Diagnosis of fetal cardiac abnormalities

Psychological distress in parents of children with severe congenital heart disease: the impact of prenatal versus postnatal diagnosis

OBJECTIVE

The purpose of the study was to evaluate coping and psychological functioning of parents of children prenatally or postnatally diagnosed with congenital heart disease.

STUDY DESIGN

Parents of 10 infants prenatally diagnosed by fetal echocardiogram and 7 infants postnatally diagnosed with severe congenital heart disease completed the Brief Symptom Inventory (BSI) at the time of diagnosis, at the time of birth and 6 months after birth. Prenatal and postnatal groups were compared to each other and to BSI norms.

RESULT

Although both groups scored higher than test norms at the time of diagnosis, they did not differ significantly from each other. Six months after birth, the postnatal group scores did not differ from test norms, but the prenatal group scores were still significantly higher than test norms. The severity of the child's heart lesion at diagnosis was related to parental distress levels; parents with children with more severe lesions had higher BSI scores.

CONCLUSION

Results suggest the need to provide parents with psychological support, regardless of the timing of diagnosis. Parents of children with more severe lesions may be at risk for higher levels of psychological distress, particularly over time.

Detection rate of early fetal echocardiography and in utero development of congenital heart defects

OBJECTIVE

The purpose of this study was to evaluate the detection rate of early fetal echocardiography and the in utero development of congenital heart defects (CHD).

METHODS

Cases were selected from all singleton pregnancies between 1997 and 2003 in which detailed fetal 2-dimensional and color-coded Doppler echocardiography was performed in our prenatal unit between 11 weeks' and 13 weeks 6 days' gestation; 2165 cases with complete outcome parameters were analyzed.

RESULTS

During this study period, CHD were diagnosed in 46 fetuses. Between 11 and 13 weeks' gestation, 29 CHD were diagnosed (11 weeks, 9 cases; 12 weeks, 8 cases; and 13 weeks, 12 cases); 9 CHD were found in the second trimester and 2 in the third trimester. The in utero detection rate of fetal echocardiography was 86.96% (n = 40). Six additional CHD (13.04%) were detected postnatally. The spectrum of detected CHD changed with advancing gestational age and was different from the postnatal detected heart defects.

CONCLUSIONS

Early fetal echocardiography is feasible and allows the detection of most CHD. Congenital heart defects vary in appearance at different stages of pregnancy and may evolve in utero with advancing gestational age. Therefore, early fetal echocardiography should always be followed by echocardiography at mid gestation.

Congenital heart defects: natural course and in utero development

BACKGROUND

Most congenital heart defects (CHDs) are diagnosed on targeted prenatal transvaginal (TVS) or transabdominal (TAS) ultrasonography during the early second trimester or at midgestation. Nevertheless, delayed diagnosis in some cardiac malformations still remains despite detailed echocardiographic examination. The present study was conducted to evaluate the evolution of fetal cardiac anomalies and assess their development in utero.

METHODS AND RESULTS

We retrospectively reviewed 22,050 pregnant women who were divided into two groups: 6924 who had initial TVSs at 13 to 16 weeks' gestation, followed by TASs at 20 to 22 weeks, and 15,126 who had initial TASs at 20 to 22 weeks. Both groups were subsequently examined in their third trimester. All newborns were examined by certified pediatricians. CHD was diagnosed in 168 babies: 66 in group A and 102 in group B. In group A, 42 malformations (64%) were detected at the first TVS examination, and 11 (17%) were found during the subsequent TAS. Three additional anomalies (4%) were found during the third trimester, and 10 malformations (15%) were detected postnatally. In group B, 80 malformations (78%) were detected in the initial examination at midtrimester, and an additional 7 (7%) were found in the third trimester, whereas 15 (15%) were diagnosed postnatally. The 10 anomalies (group A, n=3; group B, n=7) that were detected only during the third trimester comprised aortic stenosis (n=2), cardiac rhabdomyoma (n=2), subaortic stenosis (n=1), tetralogy of Fallot (n= 1), aortic coarctation (n=1), sealed foramen ovale (n=1), ventricular septal defects (n=1), and hypertrophic cardiomyopathy (n=1).

