Abstract
Objective
To investigate the structural abnormalities, genetic results, and postnatal clinical outcomes of fetuses with bovine aortic arch (Bovine Aortic Arch, BAA) to provide a basis for prenatal counseling and management.
Methods
A retrospective analysis was conducted on 216 fetuses diagnosed with bovine aortic arch through prenatal ultrasound screening at the First Affiliated Hospital of Anhui Medical University and the No.901 Hospital of the Joint Service of the People’s Liberation Army from January 2019 to February 2023. Their family history of genetic diseases, prenatal screening results, and postnatal follow-up data were collected. The fetuses were divided into an isolated BAA group (n = 192) and a non-isolated BAA group (n = 24). Chromosomal karyotyping and copy number variation (CNV) testing were conducted, and statistical analysis was performed using SPSS 22.0 software.
Results
Of the 216 fetuses with BAA, 192 were isolated BAA (88.89%), and 24 were non-isolated BAA (11.11%). Among the isolated BAA fetuses, only 1 case (0.52%) had chromosomal karyotype and pathogenic CNV abnormalities. Among the non-isolated BAA fetuses, 4 cases (16.67%) had chromosomal or CNV abnormalities, but the overall risk was low. The postnatal outcomes of isolated BAA fetuses were good (99.48%), while 79.17% of non-isolated BAA fetuses had good postnatal outcomes.
Conclusion
Most BAA fetuses are isolated, with a very low incidence of chromosomal abnormalities and pathogenic CNVs, and have good postnatal outcomes. The clinical value of isolated BAA is limited, and invasive prenatal diagnosis is not recommended for low-risk populations. Prenatal screening should focus on the risk of concurrent severe structural anomalies and chromosomal abnormalities.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12884-024-06852-x.
Keywords: Bovine aortic Arch, Prenatal Ultrasound Screening, Fetal structural abnormalities, Chromosomal Karyotype
Background
Bovine aortic arch, commonly abbreviated as BAA, represents the most prevalent variant pattern of the branches of the aortic arch, characterized by the shared origin of the brachiocephalic trunk and the left common carotid artery [1–3]. Typically asymptomatic in adults, BAA is incidentally discovered in head and neck vessel CT scans or postmortem examinations [4–6]. However, with the widespread of antenatal ultrasound screening technology, there is a growing trend in the detection of BAA cases through longitudinal sections of the aortic arch. The reported incidences of BAA in fetuses range from 1.93–27% [1, 7]. The discrepancy may be attributed to variances in detection methods and study populations. Despite the typically benign nature of BAA in adults, its identification and management during fetal development pose considerable challenges. Currently, a lack of widely accepted guidelines complicates antenatal genetic counseling and management. Existing studies on fetal BAA primarily focus on its anatomical characteristics, with few systematically on accompanying structural abnormalities, genetic results, and postnatal clinical outcomes. Therefore, delving into the comprehensive clinical characteristics of fetal BAA is imperative to establish further reliable foundations for antenatal counseling and management.
Material and method
Study subject
This study retrospectively analyzed cases diagnosed with bovine aortic arch (BAA) through cardiac screening by ISUOG guidelines at the First Affiliated Hospital of Anhui Medical University and the No.901 Hospital of the Joint Service of the People’s Liberation Army from January 2019 to February 2023. A total of 8,036 fetuses underwent examination, among which 279 were diagnosed with BAA. Exclusion criteria comprised twin pregnancies, maternal complications with secondary diseases (such as diabetes, thyroid diseases, or autoimmune diseases), and cases lost to follow-up. Accordingly, 63 cases were excluded, resulting in the inclusion of 216 fetuses with BAA. The included gravidas aged between 21 and 51 years, with a gestational age of 20–32 weeks. Detailed information on family history of genetic diseases, three-generation family history, teratogen exposure, and adverse pregnancy history were collected and recorded. Based on antenatal ultrasound results, fetuses with BAA were categorized into isolated and non-isolated groups. Isolated BAA fetuses (n = 192) exhibited BAA as the sole ultrasound finding, while non-isolated ones (n = 24) displayed BAA in conjunction with other abnormalities.
