The Accuracy and Cost-Effectiveness of Selective Fetal Echocardiography for the Diagnosis of Congenital Heart Disease in Patients with Pregestational Diabetes Stratified by Hemoglobin A1c

Matthew M. Finneran; Courtney A. Ware; Miranda K. Kiefer; Elizabeth O. Buschur; Pamela M. Foy; Stephen F. Thung; Mark B. Landon; Steven G. Gabbe

doi:10.1055/s-0039-1685490

American Journal of Perinatology, Inhaltsverzeichnis

Am J Perinatol 2019; 36(12): 1216-1222
DOI: 10.1055/s-0039-1685490

SMFM Fellowship Series Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Accuracy and Cost-Effectiveness of Selective Fetal Echocardiography for the Diagnosis of Congenital Heart Disease in Patients with Pregestational Diabetes Stratified by Hemoglobin A1c

Matthew M. Finneran

¹Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio

,

Courtney A. Ware

¹Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio

,

Miranda K. Kiefer

¹Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio

,

Elizabeth O. Buschur

²Division of Endocrinology, Diabetes, and Metabolism, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio

,

Pamela M. Foy

¹Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio

,

Stephen F. Thung

¹Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio

,

Mark B. Landon

¹Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio

,

Steven G. Gabbe

¹Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio

› Institutsangaben

Abstract

Objective To evaluate the accuracy of antenatal diagnosis of congenital heart disease (CHD) using screening methods including a combination of elevated hemoglobin A1c, detailed anatomy ultrasound, and fetal echocardiography.

Study Design This is a retrospective cohort study of all pregnancies complicated by pregestational diabetes from January 2012 to December 2016. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated for each screening regimen. The incremental cost-effectiveness ratio (ICER) was calculated for each regimen with effectiveness defined as additional CHD diagnosed.

Results A total of 378 patients met inclusion criteria with an overall prevalence of CHD of 4.0% (n = 15). When compared with a detailed ultrasound, fetal echocardiography had a higher sensitivity (73.3 vs. 40.0%). However, all cases of major CHD were detected by detailed ultrasound (n = 6). Using an elevated early A1c > 7.7% and a detailed ultrasound resulted in a sensitivity and specificity of 60.0 and 99.4%, respectively. The use of selective fetal echocardiography for an A1c > 7.7% or abnormal detailed anatomy ultrasound would result in a 63.3% reduction in cost per each additional minor CHD diagnosed (ICER: $18,290.52 vs. $28,875.67).

Conclusion Fetal echocardiography appears to have limited diagnostic value in women with pregestational diabetes. However, these results may not be generalizable outside of a high-volume academic setting.

