Impact of prenatal diagnosis of transposition of the great arteries on obstetric and early postnatal management

doi:10.1016/j.ejogrb.2008.09.001

European Journal of Obstetrics & Gynecology and Reproductive Biology

Volume 142, Issue 1, January 2009, Pages 18-22

https://doi.org/10.1016/j.ejogrb.2008.09.001 Get rights and content

Abstract

Objectives

A growing percentage of cases of transposition of the great arteries (TGA) are being diagnosed prenatally. A decrease in the percentage of spontaneous deliveries has been reported, but the rate of cesarean section (c-section) in this population has never been studied. Our goal was to determine whether prenatal diagnosis affects delivery and immediate neonatal management of TGA neonates.

Study design

A series of 121 TGA arterial switch candidates were included over a 6-year period. Variables on delivery, clinical status at ICU admission, arrival time and atrial septostomy were recorded retrospectively. Comparisons between the two groups were made by Student's t or Chi-squared test.

Results

A cohort of 121 patients was enrolled (48 prenatal and 73 postnatal diagnoses). Induced delivery and c-section were more frequent in the prenatal (54.1% and 31%) than in the postnatal diagnosis group (19.4% and 8%; p < 0.0002 and p < 0.001, respectively).

The mean interval between birth and ICU admission was 2 h 30 min in the prenatal compared to 26 h in the postnatal diagnosis group (p < 0.001). Arrival times were similar in both groups. Atrial septostomy by umbilical route was more often feasible in the prenatal (81%) than in the postnatal diagnosis group (51%; p < 0.001), with a higher rate of failure in the latter.

Conclusion

Prenatal awareness of TGA was associated with a higher percentage of induced deliveries and a major increase in the rate of c-section, without any impact on the newborn except easier umbilical atrial septostomy and earlier ICU admission.

Introduction

It is now accepted that prenatal diagnosis of transposition of the great arteries (TGA) decreases pre-operative morbidity and mortality [1], [2]. Optimal management involves delivering the neonate in close proximity to a pediatric cardiologic center, so as to enable prompt atrial septostomy in cases of severe hypoxia [3]. Delivery itself remains subject to maternal and fetal conditions independent of fetal cardiopathy. However, a decrease in the rate of spontaneous delivery after prenatal diagnosis of cardiopathy has also been reported [4], but remains to be clearly explained, while the incidence of cesarean section (c-section) has never been studied in this population. The aim of the present study was to determine whether prenatal diagnosis impacts delivery and immediate postnatal management in cases of TGA.

Section snippets

Population

Patients with TGA that were candidates for an arterial switch, admitted to our institution between 1 January 2000 and 31 December 2005, were included in this study. Data from the obstetric and pediatric charts were reviewed. Patients with cardiac anomalies other than atrial septal defect, ventricular septal defect or coarctation were excluded. Prenatal charts could not be obtained for 5 patients (2 in the prenatal and 3 the postnatal diagnosis group) living outside the local area, and these

Cohort variables

Forty-eight of the 121 patients enrolled had prenatal and 73 postnatal diagnosis. Several had additional minor anomalies such as ventricular septal defect or aortic coarctation (respectively, 43 patients (18 in the prenatal and 25 in the postnatal diagnosis group) and 4 patients (1 in the prenatal and 3 in the postnatal diagnosis group)). There were no significant inter-group differences.

The rate of prenatal diagnosis of TGA increased from 10% in 2000 to 58% in 2005 (Fig. 1; χ² 10.51, d.f. 5; p =

Discussion

Prenatal detection of TGA has an impact on delivery variables, with a lower rate of spontaneous labor and, particularly, a higher rate of cesarean section. Induction of labor was 2.5 times as frequent when cardiopathy was diagnosed prenatally. Moreover, labor was induced 1.5 weeks earlier in the prenatal than in the postnatal diagnosis group, associated with predictably lower birth weight. As the two groups did not differ for these variables in case of spontaneous delivery, earlier induction

Conclusion

The present study found that increased detection of TGA in fetuses alters the management of delivery, with more frequent induction and cesarean section and earlier induced delivery. We failed to demonstrate that this change in obstetric management had any rationale or positive impact for the newborn, except for the feasibility of atrial septostomy. The higher rate of cesarean section, on the other hand, may have a negative impact on mothers’ long-term health, and this issue needs further

Acknowledgement

Patrice Bouvagnet is actively supported by the Renaud Febvre Foundation.

