Prenatal screening reduces births with serious heart defects

Fewer children are born with major congenital heart disease (CHD) because more of these pregnancies are terminated now that prenatal screening is widespread in Denmark, according to a population-based study.

For the 2,695 pregnancies with major coronary artery disease, the termination of pregnancy (TOP) rate increased from 0.6% before 2004, when prenatal screening was offered only to women with high-risk pregnancies, 39.1% after testing was universally offered free (P

Among cases diagnosed before birth, 57.8% of pregnancies were terminated, reported Rebekka Lytzen, PhD, of the University of Copenhagen, and her colleagues from JAMA Cardiology.

The main results of the study show “that while the incidence of live births decreased significantly, the incidence was stationary when TOPs were included,” Lytzen’s group pointed out.

The live birth rate with coronary artery disease remained constant at 1.22% over the entire study period, but decreased for major coronary artery disease from 0.23% before universal screening (1996-2004) to 0.15 % after (2004-2013). The proportion of major coronary artery disease detected before birth increased from 4.5% to 71.0% (P

The study included a review of a total of 14,688 cases of children (median age 11 years) and fetuses with congenital heart disease (CHD).

More prenatal detection of CHD by screening is a benefit, Alexander Kon, MD, of the University of California, San Diego, noted in an accompanying editorial. Early detection can give families more time to make decisions and more control over whether or not to terminate the pregnancy, as well as improve surgical outcomes and facilitate excellent neonatal palliative care, he wrote. .

“We have become so good at operating on these complex hearts and we have impeccable results with overall mortality even around 1%, so in some cases [it] it depends on the morphology. So we’ve come a long way in how we manage these kids,” Hani Najm, MD, of the Cleveland Clinic in Ohio, said, commenting to MedPage today on the study, in which he did not participate.

But Kon also noted that access to such care is not available to everyone in the United States, especially those who are socioeconomically disadvantaged. For the poorest families, he suggested, the decision to carry a pregnancy to term can be particularly difficult.

In particular, they may encounter “significant pressure to minimize costly treatment” from healthcare professionals who view OPT as a more economical option or from their own socioeconomic circumstances in areas without universal healthcare, noted Kon.

Najm agreed that there were “ethical questions” when considering “the cost of these surgeries is expensive, the chances that these families and their relatives have to come back frequently to visit hospitals and maybe two or three operations , [and] quality of life may not be as normal as other children or children with simple congenital heart disease. »

These issues are “quite complex and difficult,” therefore, Najm said, “each case must be managed independently from the others, depending on the circumstances of the parents and the birth defect itself.”

Healthcare professionals should use all available information, Kon wrote, “to best support families in a nonjudgmental and supportive manner and should understand the range of choices families can reasonably make.”

Going forward, the authors said that greater “centralization of malformation testing” may improve detection rates, and “further studies of major coronary disease outcomes are warranted to prevent ODD in cases with a positive prognosis.

Disclosures

Kon, Lytzen and Najm reported no relevant conflicts of interest.

The study was supported by the Danish Children’s Heart Foundation, the Research Council of the Department of Cardiology, Rigshospitalet, Ville Heise’s Fund, Timber Merchant Johannes Fog’s Foundation, King Christian the Tenth Foundation, Master Carpenter Sophus Jacobsen & Wife Astrid Jacobsen’s Foundation and Mrs. Gudrun Elboth, and born the Døbelin Memorial Fund.