrasound examinations, 35% were interpreted as abnormal; fetal echocardiography was performed in 27% of the entire cohort. Maternal and encounter factors increasing the adjusted odds of prenatal detection included: family history of CHD (OR, 4.3 (95% CI, 1.9-9.9)), presence of extracardiac defects (OR, 2.7 (95% CI, 1.9-3.9)) and ultrasound location i.e. high risk clinic vs clinic (OR, 2.1 (95% CI, 1.3-3.1)). Defects that would be expected to have an abnormal outflow-tract view were missed more often (64%) than were those that would be expected to have an abnormal four-chamber view (42%).

CONCLUSION

The majority of CHD cases over the 10-year study period were missed prenatally and detection rates did not increase materially during that time. The failure to detect CHD prenatally was related to encounter characteristics, specifically involving screening ultrasound examinations, which may be targeted for improvement.

Outcome of fetal echocardiography: a 17 year single-institution experience in Japan

BACKGROUND

The aim of this retrospective study was to evaluate the influence of prenatal diagnosis on perinatal outcomes of congenital heart disease (CHD) over a 17 year period at a single center.

METHODS

The perinatal outcome of CHD in 146 patients diagnosed on fetal echocardiography between 1994 and 2010 were reviewed. The characteristics of 193 neonatal inpatients with CHD treated at the authors' department between 2001 and 2010 were also analyzed; among the inpatients, 61 were diagnosed before birth (prenatal group) and 132 were diagnosed after birth (postnatal group).

RESULTS

Among the 146 patients prenatally diagnosed with CHD, the prenatal mortality, including abortion and stillbirth, decreased from 1994 to 2010. Among the 193 neonatal inpatients, the prenatal group had lower gestational age and bodyweight than the postnatal group. Further, the prenatal group had lower blood pH at admission, but no patient in that group experienced ductal shock, although six patients in the postnatal group did. The average dose of prostaglandin E1 used in duct-dependent CHD was significantly lower in the prenatal group than in the postnatal group (3.4 vs. 4.6 ng/kg per min; P = 0.015).

CONCLUSIONS

Prenatal diagnosis of CHD enables planned labor, prevents ductal shock, and reduces prostaglandin E1 side-effects and medical expenditure.

Early fetal anatomical sonography

Over the past decade, prenatal screening and diagnosis has moved from the second into the first trimester, with aneuploidy screening becoming both feasible and effective. With vast improvements in ultrasound technology, sonologists can now image the fetus in greater detail at all gestational ages. In the hands of experienced sonographers, anatomic surveys between 11 and 14 weeks can be carried out with good visualisation rates of many structures. It is important to be familiar with the normal development of the embryo and fetus, and to be aware of the major anatomical landmarks whose absence or presence may be deemed normal or abnormal depending on the gestational age. Some structural abnormalities will nearly always be detected, some will never be and some are potentially detectable depending on a number of factors.

A nurse-driven algorithm to screen for congenital heart defects in asymptomatic newborns

Routine pulse oximetry screening (POS) performed on asymptomatic newborns after 24 hours of life, but before hospital discharge, may detect critical congenital heart defects (cCHD) when used as an adjunct to physical examination. Timely identification of this small percentage of newborns prompts early intervention and improves outcomes. New-generation, highly accurate pulse oximeters provide a simple, low-risk, low-cost tool to improve detection of potentially lethal cardiac lesions. The purpose of this study was to develop, implement, and test the utility of a nurse-driven algorithm that would support and serve as a guide for detection of cCHD in asymptomatic newborns using POS prior to discharge home from the hospital. Results showed that this collaborative protocol was easily implemented in a community hospital. The universal algorithm enhances POS and clinical examination to identify asymptomatic infants with undiagnosed cCHD prior to discharge from the hospital.

Interobserver agreement in detailed prenatal diagnosis of congenital heart disease by telemedicine using four-dimensional ultrasound with spatiotemporal image correlation

OBJECTIVE

To evaluate the clinical accuracy of four-dimensional (4D) echocardiography in the detailed prenatal diagnosis of congenital heart disease (CHD) in a telemedicine setting.