CONCLUSIONS

Although most fetal cardiac anomalies are detectable early in gestation, some may evolve in utero at different stages of pregnancy.

Routine prenatal screening for congenital heart disease: what can be expected? A decision-analytic approach

OBJECTIVES

This study assessed the potential impact of fetal ultrasound screening on the number of newborns affected by cardiac anomalies.

METHODS

A decision model was developed that included the prevalence and history of congenital heart disease, characteristics of ultrasound, risk of abortion, and attitude toward pregnancy termination. Probabilities were obtained with a literature survey; sensitivity analysis showed their influence on expected outcomes.

RESULTS

Presently, screening programs may prevent the birth of approximately 1300 severely affected newborns per million second-trimester pregnancies. However, over 2000 terminations of pregnancy would be required, 750 of which would have ended in intrauterine death or spontaneous abortion. Further, 9900 false-positive screening results would occur, requiring referral. Only the sensitivity of routine screening and attitude toward termination of pregnancy appeared to influence the yield substantially.

CONCLUSIONS

The impact of routine screening for congenital heart disease appeared relatively small. Further data may be required to fully assess the utility of prenatal screening.

Advances in fetal echocardiography

Fetal echocardiography is the primary modality for defining and evaluating fetal cardiac status and requires detailed analysis of the cardiac anatomy from numerous views and Doppler interrogation of the intracardiac structures, great vessels, and umbilical artery. Referrals for fetal echocardiography are determined by fetal, maternal, or familial risk factors; however, approximately 50% of neonates diagnosed with a congenital cardiac defect have no risk factor, and most have undergone an obstetrical ultrasound during the pregnancy that did not detect a cardiac defect. Advances in transducer technology have resulted in the development of small high-frequency transvaginal probes that allow fetal cardiac interrogation earlier during gestation. On the horizon is 3-dimensional fetal echocardiography, which provides rapid image acquisition and tremendous computer image reconstruction ability. At present, the computer image data analysis process is lengthy, and several technical limitations must be overcome before 3-dimensional fetal echocardiography becomes the primary modality of fetal cardiac imaging. New Doppler Tissue Imaging using color Doppler energy mapping allows more precise anatomic definition of the fetal endocardium, facilitating diagnosis of small ventricular septal defects. These new advances, along with improved image resolution, provide obstetricians and pediatric cardiologists with more tools and techniques for earlier and more precise detection of fetuses with cardiac defects.

Ultrasound screening for fetal abnormalities

Ultrasound screening for fetal abnormalities is increasingly becoming part of routine antenatal care in Europe and the UK. However, there has been very little formal evaluation of this practice. In this article reports of routine ultrasound screening are reviewed and the advantages and disadvantages discussed. The majority of routine anomaly scanning is done in the second trimester but there may be a case for screening at other times in pregnancy and alternative anomaly screening policies are discussed.

Prenatal diagnosis of congenital heart disease; prospects and problems

Routine fetal echocardiography has been submitted as an antenatal screening test for congenital heart disease despite a wide range of efficacy reported. Hence, evaluation of the variable results of prenatal ultrasound screening programs was pursued. As the studies appeared to have a heterogeneous design, the originally reported figures have been corrected for one plausible prevalence of cardiovascular anomalies. Clinical setting (general hospitals vs. teaching hospitals), case ascertainment (retrospective vs. prospective; follow-up on (suspected) cases only vs. routine follow-up) and length of follow-up (< 1 year vs. a longer period) all have similar effects on the reported yield of cases and sensitivity of the proposed screening test. Notably, a relatively low yield of cases causes a seemingly high sensitivity, whereas a higher yield of cases causes a seemingly low sensitivity. Additional factors of study design, e.g. case definition, diagnostic procedures and appliances used, were usually not described in detail, yet may also have affected the results. Evaluating diagnostic tests apparently demands a rigorous study design to overcome biased results. Furthermore, no sufficient evidence could be found meriting current routine prenatal screening for congenital heart disease.