References (15)

B.A. Johnson et al.
Delivery room and early postnatal management of neonates who have prenatally diagnosed congenital heart disease
Clin Perinatol
(2005)
M.A. Van Ham et al.
Maternal consequences of caesarean section. A retrospective study of intra-operative and postoperative maternal complications of caesarean section during a 10-year period
Eur J Obstet Gynecol Reprod Biol
(1997)
R.K. Kumar et al.
Comparison of the outcome when hypoplastic left heart syndrome and transposition of the great arteries are diagnosed prenatally versus when diagnosis of these conditions is made only postnatally
Am J Cardiol
(1999)
L.L. Simpson
Screening for congenital heart disease
Obstet Gynecol Clin North Am
(2004)
A. Chantepie et al.
Preoperative mortality in transposition of the great vessels
Arch Pediatr
(2000)
L.M. Berry et al.
Premature “closing” of the foramen ovale in transposition of the great arteries with intact ventricular septum: rare cause of sudden neonatal death
Pediatr Cardiol
(1998)
D. Bonnet et al.
Detection of transposition of the great arteries in fetuses reduces neonatal morbidity and mortality
Circulation
(1999)

There are more references available in the full text version of this article.

Cited by (36)

Decision and economic analysis of hostile abortion laws compared with supportive abortion laws
2023, American Journal of Obstetrics and Gynecology MFM
On June 24, 2022, the US Supreme Court overturned Roe v Wade in Dobbs v Jackson Women's Health Organization. Therefore, several states banned abortion, and other states are considering more hostile abortion laws.
This study aimed to assess the incidence of adverse maternal and neonatal outcomes in the hypothetical cohort where all states have hostile abortion laws compared with the pre-Dobbs v Jackson cohort (supportive abortion laws cohort) and examine the cost-effectiveness of these policies.
This study developed a decision and economic analysis model comparing the hostile abortion laws cohort with the supportive abortion laws cohort in a sample of 5.3 million pregnancies. Cost (inflated to 2022 US dollars) estimates were from a healthcare provider's perspective, including immediate and long-term costs. The time horizon was set to a lifetime. Probabilities, costs, and utilities were derived from the literature. The cost-effectiveness threshold was set to be at $100,000 per quality-adjusted life year. Probabilistic sensitivity analyses using the Monte Carlo simulation with 10,000 simulations were performed to assess the robustness of our results. The primary outcomes included maternal mortality and an incremental cost-effectiveness ratio. The secondary outcomes included hysterectomy, cesarean delivery, hospital readmission, neonatal intensive care unit admission, neonatal mortality, profound neurodevelopmental disability, and incremental cost and effectiveness.
In the base case analysis, the hostile abortion laws cohort had 12,911 more maternal mortalities, 7518 more hysterectomies, 234,376 more cesarean deliveries, 102,712 more hospital readmissions, 83,911 more neonatal intensive care unit admissions, 3311 more neonatal mortalities, and 904 more cases of profound neurodevelopmental disability than the supportive abortion laws cohort. The hostile abortion laws cohort was associated with more cost ($109.8 billion [hostile abortion laws cohort] vs $75.6 billion [supportive abortion laws cohort]) and 120,749,900 fewer quality-adjusted life years with an incremental cost-effectiveness ratio of negative $140,687.60 than the supportive abortion laws cohort. Probabilistic sensitivity analyses suggested that the chance of the supportive abortion laws cohort being the preferred strategy was more than 95%.
When states consider enacting hostile abortion laws, legislators should consider an increase in the incidence of adverse maternal and neonatal outcomes.
Prenatal Diagnosis of Transposition of the Great Arteries Reduces Postnatal Mortality: A Population-Based Study
2020, Canadian Journal of Cardiology