METHODS

Ten second-trimester spatiotemporal image correlation (STIC) volumes were sent to three observers in different tertiary care centers with expertise in 4D echocardiography. The 10 volumes were selected based on the type of diagnosis to cover a wide spectrum of CHD anomalies, and also included one normal fetal heart. Observers were asked to provide the diagnosis, the postprocessing modalities used and the time spent on examination, and to give a rating of the confidence for the diagnosis on a 5-point Likert scale. They were free to consult other colleagues, including pediatric cardiologists, but were blinded to the prenatal diagnosis and the neonatal outcome. A diagnostic scoring system was used to evaluate different aspects of the heart defects. The results were compared with neonatal echocardiography or postmortem findings ('gold standard').

RESULTS

In two cases all observers correctly diagnosed all details of the volume datasets. The observer with the best performance reached perfect agreement in six cases and nearly perfect agreement in three. The volumes were most frequently studied by sectional planes and were analyzed in a median time of 11.0 (range, 2.5-30.0) min. The median confidence score was 4.0 (range, 1.0-5.0).

CONCLUSIONS

In a telemedicine setting using STIC volumes, fetal cardiac anomalies can be diagnosed correctly by an expert. However, details required for adequate counseling and planning of postnatal care may be missed. STIC by telemedicine is a promising modality, although not accurate enough for exclusive use in clinical decision making regarding treatment, prognosis or termination of pregnancy.

The antenatal detection rate of major congenital heart disease in Scotland

Ultrasonography has been used to detect fetal congenital heart disease since the 1980s, although there has been little uniformity in policy. In the UK, data published for 1993-1995 found an average detection rate of 23.4% with a Scottish rate of 9.6%. At the time of this study, 10 out of the 14 health boards in Scotland were implementing the 16-22-week fetal anomaly scan (FAS). The aims of this study were to determine the rate of antenatal diagnosis of major congenital heart disease (MCHD) throughout Scotland during 1 January to 31 December 2006, to document the regional differences in detection and to determine if implementation of a FAS significantly improved rates. Retrospective data were collected from the centralized Paediatric Cardiac Services in Edinburgh and Glasgow. The database contains information on all infants with cardiac disease in Scotland. All infants requiring cardiac intervention or dying in the first year of life were included. The results showed that the antenatal diagnosis rate for Scotland was 28% (95% CI 21.2%, 34.9%). The Scottish health boards that had implemented the FAS had a significantly higher antenatal detection rate (χ2 test P = 0.037). In conclusion, antenatal detection rate of MCHD varies widely throughout Scotland. Implementation of the FAS has made a significant difference to antenatal diagnosis

Simultaneous real-time imaging of four-chamber and left ventricular outflow tract views using xPlane imaging capability of a matrix array probe

OBJECTIVES

To determine the feasibility and reliability of using xPlane imaging to examine simultaneously the four-chamber and left ventricular outflow tract (LVOT) views in real time, to assess rotation angles from the four-chamber view to the LVOT view, and to investigate factors affecting the angles.

METHODS

In 145 fetuses at 11-37 weeks' gestation, we visualized the four-chamber view in one of three cardiac positions: a subcostal view with the apex at the 3 or 9 o'clock position; an apical view with the apex at the 12 or 6 o'clock position; or a view with the fetal heart apex midway between these two positions. We then used the rotation function of xPlane imaging, using the four-chamber view as the reference plane, to visualize the LVOT view simultaneously in real time on the secondary image plane, on the right side of the split screen, by rotating a reference line from 0° with a rotation step of 5°. The rotation angle necessary for the first appearance of LVOT was recorded as the first rotation angle. The reference line was then rotated until the LVOT was just out of view, and this last rotation angle was recorded as the second rotation angle. The difference between these two angles was recorded as the angle span of the LVOT display. Reliability was assessed by intraclass correlation coefficient (ICC).

