Editor-in-chief Maria Respondek-Liberska
Polish National Registry for Fetal Cardiac Malformations ( initiated in 2004) was opened for primary practicioners as well as for the referral centers performing or basic fetal heart evaluation or targeted fetal echocardiography. None of the physicians until current era had regular education of fetal cardiology . It was necessary to create an audit - veryfication system, which was provided as a checking each record by the 3 most experienced fetal cardiologists in Poland, using randomised computer system. The aim of this analysis was a retrospective evaluation of „Negatively Verified”
Material and methods: The total number of fetuses in Registry during 2004 and 2013 was 5682 and there were 170 negative verified cases. Every „negative case” was analyzed and qualified to one of five categories: An error in classification of the severity of CHD ; computer mistakes , reported other prenatal problems but not CHD, different interpretation of the images (freezed frames or cine loops) and bad order of the labels of cardiac anomalies.
Results: The percentage of negative verifications was similar every year and total number of negative verification was 2,9% . The main reason for negative was first of all unproper fetal heart classification in 71 cases (42%). In majority the differences in interpretations were minor: but there were 5 huge differences between primary and secondary interpretation.
1) Fetal heart cardiology requires prenatal heart classification instead of pediatric classification
2) Computer mistakes (missing fields, missing diagnoses, lack of freezed frames or cine-loops) shoud be picked up by the system during up-loading of the cases
3) The different interpretation of the images could be used for teaching purpose of fetal cardiology .
This is review of the literature regarding fetal thymus development, its role in immune system, research regarding prenatal thymus evaluation in fetal congenital heart defects, abnormal karyotypes, intrauterine growth restriction. The methods of fetal type measurements both in singelton and multiple pregnancies are discussed and presented.
An example of missed Down syndrome with congenital heart defect by prenatal ultrasound evaluation was presented. A jury of 12 physicians, experts in prenatal ultrasonography and echocardiography were asked in questionare was this malpractice or not.
The answers were very different. The results of the questionaires were discussed with the background to the selected data from Eurocat, from Polish National Prenatal Cardiac Registry, from Polish Registry of Congenital Malformations by 2nd year of life, and financial data of the Polish Prenatal Program in Lodz Region.
Should we increase the cost of screening or the cost of ultrasound and echo training ? Or just provide patients with better knowledge regarding the differences between expertise of primary care obstetricians and experts in referral centers
Four cases of missed prenatal diagnosis by an experienced ultrasonographer and a fetal cardiologist from a tertiary teaching hospital are presented: 3-mm peri-membrane ventricular septal defect; hypoplastic aortic arch requiring prostin infusion after delivery; esophageal atresia with tracheal fistula; and right-sided diaphragmatic hernia. Freezed frames and cine loops of the prenatal ultrasound scans indicated that the missed anomalies were not visible in midgestation, suggesting that in the future, repeat ultrasound scans should be performed before delivery to reduce the occurrence of such diagnostic errors.
Maria Szubert and Maria Respondek-Liberska
Background: Inflammatory markers in prenatal ultrasound are a heterogeneous group of images that can evolve during pregnancy, due to regression or exacerbation of infection in pregnant women.
Objective:The assessment if effective rebalancing of the bacterial flora of the vagina can lead to withdrawal of the symptoms of inflammation in ultrasound examination (US).
Methods: A retrospective pilot study, among pregnant woman admitted to the Department of Prenatal Cardiology ICZMP in 2013-2014 in whom ultrasonographic signs of intrauterine infection were present. Electronic database were searched for key words ”infection, placentitis, tricuspid regurgitation, poly/oligohydramnion, IUGR, CRP, antibiotics, vaginal treatment”. The analysis included 238 patients, 30 received antibacterial vaginal treatment, from 27 patients a complete follow-up (control ultrasound after 10-14 days and data on labor) were obtained.
