Prenatal diagnosis and the pediatric surgeon: the impact of prenatal consultation on perinatal management.
OBJECTIVE
Pediatric surgeons are increasingly called on by obstetrical colleagues to counsel parents about the implications of a prenatal ultrasound finding. Our understanding of the natural history of many prenatally diagnosed surgical conditions has grown significantly in recent years. Whether prenatal surgical consultation can influence perinatal course had not been investigated.


METHODS
During an 21-month period, 12,865 prenatal ultrasound studies were performed on a total of 4,551 patients, and 221 prenatal surgical consultations were obtained through a newly established fetal treatment program at a tertiary care prenatal diagnostic center. To evaluate the impact of prenatal pediatric surgical consultation on perinatal course, the authors reviewed changes in management including termination of pregnancy, in utero intervention, and altered site, mode, or timing of delivery.


RESULTS
Two hundred twenty-one fetuses were referred for consultation; their 234 congenital anomalies included genitourinary (36%), thoracic (16%), intraabdominal (14.5%), abdominal wall (10.6%), neurological (9%), skeletal (6%), and head and neck (2.5%) defects; 2.5% had tumors and 2.5% were twin pregnancies. Pregnancy was terminated in 9.5% of cases, because of patient request, chromosomal abnormality, or dismal prognosis. In 3.6%, the decision to terminate was changed as a result of consultation. Site of delivery was changed as a result of consultation in 37% to facilitate postnatal evaluation and initiate immediate treatment. Mode of delivery was changed in 6.8% to prevent dystocia, hemorrhage into a tumor, as in sacrococcygeal teratoma, or to provide an emergency airway, as in cervical teratoma. The timing of delivery was changed in 4.5% to avoid further damage to fetal organs in cases of obstructive uropathy, gastroschisis, sacrococcygeal teratoma with high-output failure, and hydrocephalus. Five percent (11) underwent treatment in utero for fetal hydrothorax, obstructive uropathy, twin-twin transfusion syndrome, or lymphangioma. The overall perinatal mortality rate was 2.5%.


CONCLUSIONS
Prenatal pediatric surgical consultation may have a significant impact on the perinatal management of the fetus with a surgically correctable congenital anomaly. Providing obstetric colleagues and families with valuable insight into the surgical management of anomalies allows fetal intervention when appropriate, and delivery in an appropriate setting, by the safest mode of delivery, and at the gestational age appropriate to minimize effects of the anomaly.
Crombleholme
T M
TM
Division of Pediatric Surgery, Tufts University School of Medicine, Boston, MA, USA.
D'Alton
M
M
Cendron
M
M
Alman
B
B
Goldberg
M D
MD
Klauber
G T
GT
Cohen
A
A
Heilman
C
C
Lewis
M
M
Harris
B H
BH
D000032:Abortion, Therapeutic; D001900:Boston / Q000453:epidemiology; D000013:Congenital Abnormalities / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000235:genetics / Q000601:surgery*; D003663:Decision Trees; D036861:Delivery, Obstetric / Q000379:methods; D003951:Diagnostic Errors; D005260:Female; D005315:Fetal Diseases; D006801:Humans; D007226:Infant Mortality; D007231:Infant, Newborn; D017063:Outcome Assessment, Health Care; D010348:Patient Care Team; D018743:Perinatal Care / Q000379:methods*; D011247:Pregnancy; D012017:Referral and Consultation; D012189:Retrospective Studies; D016216:Ultrasonography, Prenatal