RESULTS

Of the 145 fetuses examined, 29 had cardiac defects. Using xPlane imaging, the LVOT was visualized successfully after 14 weeks in 95.1% of cases. The first and second rotation angles varied significantly with cardiac position (P < 0.001); when the fetal heart was examined using a subcostal approach with the apex at the 3 or 9 o'clock position, the first rotation angle was smaller than that at the apical view for normal hearts (20° vs. 50°, P < 0.001). There was also a significant difference for the second rotation angle and for the angle span, between fetuses with and without normal LVOT (P = 0.038 and 0.006, respectively). Regarding intra- and interobserver reliability for measurement of first and second rotation angles, the ICCs were high (range, 0.847-0.980).

CONCLUSION

Using xPlane imaging, it is feasible to examine simultaneously the four-chamber and LVOT views in real time, and measurement of the rotation angles between these two views is reproducible. The rotation angles depend on the position of the fetal heart, and the normality of the LVOT. Proposed algorithms for examination of the fetal heart with three-/four-dimensional ultrasonography may need to be adapted to optimize visualization of the standard planes.

Collaborative study on 4-dimensional echocardiography for the diagnosis of fetal heart defects: the COFEHD study

OBJECTIVE

Congenital anomalies are the leading cause of infant mortality in the United States, and congenital heart defects (CHDs) are the most common type of birth defects. Recently, 4-dimensional ultrasonography (4DUS) with spatiotemporal image correlation (STIC) has been introduced for fetal echocardiography. Accumulating evidence indicates that 4DUS with STIC may facilitate the examination of the fetal heart. Our objectives were to determine the accuracy of 4DUS for the diagnosis of CHDs and the agreement among centers.

METHODS

This study included 7 centers with expertise in 4D fetal echocardiography. Fetuses with and without confirmed heart defects were scanned between 18 and 26 weeks, and their volume data sets were uploaded onto a centralized file transfer protocol server. Intercenter agreement was determined using a κ statistic for multiple raters.

RESULTS

Ninety volume data sets were randomly selected for blinded analysis. Overall, the median (range) sensitivity, specificity, positive and negative predictive values, and false-positive and -negative rates for the identification of fetuses with CHDs were 93% (77%-100%), 96% (84%-100%), 96% (83%-100%), 93% (79%-100%), 4.8% (2.7%-25%), and 6.8% (5%-22%), respectively. The most frequent CHDs were conotruncal anomalies (36%). There was excellent intercenter agreement (κ = 0.97).

CONCLUSIONS

(1) Four-dimensional volume data sets can be remotely acquired and accurately interpreted by different centers. (2) Among centers with technical expertise, 4DUS is an accurate and reliable method for fetal echocardiography.

Single umbilical artery and congenital heart disease in selected and unselected populations

OBJECTIVE

A variable association between single umbilical artery (SUA) and congenital heart disease (CHD) has been reported previously. Discrepancies in the results may be related to the populations studied. In this study we assessed the relationship between SUA and CHD in two well-defined selected and unselected populations.

METHODS

This was a retrospective review of all cases of SUA detected antenatally in a tertiary referral center between 1997 and 2003. Umbilical arteries were routinely identified around the fetal bladder by color-flow Doppler ultrasonography. The unselected population included pregnancies from a well-defined geographical area, delivering in the same hospital. The selected group was referred from other hospitals because of suspected abnormalities or other risk factors. Major CHD was defined as CHD needing postnatal treatment or long-term follow-up.

RESULTS

There were 10 fetuses with major CHD in the selected group: four cases among 25 with extracardiac defects (16%; 95% CI, 4.5-36.1%) and six cases out of 22 with no other abnormalities (27%; 95% CI, 10.7-50.2%; P = 0.35). In the unselected group there were two cases of major CHD, both among the 13 fetuses with extracardiac abnormalities (15%; 95% CI, 2-45%), while there were no major cardiac defects in the 85 fetuses with SUA and no extracardiac abnormalities (0%; 95% CI, 0-4%; P = 0.03).