Results: The average age of patients was 29 years. In 22% of patients tricuspid regurgitation was observed and it was the most commonly recognized marker of infection. Regression of infection signs were observed in 21 patients (77.8%) after 2 weeks of vaginal treatment.
2 patients presented with ultrasound image stabilization, in 3 patients worsening of tricuspid regurgitation or cardiac hypertrophy were detected. Polyhydramnios, the second most common parameter (18.51% of patients) resolved after treatment in all studied patients. The delivery took place an average at 39th week of gestation (SD +/- 1.93).
Conclusions: Effective anti-inflammatory vaginal treatment improved ultrasound images in 21 out of 27 fetuses. These preliminary observations suggesting a beneficial role of the vaginal treatment on inflammatory markers in pregnancy ultrasound require further investigation.
Maria Kornacka and Maria Respondek-Liberska
Prenatal diagnosis and the possibility to detected and diagnose fetal abnormalities or abnormal fetal growth, created a new era in obstetrics and in neonatology. The most difficult problem for neonatologists in current perinatal care is lack of information about prenatal investigation and/or very late incorporation in the process of perinatal care. There is a need to create a special protocol in medical records which unites the obstetrical medical record and neonatal medical record in case of important prenatal findings.
Klaudia Korecka and Maria Respondek-Liberska
Obstruction of the duodenum is the most common intestinal obstruction of the fetus and newborn. A typical symptom of duodenal atresia is the double bubble sign. However, in order to diagnose annular pancreas, it is also required to locate a hyperechogenic band around the double bubble. We analysed the possibility of prenatal differential diagnosis of intestinal atresia, such as duodenal atresia and annular pancreas based on the analysis of two cases examined in the 26th week of pregnancy. This material was analysed by two ultrasonographers (one pediatric surgeon).
Conclusions: "Double bubble" symptom in prenatal sonography is typical of high level intestinal obstruction, but it can occur both in classical duodenal atresia, and in the cases of annular pancreas, and in other rare anomalies. Classic prenatal ultrasound examination using 2D option seems to be insufficient for accurate differential diagnosis.
Maciej Słodki and Maria Respondek-Liberska
Attempts to adapt the classifications of pediatric congenital heart defects (CHD) to prenatal cardiology have been lasting for many years. The paediatric cardiology CHD classifications are mainly based on anatomic details and/or pulmonary blood flow and are not always useful in fetal medicine. Because of these reasons and also many more, adaptation attempts of congenital heart defects of children, from pediatric to prenatal cardiology have not brought desired effects.Clinical course in utero and at delivery can now be predicted, and as a consequence, fetal medicine specialists are being asked to consider the fetus as a patient and the transition to postnatal life is an important part of care. The new prenatal classifications of CHD shows new particular group of CHD, requiring emergent procedure after birth. Thanks to organizing special delivery room with special team of specialist we can much more improve the outcome, especially in severest CHD.
Oskar Sylwestrzak and Maria Respondek-Liberska
Introduction: Ultrasound assessment of fetal heart size (FHS) is widely used and recommended in many guidelines of fetal echocardiography due to its clinical value. The aim of this study was an analysis of some fetal heart measurements: ratio of heart area to chest area (HA/ CA) and transversal diameter of heart (AP) and their correlation to gestational age.
Material and methods: This retrospective study was based on database of records of ultrasound and echocardiographic examinations performed in our unit and included fetuses between 15th and 39th week of gestation with no evidence of heart defect or any abnormality.
Results: 609 ultrasound examinations were analyzed. The mean HA/CA was 0,30 ± 0,015, with no statistical difference between female and male (p>0,05), and seemed to be relatively constant with slight increase with advancing gestational age. The AP diameter in whole group correlated with gestational age (r=0,94) and there was no difference related to the fetuses gender.
Conclusion: The correlation of AP diameter and relative constancy of HA/CA ratio with gestational age presented in our normograms could be used for monitoring fetal development, but also for fetal cardiomegaly assessment.