Achieving Near Universal Prenatal Detection of Congenital Heart Disease (CHD): Dismantle the Silos and Scan the High-Risk Pregnancy Population

The prenatal detection of CHD medical literature abounds with the paraphrased mantra: “We need to improve prenatal diagnosis of CHD; however, the “fact” most conditions occur in a low-risk population limits our ability to achieve high prenatal detection rates.” This mantra is based on the indisputable reality that most often, fetal echocardiography is siloed in a congenital heart center, where the fetal cardiologists wait for moms with possible fetal CHD to be referred. Nevertheless, this paradigm is flawed, as the majority of significant CHD occurs in a high-risk pregnancy population, and by moving the fetal cardiologists to scan the high-risk pregnancy population, the prenatal detection of CHD will increase. Unequivocally, we have shown this alternate paradigm to be true in Nevada [1].

A rough analysis of our current data shows the following. We define those with significant CHD as both those with critical malformations and those with conditions that require later intervention or long-term follow-up. We identified 155 patients (4.7/1000 live births) with significant CHD, live born in Nevada between May 2022 and April 2023. Of the 155, 143 had prenatal care. Of the 143 with prenatal care, 124 (87%) were diagnosed prenatally. All diagnoses we made by fetal cardiologists via comprehensive fetal echocardiography performed in approximately 3,000 pregnant women in one of the state’s maternal-fetal-medicine (MFM) clinics in Reno or Las Vegas. Of the 155 total, 12 mothers had no prenatal care, which included at least one obstetric surveillance fetal ultrasound; however, 6 (50%) of these were high-risk pregnancies defined by a maternal co-morbidly, but they did not receive MFM care for unclear reasons. Of the 143 with prenatal care, 19 did not receive MFM care. Of these 19, 9 (47%) had a high-risk maternal co-morbidity, but did not receive MFM care for unclear reasons. Thus, of the total 155 patients, only 22 (14%) were low-risk pregnancies defined by the lack of a maternal co-morbidity. The other 133 (86%) mothers had high-risk pregnancies defined by a maternal co-morbidity, a fetal co-morbidity, or both.

Nevada has the highest overall state-wide prenatal detection rate of CHD because we have demolished the usual care-based silos and rejected the decades-old mantra “that most CHD occurs in a low-risk population.” Others could follow our lead and, in doing so, improve the relatively static, unacceptable 30-35% national average rate for the prenatal detection of significant CHD. ?

1. Evans WN, Acherman RJ, Restrepo H. Prenatal diagnosis of significant congenital heart disease and elective termination of pregnancy in Nevada. J Matern Fetal Neonatal Med. 2022;35:8761-8766.