Antenatal screening
Invasive antenatal testing (amniocentesis and umbilical cord blood sampling) was performed on 39 fetuses with BAA, encompassing chromosomal karyotype analysis and copy number variation (CNV) detection (with a threshold above 100Kb), CNV were tested by Copy Number Variation sequencing (CNV-Seq). Meanwhile, 177 BAA fetuses underwent non-invasive prenatal testing, involving screening for Down syndrome and/or non-invasive antenatal detection for fetal chromosome analysis.
Antenatal ultrasound screening
The American GE company’s Voluson E8 and E10 color ultrasound diagnostic instruments, equipped with convex probes ranging from 4.0 to 8.0 MHz and 2.0 to 8.0 MHz. All fetuses have their systems checked in detail according to the ISUOG Practice Guidelines [8]. During fetal heart screening, the probe was positioned near the fetal chest or spine in the sagittal plane, with the ultrasound image near-field depicting the fetal anterior chest wall or the sagittal plane of the spine. The angle was adjusted appropriately to obtain the longitudinal section of the aortic arch until a clear and comprehensive view of the aortic arch and its branches. The direction of the branches was dynamically tracked, and images were retained for screening. The ultrasound diagnostic criteria for fetal BAA: The blood vessels branching from the aortic arch are split into two parts from front to back. The first one serves as the common origin of the brachiocephalic trunk and the left common carotid artery, and the second branch represents the left subclavian artery. The ultrasonic image of a typical bovine bow is shown in the Fig. 1. The diagnosis of any fetal abnormalities was jointly confirmed by two experienced antenatal screening doctors. Meanwhile, fetuses were observed to identify concurrent intra- or extra-cardiac abnormalities.
Fig. 1.
The ultrasound image of BAA fetuse. The longitudinal section of the aortic arch showed the aortic arch and supra-arch branch vessels of BAA fetal. A: Graycale ultrasound image of BAA fetal. B: Color Doppler ultrasound image of BAA fetal. LSA: left subclavian artery, BT: brachiocephalic trunk, LCCA: left common carotid artery, AA: aortic arch, DAO: descending aorta, white arrow: the common origin of the brachiocephalic trunk and the left common carotid artery
Follow-up
The risk of chromosomal abnormalities was assessed by clinical physicians based on antenatal ultrasound diagnosis, non-invasive prenatal testing, or invasive antenatal diagnosis. After communication with gravidas and their families, the decision to continue the pregnancy rested ultimately with gravidas. For those choosing to continue, dynamic follow-up on the growth and development of the fetus with BAA, postnatal outcomes, and postnatal growth and development was conducted until 24 months after birth. They were confirmed by echocardiography after birth. For those selecting termination, autopsy results of the fetus with BAA were tracked and recorded. All pregnant women provided written informed consent for fetal examination, and the study was approved by the First Affiliated Hospital of Anhui Medical University’s Institutional Review Board (PJ2022-08-46).
Statistical analysis
SPSS 22.0 software was employed for statistical analysis. Continuous data were expressed as 
, and categorical data were presented in percentage (%). Group comparisons were conducted using the chi-square test. The choice between Pearson’s chi-square test and Fisher’s test was based on sample size and data distribution. A significance level of P < 0.05 was considered statistically significant.
Result
Incidence rate of BAA fetuses
During the period of January 2019 and February 2023, 8,036 fetuses underwent antenatal ultrasound screening at the author’s hospital. Among them, 279 were diagnosed with BAA, with a detection rate of approximately 3.48% (279/8036).
Other associated structural abnormalities of BAA fetuses
The 216 cases of BAA fetuses consisted of 192 isolated (88.89%, 192/216) and 24 non-isolated (11.11%, 24/216). Non-isolated BAA fetuses with structural abnormalities are summarizde in Table 1. Among non-isolated cases, 16 were associated with intra-cardiac structural abnormalities (66.67%, 16/24), and ventricular septal defect was dominant (29.17%, 7/24); eight cases presented extra-cardiac abnormalities (33.33%, 8/24), among which cleft lip and palate, limb abnormalities, and single umbilical artery possessed a slightly high occurrence, two cases for each (22.22%, 2/8).
Table 1.
