Infants born with single-ventricle congenital heart disease (SVCHD) can be critically ill and require surgical palliation within the first weeks of life. With advancements in prenatal imaging, most patients with SVCHD are now diagnosed prenatally. Recent literature demonstrates that patients with SVCHD with prenatal diagnosis have better 30-day survival, lower lactates, and lower rates of mechanical ventilation.1
International Society of Ultrasound in Obstetrics and Gynecology guidelines recommend cardiac screening during the 18- to 22-week gestational anatomy screen, with a formal referral for fetal echocardiography for suspected congenital heart disease.2 Timely referral to fetal cardiology provides opportunity for prognostication and delivery planning, including whether the infant will require prostaglandin or an atrial septostomy.
The coronavirus disease 2019 (COVID-19) pandemic affected access to medical care. A Centers for Disease Control and Prevention 2020 survey revealed that 41% of adults delayed medical treatment, including emergent care.3 The volume burden of COVID-19 on hospitals and clinics also caused appointment cancellations. In Canada, 40% of pregnant women had at least one prenatal appointment canceled because of the pandemic.4
We hypothesized that the pandemic restrictions adversely affected prenatal care and referral to fetal cardiology, thereby reducing prenatal identification of SVCHD.
Institutional review board approval was obtained through Phoenix Children’s Hospital in conjunction with the University of Arizona. Demographics including gestational age, date of birth, and sex were collected from the electronic medical record. We also collected data on echocardiographic results (fetal and postnatal), prenatal visits, genetic testing, and patient outcomes.
The Arizona COVID-19 pandemic restrictions started in March 2020, creating a new potential barrier to prenatal diagnosis of SVCHD. All infants with SVCHD born between January 1, 2018, and December 31, 2021 were included in the study. Patients born July 1, 2020, to December 31, 2021, were categorized as the pandemic group. Those born in the 18 months before July 2020 were prepandemic control subjects. There was a 3-month overlap of the prepandemic group with the pandemic restrictions. We assumed that infants born between March 2020 and June 2020 would have prenatal diagnoses before the pandemic restrictions.
Patients in the prepandemic (control) group were compared with those in the pandemic group using standard tests of significance. Categorical data were analyzed using the Fisher exact test. Continuous data are expressed as median (range) and were compared using the nonparametric Mann-Whitney U test. P values of <.05 were considered to indicate statistical significance. We performed a secondary analysis comparing the accuracy of prenatal REDCap echocardiography with the postnatal findings. Data were collected and managed using REDCap electronic data tools and analyzed using SPSS 27 (SPSS) hosted at the University of Arizona.
A total of 82 infants with SVCHD were included; 89% (n = 73) had prenatal diagnoses and 11% (n = 9) were diagnosed postnatally. The prepandemic (January 2018 to June 2020) and pandemic (July 2020 to December 2021) groups had 53 and 29 patients, respectively.
There was a trend toward lower prenatal detection of SVCHD from 92% to 83% during the pandemic (P = .20), though this was not statistically significant. There was no difference in clinical outcomes, such as preoperative cardiorespiratory support or time to stage 1 surgery. Transplantation-free survival to stage 2 surgery was high (∼88%) in both groups.
Table 1 shows the demographics of our study population. The proportion of mothers who self-identified as Hispanic or non-Caucasian ethnicity decreased during the pandemic from 57% to 38% (P = .06). It was also noted that there was significant decline in patients whose mothers were on state or public insurance, which is an indirect indicator of lower socioeconomic status.
Table 1.
Impact of COVID-19 pandemic on diagnosis and outcomes of newborns diagnosed with SVCHD
| Prepandemic group (n = 53) | Pandemic group (n = 29) | P value | |
|---|---|---|---|
| Demographics | |||
| Ethnicity | .06 | ||
| Caucasian | 22 (43) | 18 (62) | |
| Hispanic | 22 (43) | 9 (31) | |
| Other non-Caucasian | 9 (14) | 2 (7) | |
| Gender, male | 31 (58) | 16 (55) | NS |
| Maternal health insurance type | .03 | ||
| Private | 13 (26) | 12 (52) | |
| State | 36 (73) | 11 (47) | |
| Maternal age, y | 27 ± 5.2 | 28 ± 5.4 | NS |
| Diagnosis | |||
| Prenatal diagnosis | 49 (92) | 24 (83) | NS |
| Gestational age at prenatal diagnosis, wk | 25 ± 5.4 | 26 ± 5.2 | NS |
| Birth weight, g | 2,918 ± 117 | 3,102 ± 126 | NS |
| Genetic anomaly | NS | ||
| Genetic testing done/available | 41 (77) | 6 (79) | |
| Significant anomaly | 10 (24) | 3 (13) | |
| Variant of unknown significance | 2 (5) | 5 (17) | |
| Clinical outcomes | |||
| Hypoplastic left heart syndrome | 47 (89) | 21 (72) | .07 |
| Restrictive atrial septum | 5 (10) | 4 (19) | NS |
| Pre–stage 1 inotropic support | 14 (26) | 5 (17) | NS |
| Pre–stage 1 mechanical ventilation | 19 (36) | 10 (34) | NS |
| Time to stage 1 surgery, d | 7 (6-11) | 7 (5-15) | NS |
| Death before stage 1 surgery | 9 (17) | 4 (14) | NS |
| Stage 1 surgery outcomes | NS | ||
| Alive at stage 2 | 39 (87) | 22 (88) | |
| Death/transplantation before stage 2 | 6 (13) | 3 (12) |
Data are expressed as number (percentage), mean ± SEM, or median (interquartile range). P values in boldface type denote statistical significance.
Our study demonstrates a nonsignificant decrease in prenatal diagnosis of SVCHD during the COVID-19 pandemic restrictions, which appears to have disproportionately affected certain ethnic and socioeconomic groups.
It has been reported that mothers in lower socioeconomic quartiles have decreased prenatal detection of SVCHD.5 The COVID-19 pandemic appears to have amplified this disparity. The diagnosis of SVCHD declined in patients who were on public insurance (an indirect indicator of lower socioeconomic status). We also noted a trend in decreased prenatal diagnosis of patients self-identifying as non-Caucasian, which has not traditionally been reported in SVCHD. This represents potential geographic and demographic variation in access to care.
We acknowledge limitations of the study, including a single-center experience and small volume of patients in the pandemic group. Despite the small cohort, these findings are important, as they highlight the impact of the COVID-19 pandemic restrictions on the prenatal diagnosis of SVCHD.
Footnotes
Conflicts of Interest: None.
References
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