CONCLUSIONS

The association between SUA and CHD varies dramatically with population selection criteria. The risk for CHD after the detection of SUA in an otherwise apparently normal fetus from an unselected population seems small and may not warrant specialist fetal echocardiography.

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Feasibility of automated 3-dimensional fetal cardiac screening in routine ultrasound practice

OBJECTIVE

The purpose of this study was to prospectively assess the clinical feasibility of an automated 3-dimensional (3D) software tool for extended basic cardiac screening in routine ultrasound practice.

METHODS

During the 2-month study period, all gravidas fitting our inclusion criteria were consecutively included. Cardiac 3D volumes were acquired within the time slot allocated for the usual 2-dimensional fetal examination. All volumes were assessed on their quality, based on display of the 4-chamber view, and on the ability to sufficiently display diagnostic cardiac planes (left ventricular outflow tract [LVOT], right ventricle outflow tract [RVOT], and stomach location) with Sonography-Based Volume Computer-Aided Diagnosis software (SonoVCAD; GE Healthcare, Milwaukee, WI).

RESULTS

Volume acquisition was successful in 107 of 126 cases (85%). For each sonographer, more than 70% of the acquired cardiac volumes were of high or sufficient quality. Separately analyzed, diagnostic planes of the LVOT, RVOT, and stomach location were visible in 62.1%, 81.6%, and 92.2%, respectively. An extended basic fetal cardiac examination based on retrieval of all diagnostic cardiac planes from a single volume using SonoVCAD could be performed in 46.6% of the cases.

CONCLUSIONS

This study shows that cardiac volume acquisition can be incorporated in a routine ultrasound screening program without much difficulty. However, currently, SonoVCAD software still lacks the consistency to be clinically feasible for cardiac screening purposes. Further advances in ultrasound technology and familiarization with 3D ultrasound might improve its performance.

A systematic analysis of the feasibility of four-dimensional ultrasound imaging using spatiotemporal image correlation in routine fetal echocardiography

OBJECTIVES

To investigate the feasibility of incorporating spatiotemporal image correlation (STIC) into a tertiary fetal echocardiography program.

METHODS

During the study period all pregnant women fitting our inclusion criteria were enrolled consecutively. Four sonographers participated in the study, one of whom had substantial previous experience of STIC volume acquisition and three of whom did not. STIC volumes were acquired within the time slot allocated for the usual examination and all attempts were recorded. STIC volumes were assessed on acquisition conditions, the quality (as defined by a checklist of cardiac structures that could be visualized), and the rendering abilities. Furthermore, possible learning effects and the influence of experience with STIC on volume acquisition were studied.

RESULTS

STIC volume acquisition was successful in 75.7% (112/148) of cases in which it was attempted. The more experienced sonographer had a higher success rate in STIC volume acquisition (experienced vs. less experienced, 88.4% vs. 70.5%, P = 0.02). Of all analyzed STIC volumes, 64.8% were of high or sufficient quality. STIC volume quality and rendering ability correlated strongly with the acquisition conditions. High-quality STIC volumes successfully rendered the intracardiac septa in 84.6% of cases. The coronal atrioventricular plane was rendered in 12/26 cases (46.2%).

CONCLUSIONS

This study shows that incorporation of STIC volume acquisition into the daily practice of a tertiary fetal echocardiography program is feasible. Sonographers do not have to be specifically experienced in three- or four-dimensional ultrasound imaging to acquire high-quality STIC volumes. For successful STIC acquisition and subsequent successful analysis, correct acquisition conditions are of major importance. Finally, our results demonstrate that STIC is as susceptible as conventional two-dimensional ultrasound imaging to individual variations and limitations in scanning windows.

Prevalence of congenital heart defects in monochorionic/diamniotic twin gestations: a systematic literature review

OBJECTIVE

Congenital heart defects (CHDs) affect approximately 0.5% of all neonates. Recent literature points to a possible increase in the CHD prevalence among monochorionic/diamniotic (MC/DA) twin gestations. We hypothesized that MC/DA twin pregnancy is a risk factor for CHD.