Non-isolated BAA fetuses with structural abnormalities
| Non-isolated BAA fetuses(n = 24) | intra-cardiac structural abnormalities(n = 16) | extra-cardiac abnormalities(n = 8) |
|---|---|---|
| ventricular septal defect(n = 7) | cleft lip and palate(n = 2) | |
| aberrant right subclavian artery(n = 6) | foot deformity(n = 2) | |
| Tetralogy of Fallot(n = 2) | single umbilical artery(n = 2) | |
| pulmonary stenosis(n = 1) | choroid plexus cysts(n = 1) | |
| pulmonary sequestration(n = 1) |
Chromosomal karyotype and CNV results of BAA fetuses
The fetal genetic diagnosis process of BAA fetuses is shown in Fig. 2. The detailed information of BAA fetuses with abnormal genetic results is shown in Table 2. Among the 216 BAA fetuses, chromosomal karyotype abnormalities were detected in only one case (0.46%, 1/216), which also exhibited pathogenic CNV abnormalities. The other 215 cases showed normal chromosomal karyotypes (99.54%, 215/216). Four cases had CNV abnormalities but normal chromosomal karyotypes (1.85%, 4/216), including one of pathogenic CNV (0.46%, 1/216), two of benign CNV, and one of clinically uncertain CNV. Among the 192 isolated BAA fetuses, one (0.52%, 1/192) displayed chromosomal karyotype and pathogenic CNV abnormalities, one (0.52%, 1/192) had benign CNV with normal chromosomal karyotype, and the remaining 190 cases (98.96%, 190/192) exhibited no abnormalities either in chromosomal karyotype or CNV. No chromosomal karyotype abnormalities were found in the 24 non-isolated BAA fetuses. Among them, one (4.17%, 1/24) showed pathogenic CNV, one (4.17%, 1/24) had benign CNV, and one (4.17%, 1/24) presented CNV of unclear clinical significance. Statistical analysis reveals no significant difference in the incidences of chromosomal karyotype abnormalities and pathogenic CNV between isolated and non-isolated BAA fetuses (Table 3).
Fig. 2.
The fetal genetic diagnosis process of BAA fetuses
Table 2.
The detailed information of BAA fetuses with abnormal genetic results
| Case | High-risk factors | Prenatal sonographic features | Chromosomal Karyotype | CNV | Genetic significance | Postnatal Outcomes |
|---|---|---|---|---|---|---|
| 1 |
Syphilis, advanced maternal age |
Isolated BAA | 45, XO |
Deletion of q11.21-q11.23 |
Pathogenic | Adverse |
| 2 | none |
non-isolated BAA, ventricular septal defect |
Normal | Duplication of chromosome 22q11.21 | Pathogenic | Adverse |
| 3 | advanced maternal age |
non-isolated BAA, aberrant right subclavian artery |
Normal | Deletion of chromosome 14q11.2 | Benign | Favorable |
| 4 | none | Isolated BAA | Normal | Duplication of chromosome Xq27.7 | Benign | Favorable |
| 5 | none |
non-isolated BAA, pulmonary stenosis |
Normal | Duplication of chromosome 3q22.3 | Unknown clinical significance | Favorable |
Table 3.
Comparison of genetic testing abnormalities between isolated and non-isolated BAA fetuses
| Total Case | Non-Triploid Chromosomal Karyotype (case) | CNV Pathogenic (case) |
P
(Fisher’s test) |
|
|---|---|---|---|---|
| Isolated BAA | 192 | 1 | 1 | 1.000 |
| Non-Isolated BAA | 24 | 0 | 1 | 0.210 |
Postnatal outcome of BAA fetuses
Out of the 216 BAA fetuses, 211 (97.22%, 211/216) demonstrated favorable postnatal outcomes, and five (2.31%, 5/216) experienced adverse outcomes. Four women chose to terminate of pregnancy due to the combination of other structural malformations or the presence of chromosomal karyotype. The proportion of isolated BAA fetuses with good postnatal outcomes (99.48%, 191/192) surpasses that of non-isolated BAA fetuses (83.33%, 20/24). Conversely, the incidence of non-isolated BAA fetuses with adverse postnatal outcomes (16.67%, 4/24) is higher than that of isolated BAA fetuses (0.52%, 1/192). The two groups show statistical differences (Table 4).
Table 4.
