title: Improving the effectiveness of routine prenatal screening for major congenital heart defects.
abstract: OBJECTIVE
  To evaluate the effectiveness of adding outlet views to the four chamber view in routine prenatal ultrasound screening for major congenital heart defects (CHD) as performed by trained sonographers, and to compare the procedure with current practice.
  
  
  METHODS
  Prospective observational study at a London teaching hospital.
  
  
  METHODS
  9277 women booked at a single institution (80% had first trimester nuchal translucency measurement) due to have routine fetal cardiac screening using the four chamber and outflow tract views at > 18 weeks of gestation.
  
  
  METHODS
  Identification of major CHD in chromosomally normal and abnormal pregnancies antenatally or postnatally.
  
  
  RESULTS
  There were 40 abnormalities (4.3/1000), of which 30 were chromosomally normal (3.3/1000). The overall antenatal detection rate was 75% (95% confidence interval (CI) 59% to 87%) and 70% (95% CI 51% to 85%) for euploid pregnancies. Abnormal cardiac views accounted for 70% of all prenatal diagnoses, 30% of which were made at < or = 18 weeks. The sensitivity of cardiac views during the first scan at > 18 weeks was 52%. Of all patients undergoing nuchal translucency screening, 34 had major CHD, nine with increased nuchal translucency (26.5%). Factors influencing the results of this screening programme were training and audit of operators, adequate equipment for antenatal examination, ease of access, and low threshold for referral to specialised fetal echocardiography.
  
  
  CONCLUSIONS
  Adding ventricular outlet views to the four chamber assessment of the heart at routine fetal anomaly scans at > 18 weeks is the most effective technique to detect CHD prenatally. The success of such a programme depends on an infrastructure committed to continuous in house training of obstetric ultrasonographers coupled with feedback from specialised fetal cardiologists, as well as adequate resource allocation to obstetric hospitals involved with antenatal screening.
authors.affiliation: Fetal Medicine Unit, St George's Hospital Medical School, London, UK. j.carvalho@rbh.nthames.nhs.uk
authors.forename: J S
authors.initials: JS
authors.lastname: Carvalho
authors.forename: E
authors.initials: E
authors.lastname: Mavrides
authors.forename: E A
authors.initials: EA
authors.lastname: Shinebourne
authors.forename: S
authors.initials: S
authors.lastname: Campbell
authors.forename: B
authors.initials: B
authors.lastname: Thilaganathan
mesh_terms: D000293:Adolescent; D000328:Adult; D002869:Chromosome Aberrations; D004452:Echocardiography / Q000379:methods; D005260:Female; D006330:Heart Defects, Congenital / Q000000981:diagnostic imaging* / Q000235:genetics; D006801:Humans; D011247:Pregnancy; D011446:Prospective Studies; D012017:Referral and Consultation; D012680:Sensitivity and Specificity; D016216:Ultrasonography, Prenatal / Q000592:standards*