Effect of prenatal screening on trends in perinatal mortality associated with congenital anomalies before and after the introduction of prenatal screening: A population-based study in the Northern Netherlands

Spectrum of congenital anomalies detected through anatomy ultrasound at a referral hospital in Ghana

BACKGROUND

Africa has a high burden of congenital anomalies due in part to limited preconception care, infections, and environmental exposures. However, the true prevalence of congenital anomalies is unclear because of insufficient access to prenatal diagnostic services. We aimed to determine the rate of congenital anomalies, and characterize the anomalies detected prenatally at a referral hospital in Ghana.

METHODS

We performed a four-year retrospective review of all fetal anomaly ultrasounds performed and congenital anomalies detected from January 1st, 2020, to December 31st, 2023, at Korle Bu Teaching Hospital, Accra, Ghana. Data were extracted from the electronic database on maternal age, gestational age at time of ultrasound, and occupation. Detected congenital anomalies were identified, and each anomaly was categorized by ICD-10 code and EUROCAT classification. Descriptive statistics were performed.

RESULTS

The mean maternal age and median gestational age at the time of ultrasound were 31.1 (SD 6.3) years and 26.9 (IQR 22.5-31.0) weeks, respectively. 3,981 anatomy ultrasounds were performed during the study period, and 7.0% (280/3,981) of fetuses had anomalies. Most (70.7%, 198/280) had anomalies detected in an isolated organ system. Anomalies were most identified in the central nervous system (CNS) (45.0%, 126/280), genitourinary (GU) (28.6%, 80/280), and gastrointestinal (GI) systems (21.8%, 61/280). The most common CNS anomaly identified was ventriculomegaly (70.6%, 89/126), out of which 26.2% (33/126) had severe ventriculomegaly, with an overall detection rate of 0.8% (33/3,981). The most common GU anomalies were congenital hydronephrosis (70.0%, 56/80), and congenital posterior urethral valves (28.8%, 23/80). The most common GI anomalies were exomphalos (49.2%, 30/61), and duodenal atresia (23.0%, 14/61). Unrelated to a specific organ system, 3.2% (9/280) of cases had hydrops and 6.1% (17/280) had an associated soft marker of aneuploidy.

CONCLUSIONS

Our study highlights the substantial burden of congenital anomalies detected through prenatal ultrasound at a tertiary referral center in Ghana, with a notably high detection rate of severe ventriculomegaly. This work underscores the feasibility and importance of performing detailed anatomy ultrasounds in Africa. Beyond the clinical benefit, these data lay the groundwork for studies to identify the underlying causes of high rates of anomalies to inform preventive policy and clinical interventions in low-resource settings.

Public's perception and attitude toward genetic testing in Jazan region

Background

With the advancements in genetic testing, a differentiated evaluation for susceptibility to diseases is becoming applicable to many disorders. Understanding the circumstances and promoting the widespread use of these tests in the Saudi setting requires understanding public opinion and attitudes. This study aimed to determine the perception and attitudes of the public in the Jazan region to genetic testing.

Material and Methods

A cross-sectional survey study of 507 participants was conducted in the Jazan region. The data were collected through an online questionnaire containing demographic information and statements assessing public perceptions and attitudes.

Results

Our findings showed that perspectives toward genetic testing, especially premarital and prenatal testing, are generally positive and consistent with previous research. Approximately 79.1% of the participants had a positive attitude toward supporting a compulsory governmental decision of genetic screening before marriage, and 67.3% were willing to perform such testing in the future. More than half of the participants were willing to allow pregnancy termination if there was a higher probability of genetic disease in the baby. In contrast, only 29.6% agreed with the decision to divorce due to the higher probability of genetic disease in their children. The predictors for a positive attitude to genetic testing were nationality, marital status, and monthly income.

Conclusion

The results of the present study indicate that there are acceptable perspectives and attitudes toward genetic testing, especially premarital and prenatal testing.