Comparison of postnatal outcomes between isolated and non-isolated BAA fetuses
| BAA Fetus (case) | Favorable Postnatal Outcome (case) | Adverse Postnatal Outcome (case) |
P
(Fisher’s test) |
|
|---|---|---|---|---|
| Isolated BAA | 192 | 191 | 1 | < 0.001 |
| Non-Isolated BAA | 24 | 20 | 4 | < 0.001 |
Discussion
The embryonic development of the aortic arch is multifaceted and susceptible to various factors such as genetics and the environment. The branches of the aortic arch have diverse variations, while their pathogenesis and clinical significance remain elusive [9–13]. Advancements in antenatal ultrasound technology and equipment have led to an increased detection rate of BAA during prenatal screening. However, there is a notable scarcity of literature on chromosomal abnormalities associated with fetal BAA and clinical prognosis [1, 7, 14]. This poses considerable impediments for healthcare professionals, expecting mothers, and their families, underscoring the need for heightened awareness regarding BAA. The longitudinal section of the aortic arch represents the most intuitive ultrasonographic plane, providing a clear and comprehensive depiction of the arterial branches arising from the aortic arch. Sequentially, from right to left, the brachiocephalic trunk, left common carotid artery, and left subclavian artery are emitted [7, 15]. The common origin between the brachiocephalic trunk and the left common carotid artery serves as the diagnostic criteria [16–19]. However, achieving an optimal longitudinal section of the aortic arch during antenatal examination is contingent upon factors such as operator proficiency, fetal position, and maternal abdominal wall thickness. Moreover, due to the location of the aortic arch within the thoracic cavity in close proximity to the spine, it is susceptible to interference from the posterior shadow of bony structures such as the scapulae, ribs, and the spinal column. Additionally, maintaining a consistent longitudinal section to ensure a clear display of the complete aortic arch and its branching vessels is challenging. Furthermore, there is a propensity for overlap and confusion with the brachiocephalic vein [20]. Consequently, acquiring a satisfactory longitudinal section of the fetal aortic arch necessitates both patience in waiting for ideal fetal positioning to avoid obstruction and operator expertise to enhance scanning accuracy, inevitably extending examination duration and reducing the efficiency of antenatal ultrasound screening [21]. Therefore, this study aimed to retrospectively analyze antenatal ultrasound results, chromosomal aberration detection results, and postnatal outcomes of BAA fetuses, ascertaining the necessity of special attention to BAA fetuses during antenatal ultrasound screening and providing valuable insights for counseling expectant parents in such cases.
In this study, the rate of concomitant intra-cardiac structural abnormalities in BAA fetuses is low, 16 cases (7.41%, 16/216) in total, including seven (3.24%, 7/216) of ventricular septal defect, six (2.78%, 6/216) of aberrant right subclavian artery, two (0.93%, 2/216) of Tetralogy of Fallot, and one (0.46%, 1/216) of pulmonary stenosis. Regarding the BAA fetuses with ventricular septal defect, six presented normal chromosomal karyotypes and CNV, with satisfying postnatal growth and development, and one case displayed pathogenic CNV involving a duplication at chromosome 22q11.21. The ClinGen database indicates significant variability in clinical presentations, with no documented association with abnormalities in aortic arch development. Ventricular septal defect stands as the predominant congenital heart anomaly, recognized as a multifactorial disorder with a notable incidence of chromosomal aberrations among affected fetuses [22]. Current literature has identified over 30 chromosomal anomalies linked to fetal ventricular septal defect, with particular emphasis on the deletion at chromosome 22q11.21 [23] and this case is also abnormal at the same chromosomal location. At the same time, this ventricular septal defect is subaortic type. This is consistent with previous reports [24] that the risk of chromosome abnormalities in subaortic type ventricular septal defect is higher than that of other types. Therefore, we can infer that this case of a pathogenic CNV in this case is most likely associated with the ventricular septal defect. Among the BAA fetuses with aberrant right subclavian artery, five showed normal chromosomal karyotypes and CNV, with favorable postnatal outcomes, and one case displayed normal chromosomal karyotype alongside benign CNV microdeletion, with good postnatal outcomes beside a risk of advanced maternal age. Meiying Cai et al. [25] suggested the potential risk of chromosomal abnormalities posed by vagus right subclavian artery combined with intra-cardiac structural abnormalities or advanced maternal age. Our results are in agreement with Meiying et al. The BAA fetuses with ventricular septal defect showed normal chromosomal karyotypes without clinically significant pathogenic CNV, displaying satisfactory growth and development during follow-up assessment. The BAA fetuses with Tetralogy of Fallot yielded normal chromosomal results. However, the respective gravidas opted for pregnancy termination. Meanwhile, the BAA fetuses with pulmonary artery stenosis manifested normal chromosomal karyotypes and benign CNV microduplication, with positive prognoses post-surgical intervention. Notably, existing literature does not unequivocally establish a direct correlation between BAA and the above intra-cardiac structural abnormalities. Isolated cases reported by Elbistanli [26] highlighted the coexistence of BAA with inferior vena cava dysgenesis. Shang M et al. [27] reported the heredity of BAA. However, these findings all diverge from the outcomes of this study.
