Prenatal Detection of Cardiac Anomalies in Fetuses with Single Umbilical Artery: Diagnostic Accuracy Comparison of Maternal-Fetal-Medicine and Pediatric Cardiologist
Aim. To determine agreement of cardiac anomalies between maternal fetal medicine (MFM) physicians and pediatric cardiologists (PC) in fetuses with single umbilical artery (SUA). Methods. A retrospective review of all fetuses with SUA between 1999 and 2008. Subjects were studied by MFM and PC, delivered at our institution, and had confirmation of SUA and cardiac anomaly by antenatal and neonatal PC follow-up. Subjects were divided into four groups: isolated SUA, SUA and isolated cardiac anomaly, SUA and multiple anomalies without heart anomalies, and SUA and multiple malformations including cardiac anomaly. Results. 39,942 cases were studied between 1999 and 2008. In 376 of 39,942 cases (0.94%), SUA was diagnosed. Only 182 (48.4%) met inclusion criteria. Cardiac anomalies were found in 21% (38/182). Agreement between MFM physicians and PC in all groups combined was 94% (171/182) (95% CI [89.2, 96.8]). MFM physicians overdiagnosed cardiac anomalies in 4.4% (8/182). MFM physicians and PC failed to antenatally diagnose cardiac anomaly in the same two cases. Conclusions. Good agreement was noted between MFM physicians and PC in our institution. Studies performed antenatally by MFM physicians and PC are less likely to uncover the entire spectrum of cardiac abnormalities and thus neonatal follow-up is suggested. 1. Introduction A normally formed umbilical cord contains two umbilical arteries and one umbilical vein. A single umbilical artery (SUA) is the most common anatomical abnormality of the umbilical cord. It is found in 0.08% to 1.90% of all pregnancies [1]. Currently, the most effective method for prenatal screening of congenital anomalies is the second trimester detailed ultrasound study. The study is performed by Maternal-Fetal-Medicine (MFM) physicians and radiologists. When properly performed, ultrasound studies will successfully reveal SUA in most pregnancies. The success rate is affected by the gestational age, maternal abdominal wall thickness, presence of a lower abdominal scar, fetal position, amniotic fluid volume, vessel tortuosity, scanning experience and skill, and lateral resolution of the equipment [2, 3]. SUAs have been associated with fetal aneuploidy, premature delivery, stillbirths, low birth-weight, and multiple congenital anomalies (including cardiac, renal, and musculoskeletal [4–6] structures). Congenital anomalies among fetuses with a SUA have been reported to be as high as 46% [6], with 31% of fetuses with a SUA having a congenital cardiac anomaly [4, 5]. The policy at University Hospitals Case Medical Center, Cleveland, Ohio,
References
[1]
A. Z. Abuhamad, W. Shaffer, G. Mari, J. A. Copel, J. C. Hobbins, and A. T. Evans, “Single umbilical artery: does it matter which artery is missing?” American Journal of Obstetrics and Gynecology, vol. 173, no. 3, pp. 728–732, 1995.
[2]
U. J. Herrmann Jr. and D. Sidiropoulos, “Single umbilical artery: prenatal findings,” Prenatal Diagnosis, vol. 8, no. 4, pp. 275–280, 1988.
[3]
L. M. Hill, D. Wibner, P. Gonzales, and P. Chenevey, “Validity of transabdominal sonography in the detection of a two-vessel umbilical cord,” Obstetrics and Gynecology, vol. 98, no. 5, pp. 837–842, 2001.
[4]
J. S. Chow, C. B. Benson, and P. M. Doubilet, “Frequency and nature of structural anomalies in fetuses with single umbilical arteries,” Journal of Ultrasound in Medicine, vol. 17, no. 12, pp. 765–768, 1998.
[5]
C. Martínez-Payo, A. Gaitero, I. Tamarit, M. García-Espantaleón, and E. I. Goy, “Perinatal results following the prenatal ultrasound diagnosis of single umbilical artery,” Acta Obstetricia et Gynecologica Scandinavica, vol. 84, no. 11, pp. 1068–1074, 2005.
[6]
S. A. Heifetz, “Single umbilical artery. A statistical analysis of 237 autopsy cases and review of the literature,” Perspectives in Pediatric Pathology, vol. 8, no. 4, pp. 345–378, 1984.
[7]
E. Buskens, D. E. Grobbee, I. M. E. Frohn-Mulder et al., “Efficacy of routine fetal ultrasound screening for congenital heart disease in normal pregnancy,” Circulation, vol. 94, no. 1, pp. 67–72, 1996.
[8]
M. Meyer-Wittkopf, S. Cooper, and G. Sholler, “Correlation between fetal cardiac diagnosis by obstetric and pediatric cardiologist sonographers and comparison with postnatal findings,” Ultrasound in Obstetrics and Gynecology, vol. 17, no. 5, pp. 392–397, 2001.
[9]
A. M. Friedman, C. K. L. Phoon, S. Fishman, D. E. Seubert, I. E. Timor-Tritsch, and N. Schwartz, “The utility of fetal echocardiography after an unremarkable anatomy scan,” Obstetrics and Gynecology, vol. 118, no. 4, pp. 921–927, 2011.
[10]
S. Sekhavat, N. Kishore, and J. C. Levine, “Screening fetal echocardiography in diabetic mothers with normal findings on detailed anatomic survey,” Ultrasound in Obstetrics and Gynecology, vol. 35, no. 2, pp. 178–182, 2010.
[11]
A. Strauss, B. Toth, B. Schwab et al., “Prenatal diagnosis of congenital heart disease and neonatal outcome—a six years experience,” European Journal of Medical Research, vol. 6, no. 2, pp. 66–70, 2001.
[12]
N. Trivedi, D. Levy, M. Tarsa et al., “Congenital cardiac anomalies: prenatal readings versus neonatal outcomes,” Journal of Ultrasound in Medicine, vol. 31, no. 3, pp. 389–399, 2012.
D. G. Altman, “Some common problems in medical research,” in Practical Statistics for Medical Research, pp. 397–398, Chapman & Hall, London, UK, 1991.
[15]
D. R. Gossett, M. E. Lantz, and C. A. Chisholm, “Antenatal diagnosis of single umbilical artery: is fetal echocardiography warranted?” Obstetrics and Gynecology, vol. 100, no. 5, pp. 903–908, 2002.
[16]
J. Orie, D. Flotta, and F. S. Sherman, “To be or not to be a VSD,” American Journal of Cardiology, vol. 74, no. 12, pp. 1284–1285, 1994.
[17]
A. Meberg, J. E. Otterstad, G. Froland, S. Sorland, and S. Nitter-Hauge, “Increasing incidence of ventricular septal defects caused by improved detection rate,” Acta Paediatrica, vol. 83, no. 6, pp. 653–657, 1994.
