Anorectal malformations and pregnancy-related disorders: a registry-based case-control study in 17 European regions

OBJECTIVE

To identify pregnancy-related risk factors for different manifestations of congenital anorectal malformations (ARMs).

DESIGN

A population-based case-control study.

SETTING

Seventeen EUROCAT (European Surveillance of Congenital Anomalies) registries, 1980-2008.

POPULATION

The study population consisted of 1417 cases with ARM, including 648 cases of isolated ARM, 601 cases of ARM with additional congenital anomalies, and 168 cases of ARM-VACTERL (vertebral, anal, cardiac, tracheo-esophageal, renal, and limb defects), along with 13 371 controls with recognised syndromes or chromosomal abnormalities.

METHODS

Multiple logistic regression analyses were used to calculate adjusted odds ratios (ORs) for potential risk factors for ARM, such as fertility treatment, multiple pregnancy, primiparity, maternal illnesses during pregnancy, and pregnancy-related complications.

MAIN OUTCOME MEASURES

Adjusted ORs for pregnancy-related risk factors for ARM.

RESULTS

The ARM cases were more likely to be firstborn than the controls (OR 1.6, 95% CI 1.4-1.8). Fertility treatment and being one of twins or triplets seemed to increase the risk of ARM in cases with additional congenital anomalies or VACTERL (ORs ranging from 1.6 to 2.5). Maternal fever during pregnancy and pre-eclampsia were only associated with ARM when additional congenital anomalies were present (OR 3.9, 95% CI 1.3-11.6; OR 3.4, 95% CI 1.6-7.1, respectively), whereas maternal epilepsy during pregnancy resulted in a five-fold elevated risk of all manifestations of ARM (OR 5.1, 95% CI 1.7-15.6).

CONCLUSIONS

This large European study identified maternal epilepsy, fertility treatment, multiple pregnancy, primiparity, pre-eclampsia, and maternal fever during pregnancy as potential risk factors primarily for complex manifestations of ARM with additional congenital anomalies and VACTERL.

Trends and geographic inequalities in the prevalence of Down syndrome in Europe, 1980-1999

BACKGROUND

EUROCAT is a network of population-based registries for the epidemiologic surveillance of congenital anomalies covering approximately one quarter of births in the European Union. Down syndrome constitutes approximately 8% of cases of registered congenital anomaly in Europe, with over 7000 affected pregnancies in the 15 current member states of the European Union each year. In this paper, we aim to examine trends in the live birth prevalence of Down syndrome in Europe in the light of trends in maternal age and in prenatal diagnosis.

METHODS

Descriptive analysis of data from 24 EUROCAT registries, covering 8.3 million births 1980-99. Cases include live births, stillbirths and terminations of pregnancy following prenatal diagnosis.

RESULTS

Since 1980, the proportion of births to mothers of 35 years of age and over has risen quite dramatically from 8 to 14% for the European Union as a whole, with steeper rises in some regions. By 1995-1999, the proportion of "older" mothers varied between regions from 10% to 25%, and the total prevalence (including terminations of pregnancy) of Down syndrome varied from 1 to 3 per 1000 births. Some European regions have shown a more than twofold increase in total prevalence of Down syndrome since 1980. The proportion of cases of Down syndrome which were prenatally diagnosed followed by termination of pregnancy in 1995-1999 varied from 0% in the three regions of Ireland and Malta where termination of pregnancy is illegal, to less than 50% in 14 further regions, to 77% in Paris. The extent to which terminations of pregnancy were concen trated among older mothers varied between regions. The live birth prevalence has since 1980 increasingly diverged from the rising total prevalence, in some areas remaining approximately stable, in others decreasing over time.

CONCLUSION

The rise in average maternal age in Europe has brought with it an increase in the number of pregnancies affected by Down syndrome. The widespread practice of prenatal screening and termination of pregnancy has in most of the regions covered by EUROCAT counteracted the effect of maternal age in its effect on live birth prevalence. Under the joint influences of maternal age and prenatal screening the pattern of geographic inequalities in Down syndrome live birth prevalence in Europe has also been changed.