Consequently, BAA does not constitute a facet of complex cardiac malformations, nor does it heighten the risk of chromosomal abnormalities or pathogenic CNV in fetuses displaying intra-cardiac structural anomalies. It appears to be an incidental phenomenon devoid of direct implications for chromosomal abnormalities. The likelihood of chromosomal karyotype or CNV abnormalities in BAA fetuses hinges on the presence of chromosomal abnormalities brought by other intra-cardiac structural abnormal signs. Therefore, when antenatal detection of BAA coincides with other intra-cardiac structural anomalies, a comprehensive assessment of the chromosomal abnormality risk predicated on concurrent intra-cardiac structural abnormalities is warranted to determine the necessity of invasive chromosomal testing.
Only eight cases of BAA fetuses were accompanied by extra-cardiac abnormalities (3.7%, 8/216), with a markedly lower incidence than that of intra-cardiac abnormalities. Accompanied extra-cardiac abnormalities contained cleft lip and palate, foot deformity, and single umbilical artery, two cases in each, possessing extremely low morbidity (0.93%, 2/216); choroid plexus cysts and pulmonary sequestration were detected in one case, respectively, with an even lower incidence rate (0.46%, 1/216). No chromosomal or karyotypic abnormalities were found in the BAA fetuses with extra-cardiac abnormalities. There has been ongoing debate regarding the increased risk of chromosomal abnormalities in cases of solely cleft lip and palate, foot malformations, single umbilical artery, and choroid plexus cysts [28–32]. It can be deduced that the presence of BAA does not promote the risk of chromosomal abnormalities in fetuses with extra-cardiac abnormalities. Therefore, when prenatal ultrasound testing reveals BAA accompanied by extra-cardiac structural abnormalities, priority should be given to investigating the potential risk of chromosomal abnormalities.
The incidence rate of chromosomal karyotypic and CNV abnormalities in BAA fetuses is extremely low. There is only one case (0.46%, 1/216) of pathogenic CNV associated with karyotypic abnormalities, specifically showing a karyotype of 45, XO, and pathogenic CNV q11.21-q11.23 deletion. This case belongs to isolated BAA, with syphilis and advanced maternal age as risk factors. Among four cases of CNV abnormalities (1.85%, 4/216), only one (non-isolated BAA combined with ventricular septal defect) had pathogenic CNV (0.46%, 1/216), involving a duplication of chromosome 22q11.21 (Figs. 3 and 4). Influenced by genetic and environmental factors, the occurrence of chromosomal and CNV abnormalities is high among fetuses with ventricular septal defect. The most common ones include trisomies 21, 13, 18, and microdeletion 22q11.2. This is consistent with the location of the chromosome copy number variation in this case. Therefore, we speculated that the pathogenic CNV in this case was be associated with ventricular septal defect, especially subaortic ventricular septal defect. One case (non-isolated BAA combined with vagus right subclavian artery and nasolacrimal duct cyst) of benign CNV (0.46%, 1/216) entails the deletion of chromosome 14q11.2, with advanced maternal age as a risk factor. Another case (isolated BAA) of benign CNV (0.46%, 1/216) involves a duplication of chromosome Xq27.7. Furthermore, one case of CNV with unknown clinical significance (0.46%, 1/216) manifests a duplication of chromosome 3q22.3, observed in a non-isolated BAA fetus combined with pulmonary artery stenosis. All BAA fetuses with the aforementioned karyotypic abnormalities and pathogenic CNV exhibited known associated chromosomal high-risk factors. However, the incidence rate of non-pathogenic CNV in BAA fetuses is significantly low, unconfirmed, and undocumented in the literature [7], suggesting that BAA is not directly correlated with the above CNV abnormalities and can be considered an incidental phenomenon. This demonstrates the absence of a direct correlation between BAA and chromosomal or CNV abnormalities.
Fig. 3.