Temporary iatrogenic fetal tricuspid valve atresia in a case of twin to twin transfusion syndrome

This report describes the sequence of events in the development and subsequent spontaneous resolution of functional tricuspid valve atresia in the donor fetus in a case of twin to twin transfusion syndrome. Fetoscopic laser coagulation of the placental anastomoses was performed at 20 weeks' gestation. Subsequently, there was evidence of increased placental vascular resistance in the donor twin and major impairment of right ventricular function with no forward flow through the tricuspid valve. During the next four weeks, however, there was spontaneous and complete recovery of ventricular function and resolution of the functional tricuspid valve atresia. These findings suggest that alterations in fetal haemodynamics may result in structural cardiac abnormality and may be the precursors of some forms of congenital heart disease.

Screening for fetal cardiac malformations

Images

Screening for congenital heart disease with the four-chamber view of the fetal heart

OBJECTIVE

Our objective was to determine the efficacy of the four-chamber view of the fetal heart in routine ultrasonographic examination as a screening tool for congenital heart defects.

STUDY DESIGN

A prospective cohort study compared the detection rate of congenital heart defects among 5336 pregnant women screened with the ultrasonographic four-chamber view of the fetal heart from 1987 through 1989 with that among 3680 patients examined ultrasonographically without the four-chamber view during the 2 preceding years (1985 through 1986). All patients were followed until delivery or termination of pregnancy, and clinical or autopsy confirmation of prenatal findings were obtained on all cases.

RESULTS

The overall incidence of congenital heart diseases was 5.2 per 1000 (47/9016). During the years 1985 through 1986 15 neonates with congenital heart diseases were identified, seven of which were prenatally diagnosed (sensitivity 43%). During the period 1987 through 1989 a four-chamber view of the fetal heart was obtained in 95% of cases; 32 cases of congenital heart disease occurred, 26 of which were diagnosed antenatally (sensitivity 81%; p = 0.01). Two false-positive diagnoses were made during the second time period, giving a specificity of 99.9%.

CONCLUSION

The four-chamber view of the fetal heart is easily obtained, does not significantly increase the duration of a routine ultrasonographic examination, and has an excellent sensitivity for the identification of congenital heart diseases.

Potential impact of population screening for prenatal diagnosis of congenital heart disease

The potential impact of prenatal screening for the detection of congenital heart disease (CHD) was assessed by prospective analysis of 428 consecutive infant admissions to a supraregional centre; 28 (6.5%) did not have CHD and were excluded from analysis. Of the 400 cases with CDH, 396 (99%) underwent fetal ultrasonography but scanning was performed only before 18 weeks' gestation in 200 (50%). One hundred and forty nine (37%) of all cardiac abnormalities and 149/283 (53%) of severe abnormalities were considered to be detectable prenatally in a screening echocardiographic four chamber view had this technique been used. Prenatal diagnosis of severe CHD actually occurred in only eight (2%) cases and was after 30 weeks' gestation in all. There were 181/347 (52%) of all mothers and 177/253 (70%) of the subgroup with severe abnormalities who expressed an opinion volunteered their preference for termination of pregnancy if mid-trimester diagnosis had been available. Mid-trimester detection of congenital heart disease rarely occurs at present despite fetal ultrasound scanning in almost all pregnancies. More than half of all severe congenital heart defects seen in infancy are potentially detectable by screening. Major training at primary scan level and modification of the timing of existing fetal anomaly scanning would be required for a screening programme to be effective.

The associated anomalies that determine prognosis in congenital omphaloceles

Cogenital abdominal wall defects such as omphaloceles can be recognized by fetal ultrasonography. To determine whether associated anatomic features may be useful in determining fetal prognosis, a retrospective study was performed over a 5-year period. There were 28 cases of omphalocele; 16 were larger than 5 cm and classified as giant, and the remainder were considered small. Eleven of the 12 infants with small omphaloceles survived with minimal neonatal complications. Ten of the 16 infants with giant omphaloceles died because of associated congenital anomalies. These were congenital heart disease, central nervous system malformations, and diaphragmatic hernias. This review suggests that the prognosis is good when a prenatal diagnosis of giant omphalocele is made and careful fetal ultrasonography, including echocardiography, does not identify heart, central nervous system, or diaphragmatic malformations, even when there is liver herniation into the omphalocele.