Prenatal detection of congenital renal malformations by fetal ultrasonographic examination: an analysis of 709,030 births in 12 European countries

The study was performed to evaluate the prevalence of prenatal ultrasound diagnoses for renal anomalies in 20 registries of 12 European countries, and to compare the different prenatal scanning policies. Standardized data were acquired from 709,030 livebirths, stillbirths, and induced abortions during the study period of 2.5 years and transmitted for central analysis. At least one renal malformation was diagnosed in 1130 infants and fetuses. Prenatal diagnosis (PD) was given in 81.8% of all cases, 29% of these pregnancies were terminated. The highest detection rate was reported for unilateral multicystic dysplastic kidneys with 97% (102/105). An early diagnosis was documented for exstrophy of bladder at a mean gestational age of 18.5 weeks. Dilatations of the upper urinary tract were seen late in pregnancy at 28.3 weeks. Terminations of pregnancies (TOP) were performed in 67% (58/86) of the detected bilateral renal agenesis/dysgenesis, but only 4% of the unilateral multicystic dysplastic renal malformations (4/102). In about 1/3 of the cases, renal malformations are within the category of associated malformations, which include multiple non-syndromal malformations, chromosomal aberrations, and non-chromosomal syndromes. Renal malformations were detected in 2/3 of the associated category by the first prenatal ultrasound scan. Detection rates vary in the different countries of the European community due to diverse policies, ethical, and religious background. Countries with no routine ultrasound show the lowest rates in detection, and termination of pregnancy. Prenatally detected renal malformations should result in a careful examination for further anomalies. Prenatal ultrasound fulfills the needs of screening examinations and is a good tool in detecting lethal and severe renal malformations.

Prenatal diagnosis of severe structural congenital malformations in Europe

OBJECTIVES

To assess at a population-based level the frequency with which severe structural congenital malformations are detected prenatally in Europe and the gestational age at detection, and to describe regional variation in these indicators.

METHODS

In the period 1995-1999, data were obtained from 17 European population-based registries of congenital malformations (EUROCAT). Included were all live births, fetal deaths and terminations of pregnancy diagnosed with one or more of the following malformations: anencephalus, encephalocele, spina bifida, hydrocephalus, transposition of great arteries, hypoplastic left heart, limb reduction defect, bilateral renal agenesis, diaphragmatic hernia, omphalocele and gastroschisis.

RESULTS

The 17 registries reported 4366 cases diagnosed with the 11 severe structural malformations and of these 2300 were live births (53%), 181 were fetal deaths (4%) and 1863 were terminations of pregnancy (43%); in 22 cases pregnancy outcome was unknown. The overall prenatal detection rate was 64% (range, 25-88% across regions). The proportion of terminations of pregnancy varied between regions from 15% to 59% of all cases. Gestational age at discovery for prenatally diagnosed cases was less than 24 weeks for 68% (range, 36-88%) of cases. There was a significant relationship between high prenatal detection rate and early diagnosis (P < 0.0001). For individual malformations, the prenatal detection rate was highest for anencephalus (469/498, 94%) and lowest for transposition of the great arteries (89/324, 27%). Termination of pregnancy was performed in more than half of the prenatally diagnosed cases, except for those with transposition of the great arteries, diaphragmatic hernia and gastroschisis, in which 30-40% of the pregnancies with a prenatal diagnosis were terminated.

CONCLUSION

European countries currently vary widely in the provision and uptake of prenatal screening and its quality, as well as the "culture" in terms of decision to continue the pregnancy. This inevitably contributes to variation between countries in perinatal and infant mortality and in childhood prevalence and cost to health services of congenital anomalies.

[Pre- and postnatal kidney screening compared: an analysis of 34,450 newborn infants of the Mainz model birth register]

Malformations of the internal urogenital system are common. The birth registry "Mainz Model" reflects population-based prevalence of renal malformations, calculates sensitivity rates of the prenatal ultrasonographic findings and demonstrates rates of surgery needed.

METHOD AND MATERIAL

During the study period (1990-2001) all newborns of the area of Mainz were examined according to a standardized procedure including ultrasonography of the kidneys. Pathology reports were reviewed for stillbirth, abortions (> 15.SSW) and induced abortions. Beside these clinical findings, since 1996 (after implementation of a special ultrasonographic malformation screening according to the german maternity guidelines) the results of prenatal as well as postnatal ultrasonographic examinations of the kidney were recorded. All children with pathologic diagnoses of the kidneys were retrospectively analysed. Data about the follow up and surgery if needed, were collected.