Preconception Care Interventions for Adolescents and Young Adults to Prevent Adverse Maternal and Child Health Outcomes: Protocol for an Evidence Gap Map

BACKGROUND

Preconception is the period before a young woman or woman conceives, which draws attention to understanding how her health condition and certain risk factors affect her and her baby's health once she becomes pregnant. Adolescence and youth represent a life-course continuum between childhood and adulthood, in which the prepregnancy phase lacks sufficient research.

OBJECTIVE

The aim of the study is to identify, map, and describe existing empirical evidence on preconception interventions that enhance health outcomes for adolescents, young adults, and their offspring.

METHODS

We will conduct an evidence gap map (EGM) activity following the Campbell guidelines by populating searches identified from electronic databases such as MEDLINE, Embase, CINAHL, and Cochrane Library. We will include interventional studies and reviews of interventional studies that report the impact of preconception interventions for adolescents and young adults (aged 10 to 25 years) on adverse maternal, perinatal, and child health outcomes. All studies will undergo title or abstract and full-text screening on Covidence software (Veritas Health Innovation). All included studies will be coded using the Evidence for Policy and Practice Information (EPPI) Reviewer software (EPPI Centre, UCL Social Research Institute, University College London). Cochrane Risk of Bias tool 2.0 and Assessing the Methodological Quality of Systematic Reviews-2 (AMSTAR-2) tool will be used to assess the quality of the included trials and reviews. A 2D graphical EGM will be developed using the EPPI Mapper software (version 2.2.4; EPPI Centre, UCL Social Research Institute, University College London).

RESULTS

This EGM exercise began in July 2023. Through electronic search, 131,031 publications were identified after deduplication, and after the full-text screening, 18 studies (124 papers) were included in the review. We plan to submit the paper to a peer-reviewed journal once it is finalized, with an expected completion date in May 2024.

CONCLUSIONS

This study will facilitate the prioritization of future research and allocation of funding while also suggesting interventions that may improve maternal, perinatal, and child health outcomes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56052.

Has the introduction of increased genetic prenatal testing affected rates of termination of pregnancy due to fetal abnormality?

OBJECTIVE

Genetic high-resolution analyses and improved diagnostic imaging have impacted the ability to detect fetal disorders. It is unknown if this resulted in an alteration in the number of terminations of pregnancy due to fetal anomalies (TOPFA). The objective was to describe the incidence and indication of TOPFA.

METHODS

A descriptive study based on records from the Regional Abortion Council in the Central Denmark Region from 2008 to 2021 consisting of 1895 TOPFA.

RESULTS

A consistent incidence of TOPFA was observed, accounting for 0.96% of the total births during that period. When examining fetal indications, there was a small increase in the occurrence of genetic aberrations, primarily caused by deletions, duplications, and single nucleotide variations, whereas the number of chromosomal aberrations remained stable. Of 35.5% of the cases with malformations, the central nervous system was the most affected organ system, followed by malformations of the heart 29.6%. Overall, the total number of cases remained stable.

DISCUSSION AND CONCLUSION

Unexpectedly, despite the development of new diagnostic tools, the incidence of TOPFA from 2008 to 2021 remained stable. However, the number of cases with genetic aberrations increased. This may be attributed to increased genetic testing for fetuses with identified malformations, resulting in more accurate diagnoses.

Prevalence and One-Year Survival of Selected Major Congenital Anomalies in Germany: A Population-Based Cohort Study

INTRODUCTION

 Congenital anomalies play an important role in infant mortality worldwide. The present study aims to present the current data on the prevalence rates and the 1-year survival rates for selected major congenital anomalies in Saxony-Anhalt, Germany.

MATERIALS AND METHODS

 The data were collected systematically by the Malformation Monitoring Centre Saxony-Anhalt. Cohort from 2000 to 2017 was retrospectively analyzed to determine the prevalence rates and the survival rates of nine major congenital anomalies. The survival analysis was conducted, including all pregnancy outcomes and various risk factors.