METHODS

A systematic review of all published English literature was conducted on MEDLINE (Ovid and PubMed) from January 2000 through April 2007 using the medical subject heading terms "congenital heart defect" and "monozygotic twins." Four observational studies were included in the final analysis. Published historical data were used for the population background risk of CHD. Relative risk (RR) estimates with 95% confidence intervals (CIs) were calculated by fixed and random effect models.

RESULTS

We included a total of 40 fetuses with CHDs among 830 fetuses from MC/DA twin gestations. Compared with the population, CHDs were significantly more prevalent in MC/DA twins regardless of the presence of twin-twin transfusion syndrome (TTTS) (RR, 9.18; 95% CI, 5.51-15.29; P < .001). Monochorionic/diamniotic twin gestations affected by TTTS were more likely to be complicated by CHDs than those that did not have TTTS (RR, 2.78; 95% CI, 1.03-7.52; P = .04). Ventricular septal defects were the most frequent heart defects. Pulmonary stenosis and atrial septal defects were significantly more prevalent in pregnancies complicated with TTTS.

CONCLUSIONS

Monochorionic/diamniotic twin gestation appears to be a risk factor for CHDs. Conditions that lead to abnormal placentation may also contribute to abnormal heart development, especially in MC/DA twin pregnancies complicated with TTTS. Fetal echocardiography may be considered for all MC/DA twin gestations because ventricular septal defects and pulmonary stenosis are the most common defects.

A systematic review of the accuracy of first-trimester ultrasound examination for detecting major congenital heart disease

OBJECTIVE

To evaluate the accuracy of first-trimester ultrasound examination in detecting major congenital heart disease (CHD) using a systematic review of the literature.

METHODS

General bibliographic and specialist computerized databases along with manual searching of reference lists of primary and review articles were used to search for relevant citations. Studies were included if a first-trimester ultrasound scan was carried out to detect CHD that was subsequently verified by a reference standard. Data were extracted on study characteristics and quality, and 2 x 2 tables were constructed to calculate sensitivity and specificity.

RESULTS

Ten studies (involving 1243 patients) were suitable for inclusion. Of these, four used transabdominal ultrasonography, four used transvaginal and two used a combination. Pooled sensitivity and specificity were 85% (95% CI, 78-90%) and 99% (95% CI, 98-100%), respectively.

CONCLUSION

Ultrasound examination of the fetus in the first trimester is feasible for accurately detecting major CHD. It may be offered to women at high risk of having children with CHD.

A critical analysis on Italian perinatal mortality in a 50-year span

BACKGROUND

Perinatal mortality rate is used as an indicator of reproductive health worldwide. In western countries, national mortality registers are usually accurate and reliable.

METHODS AND AIMS

We reviewed the data recorded in the past 50 years in Italy on perinatal and infant mortality. Each single class of mortality rate (according to WHO definitions) was assessed on temporal trends allowing a critical speculative analysis, mainly focusing on the last 20 years, in an attempt to evaluate the impact of prenatal diagnosis.

RESULTS

Infant mortality rate (IMR) constantly decreased in the study period whereas early neonatal mortality rate progressively diminished in a 5-year comparison till the early 1990s. Perinatal mortality showed a linear negative trend until the 1980s, after which the decrease steadied at about 23% in the following 5-year period. Infant mortality attributable to congenital anomalies throughout a 20-year span (1980-2000) was steady at about 23% although a progressive reduction in general infant mortality was reported.

CONCLUSIONS

A higher reduction in neonatal and perinatal mortality rate was found before the wide availability of the ultrasonographic prenatal diagnosis and the introduction of the law on voluntary abortion in Italy. Given these data, it seems that advances in neonatal care have improved the infant survival rates more than prenatal diagnosis, whereas obstetric care is linked to a reduction of the early perinatal mortality rate.