RESULTS

During the study period from 1990-2001 34.450 newborns were examined. 407 of the neonates (1.2%) had a malformation of the kidney. During the study period from 1996-2001 13.162 neonates were examined. 194 neonates (1.5%) had pathologic and 225 neonates (2.07%) had controllable findings. The most common diagnoses were supernumerary kidney, hydronephroses und megaureter. 22 neonates (12.8%) underwent surgery. The sensitivity of the prenatal ultrasonography was 36% and the specificity was 99%.

CONCLUSION

Both, the prenatal as well as the postnatal ultrasonographic screening of the kidneys are ingenious examinations. The prenatal examination detects life threatening malformations of the kidneys. The postnatal examination completes early diagnosis of renal defects by uncovering the malformations, which have been missed prenatally. The prevalence of malformations of the kidney is comparable to the one of hip dislocation. We therefore conclude, that ultrasonographic screening of the kidneys is needed.

Malformations in newborn: results based on 30,940 infants and fetuses from the Mainz congenital birth defect monitoring system (1990-1998)

Prevalence rates of birth defects in the Federal Republic of Germany are informative to assess the general background risk of having a child with a birth defect. They provide basic figures to determine temporal and regional prevalence trends, to evaluate and initiate preventive measures and to initiate research projects. To avoid observer, definition and collection bias, active monitoring systems are required. Data collected in the active monitoring system of the Mainz Birth Defects Registry are presented. From 1990-1998, 30,940 live-births, stillbirths and abortions underwent standardized physical and sonographic examinations. Anamnestic data were collected from prenatal care records, maternity files and hospital records. Major malformations were diagnosed in 2144 (6.9%) and mild errors of morphogenesis in 11,104 (35.8%) of all infants. Risk factors associated with the occurrence of major malformations were identified by comparing anamnestic data from infants with and without major malformations. Using multivariate regression models, statistically significant associations were established for 9 risk factors. Causally related risk factors were parents or siblings with malformations, parental consanguinity, more than 3 minor errors of morphogenesis in the proband, maternal diabetes mellitus and ingestion of antiallergic drugs in the first trimester of pregnancy. Conjunctional risk factors were polyhydramnios, oligohydramnios and gestational age <32 weeks at birth. Using these risk factors, populations at risk for the occurrence of major malformation can be identified.

[Pre- and postpartum ultrasound examinations for diagnosis of urogenital abnormalities]

BACKGROUND

The aim of the study was to evaluate prenatal and postpartal sonographic investigations to diagnose congenital uropathies.

PATIENTS/METHODS

The Mainz birth defect monitoring system, the "Mainzer Model", was launched in 1990. Over a period of five years (1/90 to 1/95) 19,028 newborns underwent postpartal sonographic examination. Anamnestic data including prepartal sonographic examination were collected. According to a defined ultrasound criteria list, ultrasound findings were considered normal in 94.8% of the neonates, 4.4% were defined as requiring a follow-up examination and 0.8% were pathological. In the current study we analyzed patients with pathological findings with their pre- and postpartal sonographic investigations as well as their clinical data (urinary tract infections, operative procedures).

RESULTS

In the study group prenatal ultrasonography showed evidence of severe anomalies only in 51 fetuses (32.9%). Surgical correction was required in 39 cases. 20 (51%) have been diagnosed prenatally. 28 patients presented with urinary tract infections. Out of this group only 11 patients have been detected by prenatal ultrasound.

CONCLUSION

In conclusion, postnatal ultrasound is more effective to diagnose anomalies of the urinary tract. To prevent complications i.e. urinary tract infections a neonatal screening program would be valuable.