RESULTS

 In total, 1,012 cases of the selected congenital anomalies were registered. The total prevalence rates ranged from 2.5 (congenital diaphragmatic hernia [CDH]) to 5.8 (spina bifida [SB]) per 10,000. The live birth prevalence was lower. In total, 88.3% of live-born cases survived the first year. The 1-year survival rate of all cases, including fetal losses, was merely 61.7%. There was no continual improvement in survival during the study period noted. The 1-year survival rate was 35.7% for "genetic" malformations, 57.6% for "multiple congenital anomalies," and 68.6% for "isolated" cases, with 44.6% for prenatally detected anomalies and 85.2% for postnatally identified anomalies. Gestational age less than 31 weeks and birth weight below 1,000 g affected the survival rate adversely.

CONCLUSION

 The survival rate of infants suffering from congenital anomalies in Saxony-Anhalt is comparable to that reported by national and international studies. Registering all pregnancy outcomes irrespective of whether they result in a live birth, stillbirth, or fetal loss in a malformation register seems to be important as it affects the statistical survival analysis in general.

Decrease in perinatal mortality after closure of obstetric services in a community hospital in Amsterdam, the Netherlands. A retrospective cohort study

OBJECTIVE

To assess differences in adverse maternal and neonatal outcomes before and after closure of a secondary obstetric care unit of a community hospital in an urban district.

STUDY DESIGN

Retrospective cohort study using aggregated data from National Perinatal Registry of the Netherlands (PERINED) in the very urban region of Amsterdam, consisting of data of five secondary and two tertiary hospitals. We assessed maternal and neonatal outcomes in singleton hospital births between 24+0 weeks of gestational age (GA) up to 42+6 weeks. Data of 78.613 births were stratified in two groups: before closure (years 2012-2015) and after closure (2016-2019).

RESULTS

Perinatal mortality decreased significantly from 0.84 % to 0.63 % (p = 0.0009). The adjusted odds ratio (aOR) of the closure on perinatal mortality was 0.73 (95 % CI 0.62-0.87). Both antepartum death (0.46 % vs 0.36 %, p = 0.02) and early neonatal death (0.38 % vs 0.28 %, p = 0.015) declined after closure of the hospital. The number of preterm births decreased significantly (8.7 % vs 8.1 %, p=<0.007) as well as number of neonates with congenital abnormalities (3.2 % vs2.2 %, p=<0.0001). APGAR < 7 after 5 min increased (2.3 % vs 2.5 %, p = 0.04). There was no significant difference in SGA or NICU admission. Postpartum hemorrhage increased significantly from 7.7 % to 8.2 % (p=<0.003). Perinatal mortality from 32 weeks onwards was not significantly different after closure 0.29 % to 0.27 %.

CONCLUSIONS

After closure of an obstetric unit in a community hospital in Amsterdam, there was a significant decrease in perinatal, intrapartum and early neonatal mortality in neonates born from 24+0 onwards. The mortality decrease coincides with a reduction of preterm deliveries. The increasing trend in asphyxia and postpartum hemorrhage is of concern.. Centralization of care and increasing birth volume per hospital may lead to improvement of quality of care. A broad integrated, multidisciplinary maternity healthcare system linked with the social domain can achieve health gains in maternity care for all women.

Impact of a prenatal screening program on the Down syndrome phenotype: An interrupted time series analysis

INTRODUCTION

We hypothesized that children with Down syndrome who were born after the implementation of first-trimester combined screening for trisomy 13, 18, and 21 and a second-trimester ultrasound scan in Denmark would show a milder syndrome phenotype. We investigated the birth biometry, prevalence of congenital malformations, and early childhood morbidity of children with Down syndrome before and after implementation of this screening program.

MATERIAL AND METHODS

A nationwide register-based study of all live born singletons with Down syndrome in Denmark from 1995 to 2018. In interrupted time series analyses, we studied the temporal developments in birth biometry, prevalence of congenital malformations, and early childhood morbidity related to the implementation of a national prenatal screening program.