Transposition of the great arteries (TGA) may present as a life-threatening neonatal malformation. Although prenatal detection facilitates the perinatal management, the impact on outcome is controversial.
This study reviewed the differences in prenatal diagnosis of TGA from 2009 to 2014 among the 5 geographic areas in Ontario and compared the management, morbidity, and mortality among neonates with a prenatal (prenatal cohort; n = 70) vs a postnatal (postnatal cohort; n = 76) anomaly diagnosis. Cases were identified from prospective databases of the provincial cardiac tertiary centres and the coroner’s office.
Prenatal TGA detection rates varied significantly among areas (median: 50%; range: 14% to 72%; P = 0.03). Compared with the postnatal cohort, time from birth to tertiary care admission (1.4 vs 10.4 hours, P < 0.001), prostaglandin therapy (0.1 vs 5.3 hours; P < 0.001), balloon atrial septostomy (5.3 vs 14.9 hours; P <0.001), and arterial switch operation (6 vs 9 days, P = 0.002) was significantly shorter in the prenatal cohort. Although other preoperative variables—including the need of ventilation and mechanical support, morbidity score, and lowest pH and preductal oxygen saturations—were comparable, a prenatal diagnosis was associated with improved 1-year survival (odds ratio: 0.108; 95% confidence interval, 0.013-0.88; P = 0.0184).
Prenatal diagnosis of TGA significantly shortened time intervals from birth to neonatal care and surgery and was associated with improved survival. The prenatal detection rate of TGA in Ontario was low (50% or less) outside of Metropolitan Toronto, suggesting the need for new strategies to further improve intraprovincial detection rates.
La transposition des grosses artères (TGA) est une malformation néonatale potentiellement mortelle. Même si sa détection avant la naissance peut faciliter la prise en charge périnatale, son incidence sur l’issue ne fait pas l’unanimité.
Les auteurs ont examiné les différences entre les diagnostics périnataux de TGA posés entre 2009 et 2014 dans cinq régions de l’Ontario et comparé la prise en charge, la morbidité et la mortalité des nouveau-nés chez qui l’anomalie a été diagnostiquée avant la naissance (cohorte prénatale; n = 70) ou après la naissance (cohorte postnatale; n = 76). Les cas relevés proviennent des bases de données prospectives des centres de soins tertiaires en cardiologie provinciaux et du Bureau du coroner.
Les taux de détection de la TGA avant la naissance varient sensiblement d’une région à l’autre (médiane : 50 %; plage : 14 à 72 %; p = 0,03). Le temps écoulé entre la naissance et l’admission dans un centre de soins tertiaires (1,4 vs 10,4 heures, p < 0,001), l’instauration d’un traitement par une prostaglandine (0,1 vs 5,3 heures; p < 0,001), la septostomie auriculaire par ballonnet (5,3 vs 14,9 heures; p < 0,001) et l’intervention de détransposition artérielle (6 vs 9 jours, p = 0,002) était significativement plus court dans la cohorte prénatale que dans la cohorte postnatale. Même si d’autres variables préopératoires étaient comparables, notamment le besoin d’une ventilation artificielle et d’une assistance mécanique, le score de morbidité et les valeurs les plus faibles du pH et de la saturation en oxygène préductale, le diagnostic prénatal a été associé à une meilleure survie à 1 an (rapport de cotes : 0,108; intervalle de confiance à 95 %, 0,013-0,88; p = 0,0184).
Le diagnostic prénatal de TGA a significativement réduit le temps écoulé entre la naissance et les soins néonataux et la chirurgie, et a été associé à une meilleure survie. En Ontario, les taux de détection prénatale de la TGA étaient faibles (50 % ou moins) en dehors de Toronto Métropolitain, ce qui semble indiquer que de nouvelles stratégies s’imposent afin d’améliorer les taux de détection dans la province.
Five-year Experience With Arterial Switch Operation in the First Hours of Life
2017, Seminars in Thoracic and Cardiovascular Surgery
Citation Excerpt :