Evaluation of the prenatal diagnosis of limb reduction deficiencies. EUROSCAN Study Group

Ultrasound scans in the mid-trimester of pregnancy are now a routine part of antenatal care in most European countries. Using data from registries of congenital anomalies a study was undertaken in Europe. The objective of the study was to evaluate prenatal detection of limb reduction deficiencies (LRD) by routine ultrasonographic examination of the fetus. All LRDs suspected prenatally and all LRDs (including chromosome anomalies) confirmed at birth were identified from 20 Congenital Malformation Registers from the following 12 European countries: Austria, Croatia, Denmark, France, Germany, Italy, Lithuania, Spain, Switzerland, The Netherlands, UK and Ukrainia. These registries are following the same methodology. During the study period (1996-98) there were 709,030 births, and 7,758 cases with congenital malformations including LRDs. If more than one LRD was present the case was coded as complex LRD; 250 cases of LRDs with 63 (25.2%) termination of pregnancies were identified including 138 cases with isolated LRD, 112 with associated malformations, 16 with chromosomal anomalies and 38 non chromosomal recognized syndromes. The prenatal detection rate of isolated LRD was 24.6% (34 out of 138 cases) compared with 49.1% for associated malformations (55 out of 112; p<0.01). The prenatal detection of isolated terminal transverse LRD was 22.7% (22 out of 97), 50% (3 out of 6) for proximal intercalary LRD, 8.3% (1 out of 12) for longitudinal LRD and 0 for split hand/foot; for multipli-malformed children with LRD those percentages were 46.1% (30 out of 65), 66.6% (6 out of 9), 57.1% (8 out of 14) and 0 (0 out of 2), respectively. The prenatal detection rate of LRDs varied in relation with the ultrasound screening policies from 20.0% to 64.0% in countries with at least one routine fetal scan.

Prenatal diagnosis of major malformations: quality control of routine ultrasound examinations based on a five-year study of 20,248 newborn fetuses and infants

Antenatal ultrasound screening for birth defects is increasingly becoming a routine procedure of prenatal care. Prenatal detection of malformations and subsequent adjustment of obstetric management are essential for secondary prevention. It is unknown whether ultrasound screening is effective in all pregnant women, or should only be performed in high risk populations. From 1990-1994, 20,248 livebirths, stillbirths and abortions underwent physical and sonographic examinations and anamnestic data were collected. To identify the high risk group, case control analyses of births with one of the 23 selected major malformations (controls) were performed with respect to anamnestic risk factors. All women had at least three routine ultrasound scans. The selected malformations were diagnosed in 298 children; 95 (30.3 per cent) were diagnosed antenatally. Detection rates were: CNS (68.6 per cent), gastro-intestinal tract (42.3 per cent), urinary system (24.1) per cent), heart (5.9 per cent). Complications during pregnancy were calculated as indicators of congenital anomalies: premature labour (< 28 week) OR 4.7 (3.8-5.9), placental insufficiency OR 1.9 (1.1-2.7) and vaginal bleeding OR 1.5 (1.2-1.8), etc. Antenatal routine ultrasound screening is not effective risk populations. Anamnestic risk factors risk factors during pregnancy may be essential indicators for identifying high risk populations. We propose screening of the described high risk pregnancies (about 22 per cent of all pregnancies) to be performed by specially trained and highly experienced ultrasonographers to increase sensitivity rates and benefit cost effectiveness.

[Does maternal obesity increase the risk of fetal abnormalities? Analysis of 20,248 newborn infants of the Mainz Birth Register for detecting congenital abnormalities]

AIM

To investigate the risk of congenital malformations for newborn of obese women (BMI > or = 30) compared with women of average prepregnancy weight.

METHODS

We performed a prospective, population-based case-control study of 20,248 newborn born in the city of Mainz. A total of 1,451 infants (cases) with and 8,088 without congenital malformations (controls) were analysed. The relative risks of associations between obesity and malformations were calculated as odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

The prevalence of malformations in children of obese mothers is 11.1% and thus approximately 4% higher than those of the total study population. There is a significant odds ratio for major malformations (OR 1.3; KI 1.0-1.7). Statistically significant associations were calculated for malformations of the internal urogenital system (OR 1.7; 1.1-2.8), the eyes (OR 5.0; 1.3-20.0) and for orofacial clefts (OR 1.7; 1.1-2.8). Among the specific malformations the highest associations occurred for encephalocele (OR 7.3; 1.1-50.6), common truncus arteriosus (OR 6.3; 1.6-24.8) and Potter sequence (OR 6.3; 1.6-24.8). Adjustment for confounding factors (e.g. maternal diabetes mellitus and age) did not change the odds ratios.