RESULTS

We included 602 singletons with Down syndrome born before and 308 after implementation of the screening program. Z-scores of birthweight and head circumference increased over time before screening, but this temporal development changed after implementation by -0.05 (95% confidence interval [CI]: -0.11 to 0.01) and -0.05 (95% CI -0.12 to 0.02), respectively. Just after implementation, the prevalence of non-severe congenital heart disease decreased (relative change in odds 0.48 [95% CI: 0.24-0.94]). For severe congenital heart disease, atrioventricular septal defect, and non-heart malformations, this change was 1.16 (95% CI: 0.56-2.41), 0.95 (95% CI: 0.43-2.03), and 0.98 (95% CI: 0.33-2.76), respectively. For all malformations, pre-existing temporal developments did not change following implementation of screening. The implementation was associated with higher odds of admission to a neonatal intensive care unit (relative change 1.98 [95% CI: 0.76-5.26]) and an increased risk of hearing impairment (risk difference 3.4% [95% CI: -0.4% to 7.1%]). In contrast, the implementation was not associated with the incidence of hospital admissions by 2 years of age or with the probability of a thyroid disorder.

CONCLUSIONS

After implementation of a national prenatal screening program, we did not observe a milder Down syndrome phenotype apart from an apparent reduction in the proportion of children with non-severe congenital heart disease; this result is, however, limited by small numbers.

Temporal and geographical variations in survival of children born with congenital anomalies in Europe: A multi-registry cohort study

BACKGROUND

Congenital anomalies are a major cause of perinatal, neonatal and infant mortality.

OBJECTIVES

The aim was to investigate temporal changes and geographical variation in survival of children with major congenital anomalies (CA) in different European areas.

METHODS

In this population-based linkage cohort study, 17 CA registries members of EUROCAT, the European network for the surveillance of CAs, successfully linked data on 115,219 live births with CAs to mortality records. Registries estimated Kaplan-Meier survival at 28 days and 5 years of age and fitted Cox's proportional hazards models comparing mortality at 1 year and 1-9 years of age for children born during 2005-2014 with those born during 1995-2004. The hazard ratios (HR) from each registry were combined centrally using a random-effects model. The 5-year survival conditional on having survived to 28 days of age was calculated.

RESULTS

The overall risk of death by 1 year of age for children born with any major CA in 2005-2014 decreased compared to 1995-2004 (HR 0.68, 95% confidence interval [CI] 0.53, 0.89). Survival at 5 years of age ranged between registries from 97.6% to 87.0%. The lowest survival was observed for the registry of OMNI-Net (Ukraine) (87.0%, 95% CI 86.1, 87.9).

CONCLUSIONS

Survival of children with CAs improved for births in 2005-2014 compared with 1995-2004. The use of CA registry data linked to mortality data enables investigation of survival of children with CAs. Factors such as defining major CAs, proportion of terminations of pregnancy for foetal anomaly, source of mortality data and linkage methods are important to consider in the design of future studies and in the interpretation of the results on survival of children with CAs.

Prenatal diagnosis and pregnancy outcome of major structural anomalies detectable in the first trimester: A population-based cohort study in the Netherlands

BACKGROUND

Prenatal diagnosis of several major congenital anomalies can be achieved in the first trimester of pregnancy.

OBJECTIVE

This study investigates the timing of diagnosis and pregnancy outcome of foetuses and neonates with selected structural anomalies in the Northern Netherlands over a 10-year period when the prenatal screening programme changed significantly, but no first-trimester anatomical screening was implemented.

METHODS

We performed a population-based retrospective cohort study with data from the EUROCAT Northern Netherlands database on pregnancies with delivery or termination of pregnancy for fetal anomaly (TOPFA) date between 2010 and 2019. The analysis was restricted to anomalies potentially detectable in the first trimester of pregnancy in at least 50% of cases, based on previously published data. These included: anencephaly, encephalocele, spina bifida, holoprosencephaly, tricuspid/pulmonary valve atresia, hypoplastic left heart, abdominal wall and limb reduction defects, lethal skeletal dysplasia, megacystis, multiple congenital anomalies. The primary outcome was the timing of diagnosis of each structural anomaly. Information on additional investigations, genetic testing and pregnancy outcome (live birth, TOPFA and foetal/neonatal death) was also collected.