We were not able to explain this relationship; however, mothers' recovery from cesarean section in prenatally diagnosed patients may contribute to this, too. It is known that prenatal awareness of TGA was associated with a higher percentage of induced deliveries and a major increase in the rate of cesarean section.13 A cohort of 121 patients was studied (48 prenatal and 73 postnatal diagnoses), and it was shown that induced delivery and cesarean section were more frequent in the prenatal (54.1% and 31%) than in the postnatal diagnosis group (19.4% and 8%; P < 0.001 and P < 0.001, respectively).
We assessed morbidity after 2 management strategies for arterial switch operation (ASO) in a single institution: first hours of life surgery and conventional approach. From September 2009 to September 2014, 346 consecutive patients who underwent ASO were enrolled. The study group included 92 patients who underwent ASO in the first 24 hours after birth (group I). The control group consisted of 254 patients who underwent ASO after 24 hours of life in the conventional way (group II). Three outcomes were analyzed: postoperative ventilation time (VT), post-extubation hospital length of stay (peLOS), and a composite morbidity index, defined as postoperative VT + peLOS + occurrence of selected major complications. Overall 30-day survival was 98% (2 [2%] group I vs 5 [2%] group II, P = 1.000). Fifty (13.3%) major complications were observed: 14 (15%) in group I and 36 (15%) in group II (P = 0.635). Although peLOS and morbidity index did not differ significantly between groups, postoperative VT (42 hours [24, 67] vs 27 hours [22, 47], P = 0.008) and total hospital stay were significantly longer in group II (18 days [10, 19] vs 14 days [12, 18]). A median volume of 80 mL (60-100 mL) of autologous umbilical cord blood was collected (80 mL, group 1 vs 60 mL, group II; P = 0.090). Homologous blood cell transfusion was avoided in 70 patients (78%) in group I and in 13 patients (6%) in group II (P < 0.001). Arterial switch operation during the initial 24 hours of life has similar outcomes in view of morbidity and mortality to the conventional approach.
Does prenatal diagnosis modify neonatal management and early outcome of children with esophageal atresia type III?
2015, Journal de Gynecologie Obstetrique et Biologie de la Reproduction
Évaluer l’impact du diagnostic anténatal sur la prise en charge néonatale et le devenir à 1 an des nouveaux-nés suivis pour atrésie de l’œsophage (AO) de type III.
Étude de population issue du registre national des atrésies de l’œsophage avec inclusion de tous les cas d’AO de type III entre 2008 et 2010. Deux groupes ont été constitués : les cas ayant bénéficié d’un dépistage anténatal et ceux dont l’atrésie de l’œsophage a été découverte à la naissance. Une variable composite de morbidité (lâchage de suture, fuite de l’anastomose, sténose œsophagienne) et de mortalité à 1 an a été définie.
Quatre cent huit cas d’atrésie de l’œsophage de type 3 ont été inclus avec un taux de dépistage anténatal de 18,1 %. Le taux de transfert après la naissance était plus faible dans le groupe DAN (32,4 % versus 81,5 %, p < 0,001). Le délai entre la naissance et la première intervention chirurgicale n’était pas différent. La longueur du défect (2 cm vs 1,4 cm, p < 0,001), le taux de gastrostomie (21,6 % versus 8,7 %, p < 0,001) et la durée de séjour en néonatologie étaient plus élevés dans le groupe DAN (47,9j versus 33,6j, p < 0,001). La variable composite était plus élevée dans le groupe diagnostique anténatal (38,7 % vs 26,1 %, p = 0,044).
Les cas diagnostiqués en anténatal ont une morbidité plus élevée liée au type d’atrésie de l’œsophage (défects plus longs). Même si le diagnostic anténatal ne modifie pas la prise en charge néonatale et la survie à 1 an, il permet une information des parents et une préparation de la naissance dans un centre de néonatologie adapté.
Evaluate neonatal management and outcome of neonates with either a prenatal or a post-natal diagnosis of EA type III.