The case of duplication of chromosome 22q11.2. A: The ultrasound image of bovine aortic arch. B: The ultrasound image of ventricular septal defect. LA: left atrium, RA: right atrium, LV: left ventricle, RV: right ventricle. “+”: ventricular septal defect
Fig. 4.
Chromosomal Karyotype and CNV Results of the BAA fetuse with a duplication of chromosome 22q11.2. Genome sequencing、Chromosome 11 and Chromosome 22 test results are shown from top to bottom. The abscissa represents the chromosome position, and the ordinate represents the copy number
The postnatal outcomes of BAA fetuses manifested favorably in 211 cases (97.69%, 211/216), and those who experienced adverse outcomes or pregnancy termination only accounted for 2.31% (5/216). The five cases of adverse outcomes are associated with factors such as syphilis-induced malformations, genetic risks linked to ventricular septal defects, Tetralogy of Fallot complex cardiac malformations, facial structural deformities in cleft lip and palate, and premature asphyxia, all of which profoundly influence fetal prognosis. Isolated BAA fetuses (99.48%, 191/192) exhibited notably favorable postnatal outcomes compared to those of non-isolated BAA fetuses, and only one had adverse outcomes (0.52%, 1/192). Conversely, non-isolated BAA fetuses demonstrated a significantly elevated occurrence of adverse outcomes or pregnancy termination (16.67%, 4/24), highlighting a marked contrast to isolated cases. These findings align with prior international research [7].
In summary, the majority of BAA fetuses present in isolation with typically favorable postnatal outcomes. BAA does not serve as a direct indicator of chromosomal abnormalities, nor is it indicative of complex cardiac malformations or genetic syndromes. There is no substantiated evidence to suggest its utility as an independent indicator for invasive antenatal examination. The postnatal prognosis of BAA fetuses is primarily influenced by concurrent complicated deformities, chromosomal testing results, and maternal preference rather than BAA alone.
For gravidas deemed high-risk, the emphasis of antenatal ultrasound screening should be directed toward efficiently identifying ultrasound markers of complex and severe cardiac malformations and structural abnormalities intra- and extra-cardiac, which are more reliably associated with chromosomal abnormalities and hold greater clinical significance than merely screening for BAA. Clinical practitioners should prioritize screening for chromosomal or genetic etiologies and whether BAA is accompanied by severe structural malformations. We form a flowchart for approach to BAA in utero(Fig. 5). Engaging in comprehensive communication with expectant mothers is essential for formulating reasoned diagnostic and treatment strategies, mitigating the risk of chromosomal abnormalities, and minimizing the likelihood of birth defects.
Fig. 5.
A flowchart for approach to BAA in utero
This study is subject to several limitations. Firstly, this study omitted the potential influence of various racial factors on the findings. Secondly, variations in technical proficiency among examiners may impact the sensitivity of detecting ultrasound abnormalities, potentially leading to missed diagnoses of BAA. Moreover, some examiners may perceive BAA as a normal vascular variation and do not document it, affecting the accuracy of sample size and the representativeness of the results. These factors collectively may introduce bias into the study findings, necessitating validation through future multi-center and large-sample investigations.
Conclusion
This study underscores that the majority of BAA fetuses exist in isolation, with only a minority presenting concurrent cardiac and extra-cardiac structural abnormalities. The incidence of chromosomal abnormalities is notably low, and overall postnatal clinical outcomes tend to be favorable. Consequently, the clinical utility of obtaining the long-axis view of the aortic arch for diagnosing isolated BAA during antenatal ultrasound screening appears limited. For low-risk populations, invasive antenatal diagnosis is not recommended. However, for fetuses exhibiting concurrent structural abnormalities or those at risk of chromosomal abnormalities, continued vigilance and provision of appropriate genetic counseling and management remain imperative.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
Thanks to all pregnant women and their families who actively cooperated with information registration and follow-up investigation.
Author contributions
CZ and YL develop concept ，collect data，write manuscript .CG, YZ, SZ, XS, EZ and FC collect data, regist data , follow-up cases.
Funding
This work was supported by the Research fund Project of Anhui institude of Translational Medicine (2021zhyx-C35) and Scientific research project of Health Commission of Anhui Province(AHWJ2023A10017).
Data availability
Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
All pregnant provided written informed consent for fetal examination. This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the First Affiliated Hospital of Anhui Medical University’s Institutional Review Board (PJ2022-08-46).
Consent for publication
NA.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.