Keywords

CHD - hyperglycemia - hemoglobin A1c - pregnancy - screening - fetal anomalies

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References
1 ACOG Committee on Practice Bulletins. ACOG Practice Bulletin No. 201: pregestational diabetes mellitus. Obstet Gynecol 2018; 132 (06) e228-e248
2 Kapoor N, Sankaran S, Hyer S, Shehata H. Diabetes in pregnancy: a review of current evidence. Curr Opin Obstet Gynecol 2007; 19 (06) 586-590
3 Landon MB, Catalano PM, Gabbe SG. Diabetes mellitus complicating pregnancy. In: Gabbe SG, Niebl JR, Galan HL. , et al. Obstetrics: Normal and Problem Pregnancies. 7th ed. Philadelphia, PA: Elsevier; 2016: 862-898
4 Lisowski LA, Verheijen PM, Copel JA. , et al. Congenital heart disease in pregnancies complicated by maternal diabetes mellitus. An international clinical collaboration, literature review, and meta-analysis. Herz 2010; 35 (01) 19-26
5 Nassr AA, El-Nashar SA, Shazly SA, White WM, Brost BC. Expected probability of congenital heart disease and clinical utility of fetal echocardiography in pregnancies with pre-gestational diabetes. Eur J Obstet Gynecol Reprod Biol 2016; 201: 121-125
6 Stümpflen I, Stümpflen A, Wimmer M, Bernaschek G. Effect of detailed fetal echocardiography as part of routine prenatal ultrasonographic screening on detection of congenital heart disease. Lancet 1996; 348 (9031): 854-857
7 Albert TJ, Landon MB, Wheller JJ, Samuels P, Cheng RF, Gabbe S. Prenatal detection of fetal anomalies in pregnancies complicated by insulin-dependent diabetes mellitus. Am J Obstet Gynecol 1996; 174 (05) 1424-1428
8 Lee W, Allan L, Carvalho JS. , et al; ISUOG Fetal Echocardiography Task Force. ISUOG consensus statement: what constitutes a fetal echocardiogram?. Ultrasound Obstet Gynecol 2008; 32 (02) 239-242
9 Smith RS, Comstock CH, Lorenz RP, Kirk JS, Lee W. Maternal diabetes mellitus: which views are essential for fetal echocardiography?. Obstet Gynecol 1997; 90 (4, Pt 1): 575-579
10 Friedman AM, Phoon CKL, Fishman S, Seubert DE, Timor-Tritsch IE, Schwartz N. The utility of fetal echocardiography after an unremarkable anatomy scan. Obstet Gynecol 2011; 118 (04) 921-927
11 Pinto NM, Nelson R, Puchalski M, Metz TD, Smith KJ. Cost-effectiveness of prenatal screening strategies for congenital heart disease. Ultrasound Obstet Gynecol 2014; 44 (01) 50-57
12 Odibo AO, Coassolo KM, Stamilio DM, Ural SH, Macones GA. Should all pregnant diabetic women undergo a fetal echocardiography? A cost-effectiveness analysis comparing four screening strategies. Prenat Diagn 2006; 26 (01) 39-44
13 Shields LE, Gan EA, Murphy HF, Sahn DJ, Moore TR. The prognostic value of hemoglobin A1c in predicting fetal heart disease in diabetic pregnancies. Obstet Gynecol 1993; 81 (06) 954-957
14 Miller E, Hare JW, Cloherty JP. , et al. Elevated maternal hemoglobin A1c in early pregnancy and major congenital anomalies in infants of diabetic mothers. N Engl J Med 1981; 304 (22) 1331-1334
15 Bernard LS, Ramos GA, Fines V, Hull AD. Reducing the cost of detection of congenital heart disease in fetuses of women with pregestational diabetes mellitus. Ultrasound Obstet Gynecol 2009; 33 (06) 676-682
16 Marek J, Tomek V, Skovránek J, Povysilová V, Samánek M. Prenatal ultrasound screening of congenital heart disease in an unselected national population: a 21-year experience. Heart 2011; 97 (02) 124-130
17 Pinto NM, Keenan HT, Minich LL, Puchalski MD, Heywood M, Botto LD. Barriers to prenatal detection of congenital heart disease: a population-based study. Ultrasound Obstet Gynecol 2012; 40 (04) 418-425
18 Rychik J. Hypoplastic left heart syndrome: can we change the rules of the game?. Circulation 2014; 130 (08) 629-631
19 Bonnet D, Coltri A, Butera G. , et al. Detection of transposition of the great arteries in fetuses reduces neonatal morbidity and mortality. Circulation 1999; 99 (07) 916-918
20 Franklin O, Burch M, Manning N, Sleeman K, Gould S, Archer N. Prenatal diagnosis of coarctation of the aorta improves survival and reduces morbidity. Heart 2002; 87 (01) 67-69
21 Tworetzky W, McElhinney DB, Reddy VM, Brook MM, Hanley FL, Silverman NH. Improved surgical outcome after fetal diagnosis of hypoplastic left heart syndrome. Circulation 2001; 103 (09) 1269-1273
22 Karonis T, Scognamiglio G, Babu-Narayan SV. , et al. Clinical course and potential complications of small ventricular septal defects in adulthood: late development of left ventricular dysfunction justifies lifelong care. Int J Cardiol 2016; 208: 102-106
23 Soufflet V, Van de Bruaene A, Troost E. , et al. Behavior of unrepaired perimembranous ventricular septal defect in young adults. Am J Cardiol 2010; 105 (03) 404-407
24 Hu X-J, Ma X-J, Zhao Q-M. , et al. Pulse oximetry and auscultation for congenital heart disease detection. Pediatrics 2017; 140 (04) 1-9
25 Mahle WT, Martin GR, Beekman III RH, Morrow WR. ; Section on Cardiology and Cardiac Surgery Executive Committee. Endorsement of Health and Human Services recommendation for pulse oximetry screening for critical congenital heart disease. Pediatrics 2012; 129 (01) 190-192
26 Gómez O, Martínez JM, Olivella A. , et al. Isolated ventricular septal defects in the era of advanced fetal echocardiography: risk of chromosomal anomalies and spontaneous closure rate from diagnosis to age of 1 year. Ultrasound Obstet Gynecol 2014; 43 (01) 65-71
27 Heirtz BT. Facility fees can change the economic equation. Med Econ 2013; 90 (01) 20
28 Vavolizza RD, Dar P, Suskin B, Moore RM, Stern KWD. Clinical yield of fetal echocardiography for suboptimal cardiac visualization on obstetric ultrasound. Congenit Heart Dis 2018; 13 (03) 407-412

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