Population-based study using data from the French National Register for EA from 2008 to 2010. We compared children with prenatal versus post-natal diagnosis in regards to prenatal, maternal and neonatal characteristics. We define a composite variable of morbidity (anastomotic esophageal leaks, recurrent fistula, stenosis) and mortality at 1 year.
Four hundred and eight live births with EA type III were recorded with a prenatal diagnosis rate of 18.1%. Transfer after birth was lower in prenatal subset (32.4% versus 81.5%, P < 0.001). Delay between birth and first intervention was not significantly different. Defect size (2 cm vs 1.4 cm, P < 0.001), gastrostomy (21.6% versus 8.7%, P < 0.001) and length in neonatal unit care were higher in prenatal subset (47.9 days versus 33.6 days, P < 0.001). The composite variables were higher in prenatal diagnosis subset (38.7% vs 26.1%, P = 0.044).
Despite the excellent survival rate of EA, cases with antenatal detection have a higher morbidity related to the EA type (longer gap). Even if it does not modify neonatal management and 1-year outcome, prenatal diagnosis allows antenatal parental counseling and avoids post-natal transfer.
Does prenatal diagnosis modify neonatal treatment and early outcome of children with esophageal atresia?
2015, American Journal of Obstetrics and Gynecology
Citation Excerpt :
First, EA does not require an “emergency” surgery at birth, unlike other malformations such as a transposition of the great arteries. In this congenital heart malformation, prenatal diagnosis reduced mortality and morbidity rates, improved the early neonatal treatment, and allowed a Rashkind procedure, if necessary.24,25 In our study, a trend of shorter delays between the birth and the first intervention was observed, but this delay had no impact on the treatment.
Our study aimed at (1) evaluating neonatal treatment and outcome of neonates with either a prenatal or a postnatal diagnosis of esophageal atresia (EA) and (2) analyzing the impact of prenatal diagnosis on outcome based on the type of EA.
We conducted a population-based study using data from the French National Register for infants with EA born from 2008-2010. We compared prenatal, maternal, and neonatal characteristics among children with prenatal vs postnatal diagnosis and EA types I and III. We defined a composite variable of morbidity (anastomotic esophageal leaks, recurrent fistula, stenosis) and death at 1 year.
Four hundred sixty-nine live births with EA were recorded with a prenatal diagnosis rate of 24.3%; 82.2% of EA type I were diagnosed prenatally compared with 17.9% of EA type III (P < .001). Transfer after birth was lower in case of prenatal diagnosis (25.6% vs 82.5%; P < .001). The delay between birth and first intervention did not differ significantly among groups. The defect size was longer among the prenatal diagnosis group (2.61 vs 1.48 cm; P < .001). The composite variables were higher in prenatal diagnosis subset (44% vs 27.6%; P = .003) and in EA type I than in type III (58.1% vs 28.3%; P < .001).
Despite the excellent survival rate of EA, cases with antenatal detection have a higher morbidity rate related to the EA type (type I and/or long gap). Even though it does not modify neonatal treatment and the 1-year outcome, prenatal diagnosis allows antenatal parental counselling and avoids postnatal transfers.
Impact of prenatal diagnosis on the management and early outcome of critical duct-dependent cardiac lesions
2018, Cardiology in the Young

View all citing articles on Scopus

View full text

Impact of prenatal diagnosis of transposition of the great arteries on obstetric and early postnatal management

Abstract

Objectives

Study design

Results

Conclusion

Introduction

Section snippets

Population

Cohort variables

Discussion

Conclusion

Acknowledgement

Clin Perinatol

Eur J Obstet Gynecol Reprod Biol

Am J Cardiol

Obstet Gynecol Clin North Am

Arch Pediatr

Premature “closing” of the foramen ovale in transposition of the great arteries with intact ventricular septum: rare cause of sudden neonatal death

Pediatr Cardiol

Detection of transposition of the great arteries in fetuses reduces neonatal morbidity and mortality

Circulation