CONCLUSIONS

Our data demonstrate that newborn of obese mothers are at an increased risk for malformations. An adequate prenatal examination of these pregnancies should include ultrasound screening by specially trained ultrasonographers in tertiary units (DEGUM II/DEGUM III) and serum alpha-fetoprotein measurements. Public health campaigns for prevention are advised.

Serial examination of 20,248 newborn fetuses and infants: correlations between drug exposure and major malformations

Maternal medication during the first trimester of pregnancy has been discussed as a risk factor for development of birth defects. The correlation between maternal drug use and major malformations was investigated in a population-based case-control study in Mainz. Over a period of 5 years (1990-1994), 20,248 livebirths, stillbirths, and abortions underwent physical and sonographic examination, and anamnestic data were collected. A total of 1,472 births with congenital anomalies (cases) and 9,682 births without major and minor malformations (controls) were analyzed. We distinguished between 30 different drug categories, which were divided into medication taken continuously (before and during pregnancy; CM) and acute medication (drugs given within the first 3 months of gravidity; AM). Statistically highly-significant results [CM: Odds Ratios (OR) 1.2, Confidence Intervals (CI) 1.1-1.4, P = 0.008; AM: OR 1.2, CI 1.1-1.3, P = 0.008] were established for maternal drug use in correlation to birth defects. For the majority of combinations between drugs and specific malformations no teratogenic risks were found. However, statistically significant associations were recorded for antiallergics and heart anomalies (CM, AM) as well as musculoskeletal anomalies (AM); for bronchodilators and heart anomalies (CM, AM); for antiepileptics and anomalies of the internal urogenital system (CM), as well as cleft palate/cleft lips (AM); for thyroid hormones and anomalies of the nervous system (CM, AM), as well as anomalies of the external urogenital system (CM, AM); for insulin and anomalies of the musculoskeletal system (CM); for digitalis and anomalies of the musculoskeletal system (AM).

The effect of antenatal intravenous immunoglobulin on ascending intrauterine infection after preterm premature rupture of the membranes: a pilot study

Ascending infection is a serious threat in pregnancies complicated by preterm premature rupture of the membranes (PROM). In a controlled randomized prospective pilot study (n = 18) we have evaluated the effect of intravenous IgM enriched immunoglobulin given to the mothers 24-48 hours after preterm PROM in reducing ascending infection. Using a validated infection score from laboratory and clinical data at birth, we found a significant reduction of probable infection in the neonates of the treatment group compared to the control group (p = 0.0022). Histopathological investigation of the placentas, membranes and umbilical cords revealed significantly lower stages and grades of chorioamnionitis in the treatment group (p = 0.036). From these preliminary results we conclude, that intravenous broad spectrum immunoglobulin given antenatally to patients with preterm PROM may reduce ascending infection. However, studies with a much larger cohort of patients are necessary to confirm these preliminary results and to detect potential clinical benefits from this treatment mode.

Differences in the clinical and radiologic patterns of rotavirus and non-rotavirus necrotizing enterocolitis

We analyzed retrospectively 32 successive infants who developed necrotizing enterocolitis (NEC), 13 with rotavirus (RV) infection (RV+) and 19 RV-negative (RV-). All patients showed at least pneumatosis intestinalis. All patients except one had risk factors for perinatal asphyxia. Our study demonstrated significant differences between RV+ NEC and RV- NEC cases: RV+ NEC infants had a higher birth weight and were born at a later gestational age. Oral feeding was started earlier and symptoms developed later and more insidiously in RV+ patients than in RV- NEC babies. Radiology revealed a less severe and more distal colon involvement in RV+ NEC infants, whereas the RV- NEC patients mostly had small intestinal or ileocecal changes and more frequent complications of pneumoportogram and intestinal perforations. These latter infants often had a rapidly deteriorating clinical course; 84% needed surgical treatment. In conclusion RV may be a cause of NEC in susceptible infants. Historic and clinical data and a more distal colonic pneumatosis allow a differentiation of RV+ NEC from other forms of NEC.

