Retrospective Analysis Of Referral Indications For Fetal Echocardiography

[Objective]To retrospectively review the characteristics of referral indications for second or third trimester fetal echocardiography,analyze the association between prenatal detection rate of congenital heart disease(CHD)and each referral indication Subgroup analysis was performed in indications with high referral and low yield,and theoretical minimization cost analysis was performed in the fetal cardiac screening of diabetic pregnancies to assess its referral efficiency.Combined with current health care environment and available medical resources in China,evidence of better cardiac screening strategy for fetal echocardiography was provided[Methods]Study subjects were 1036 cases of pregnancies referred for fetal echocardiography at Xinhua Hospital affiliated to Shanghai Jiaotong University from September 2009 to April 2013,152 cases of singleton pregnancies with single umbilical artery(SUA)from September 2009 to February 2014,and 199 cases of diabetic pregnancies from October 2009 to January 2015.Medical records and image data were recorded for all referral patients.Statistic analysis was used to summarize the distribution characteristics of fetal echocardiography referral indications,screen for indications significantly associated with high prenatal detection rate of CHD,and further evaluate individually the indications with high referral and low yield,including intracardiac echogenic focus(IEF),SUA and DM.These pregnancies were divided into groups respectively according to whether they were with other risk factors for CHD or not.The incidence of CHD between referral cases with or without other risk factors for CHD was compared,and the additional information added by specialist fetal echocardiography when the cardiac views were normal during anatomic survey was also assessed.Theoretical minimized cost analysis was performed in diabetic pregnancies,to evaluate the cost and effectiveness of the screening strategy for these referrals[Results]In 1036 cases of referral pregnancies,cases referred because of suspicion of cardiac structural abnormalities during anatomic survey were with significantly increased risk(OR=13.7).On the condition of without other referral indications,the indications of isolated IEF(25.0%),SUA(5.6%)and abnormal maternal blood sugar(8.5%)were with high referral rater,but low yield rate of 0.5%,0.0%and 2.7%respectively.Only one case of occasional premature atrial contraction was found in cases referred for isolated IEF(0.5%,P<0.001).Logistic regression analysis found a negative correlation between isolated IEF and prenatal detection of fetal cardiac abnormalities(OR=0.24).In fetuses with isolated single umbilical artery(iSUA),all cases of major CHD were detectable with four chamber view and outflow tract views during fetal anatomic survey.Three cases were postnatally diagnosed as minor CHD For pregnancies referred for DM,the current cardiac screening strategy of anatomic survey and fetal echocardiography for all diabetic pregnancies,and postnatal echocardiography only for cases with prenatal detection of CHD or even benign findings as indicated,would cost 6343.3 CNY for each prenatal detection of CHD.If fetal echocardiography were performed in diabetic pregnancies with other referral indications and postnatal echocardiography were performed only in cases with prenatal detection of CHD or other benign findings,the cost of each prenatal detection of CHD would decrease to 3205.0 CNY[Conclusions]The four chamber and outflow tract views during second trimester anatomic survey was sufficient for prenatal detection of major CHD,and suspicion of cardiac structural abnormalities was significantly associated with prenatal detection of fetal cardiac abnormalities.IEF was normally considered as a benign variant when it was an isolated prenatal finding,therefore pregnancies with isolated IEF need no further referral for fetal echocardiography.Fetal echocardiography was not necessary for SUA fetus with normal cardiac views during anatomic survey and no other risk factors for CHD.The economic analysis of diabetic pregnancies indicated that,the cardiac screening strategy of selective fetal echocardiography for diabetic pregnancies with other referral indications for fetal echocardiography after fetal anatomic survey and selective postnatal echocardiography only for cases with prenatal cardiac findings,was more cost-effective.