RESULTS

A total of 478 foetuses were included; 95.0% (n = 454) of anomalies were detected prenatally and 5.0% (n = 24) postpartum. Among the prenatally detected cases, 31% (n = 141) were diagnosed before 14 weeks of gestation, 65.6% (n = 298) between 14-22 weeks and 3.3% (n = 15) after 22 weeks. Prenatal genetic testing was performed in 80.4% (n = 365) of cases with prenatally diagnosed anomalies, and the results were abnormal in 26% (n = 95). Twenty-one% (n = 102) of pregnancies resulted in live births and 62.8% (n = 300) in TOPFA. Spontaneous death occurred in 15.9% (n = 76) of cases: in-utero (6.1%, n = 29), at delivery (7.7%, n = 37) or in neonatal life (2.1%, n = 10).

CONCLUSION

Major structural anomalies amenable to early diagnosis in the first trimester of pregnancy are mostly diagnosed during the second trimester in the absence of a regulated first-trimester anatomical screening programme in the Netherlands and are associated with TOPFA and spontaneous death, especially in cases with underlying genetic anomalies.

Prepregnancy overweight and obesity as risk factors for birth defects: a cross-sectional study over a 30-year period

Overweight and obesity are public health problems worldwide despite being modifiable conditions. The association between birth defects and pregestational maternal body mass index is not entirely clear. We aimed to assess the prevalence and estimate the risk of birth defects related to pregestational body mass index and other maternal factors. We explored a 30-year time series database in a cross-section study. We analysed 40,217 cases, among them 2.8% had birth defects. Bivariate analysis showed a higher prevalence of birth defects with increased pre-pregnancy body mass index and in extremes of maternal age, white skin colour, and primiparity. Multivariable logistic regression showed a higher chance of birth defects in women with pre-pregnancy overweight/obesity (OR:1.19 [CI95%:1.01-1.41]), maternal age ≥ 40 years (OR:1.68 [CI95%:1.11-2.54]), and white skin colour (OR:1.44 [CI95%:1.19-1.75]). Maternal weight is a modifiable risk factor that must be considered and addressed in preconception counselling to minimise possible deleterious effects on embryogenesis.IMPACT STATEMENTWhat is already known on this subject? Previous studies have linked some maternal factors with birth defects. However, the association with prepregnancy maternal body mass index is not clear.What do the results of this study add? Our findings provide support for the association of prepregnancy maternal overweight and obesity with birth defects and highlight that BMI is a modified risk factor.What are the implications of these findings for clinical practice and/or further research? Maternal body mass index is a modifiable risk factor, highlighting the importance of preconception counselling for the prevention and possible reduction of factors that increase the risk of birth defects.

Every Mother and Every Fetus Matters: A Positive Pregnant Test = Multiple Offerings of Reproductive Risk Screening for personal, family, and specific obstetrical-fetal conditions

Structured OBJECTIVE: The requirement and need for a focused 'pregnant person -centered' antenatal care process with time for informed consent and shared decision making are important for optimal antenatal care. This commentary focuses on the evidenced -based screening test options and timing as part of the overall 'pregnant person-centered' preconception and antenatal care journey.

METHODS

A structured quality improvement (QI) review (Squire 2.0) was undertaken to examine the appropriate reproductive screening process in the periods of preconception and during pregnancy.

RESULTS

First, evaluated the broader antenatal care structure which, second, enabled the directed reproductive risk screening processes to be offered within an informed consent process. Four international pre-conception and antenatal evidenced-based consensus would routinely offer specific gestational age reproductive risk screening elements: totaling 21 screening elements (preconception 3; 1st trimester 9; 2nd trimester 3; 3rd trimester 4; intrapartum 1; postpartum 1).

CONCLUSION

The best evidenced-based opportunity for comprehensive and collaborative antenatal care with appropriate screening elements requires: single national access healthcare system; expert evidenced-based guideline creation; collaborative maternity care providers based for risk assessment, triage, and management; pregnant person (women) centered care model of maternity care; clearly identified evidenced-based gestational age directed screening elements; international pre-conception and antenatal guideline consensus.