Effects of dopamine infusion on plasma catecholamines in preterm and term newborn infants

Newborn infants (21 preterm and 13 term) received dopamine infusions at a low (2.5-3.4 micrograms/kg per min) and/or high (5-10 micrograms/kg per min) infusion rate and changes in plasma catecholamines were monitored. The mean baseline values for dopamine, noradrenaline and adrenaline were between 240 and 560, 125 and 144 and 62 and 82 pg/ml, respectively. During low-rate infusion of dopamine, there was a significant increase in plasma dopamine (20-100 fold), noradrenaline (three- to five-fold) and adrenaline (threefold). Administration of dopamine at the high rate resulted in an even larger increase in the plasma catecholamines (dopamine, 100-300 fold; noradrenaline, seven- to eightfold; adrenaline, four- to sixfold). In a double-log plot, there was a highly significant correlation between the plasma concentrations of dopamine and noradrenaline (r = 0.77; P less than 0.001). In conclusion, infusion of dopamine in term and preterm newborn infants is accompanied by an enhanced sympatho-adrenal tone which may contribute to the cardiovascular effects of dopamine in these patients.

[Hepatitis A, B, CMV, EBV and HIV infections in premature and term newborn infants following polytransfusion]

306 children who received polytransfusion or exchange transfusion between 1979 and 1983 and 104 age-matched controls were re-examined at a median age of 2.9 years for hepatitis A and B, CMV, EBV, and HIV infections. This retrospective study revealed no differences between transfused children and controls. HBsAg and anti-HIV were not detected. Two children were suspected of having hepatitis C. In both groups the incidence of positive CMV and EBV serologies was significantly increased in children from Mediterranean countries. Red cell concentrates were less frequently associated with CMV infection. These results confirm the exclusive recruitment of volunteer donors from a "healthy", mainly rural population and support the preferred use of red cell concentrates in paediatric patients.

Cardiovascular responses to dobutamine determined by systolic time intervals in preterm infants

We investigated the effects of dobutamine therapy on myocardial function in premature infants. Left ventricular performance was assessed by measuring left ventricular systolic time intervals: rate-corrected pre-ejection period (PEPI), rate-corrected left ventricular ejection time (LVETI), and pre-ejection period to left ventricular ejection time ratio (PEP/LVET) which was obtained by echocardiography. Measurements were performed in 17 hemodynamically unstable premature infants who had an elevated PEP/LVET ratio before and 30 min after starting dobutamine infusion (10 micrograms/kg.min). Dobutamine infusion resulted in a significant decrease in PEPI (from 108 +/- 16 [SEM] to 95 +/- 17 msec; p less than .01) and in PEP/LVET ratio (from 0.55 +/- 0.16 [SEM] to 0.45 +/- 0.17; p less than .01), and in a significant increase in LVETI (from 255 +/- 15.7 [SEM] to 264 +/- 16.2 msec; p less than .01). Heart rate increased significantly from 146 +/- 17 (SEM) to 163 +/- 16 beat/min; p less than .01. Mean arterial pressure increased in 12 of 14 infants. These results show that dobutamine enhances left ventricular performance in premature infants who have depressed left ventricular function.

Congenital diastematomyelia in the upper thoracic spine. Diagnostic comparison of CT, CT-myelography, MRI, and US

Diastematomyelia (DM) in the upper thoracic spine is a rare congenital abnormality. The case presented is a comparison of CT, CT myelography, magnetic resonance imaging (MRI), and high resolution ultrasound imaging (US) in a female newborn.

[Results of cardiopulmonary resuscitation in children]

We retrospectively evaluated the outcome from cardiopulmonary resuscitation (CPR) in 149 children of all age groups. Only 7 children experienced ventricular fibrillation. 47 children (31.5%) died immediately. Further 47 children died within 24 hours of their arrest, 24 (16.1%) survived longer than 24 hours after CPR but not until discharge. Only 31 children (20.8%) survived to discharge, 5 with severe neurologic sequelae, attributable to the arrest or resuscitation efforts. Cardiopulmonary arrests in the Pediatric Intensive Care Unit carried the worst prognosis. Better results were obtained out-of-hospital, in the OR or on the pediatric floor. Long-term survival rate did not correlate with age, or type of administered catecholamine. None of the children receiving calcium survived. This large study confirms the poor outcome of CPR in children.