[Intrauterine growth retardation--perinatal mortality and postnatal

morbidity in a perinatal center]

[Article in German]

Meyberg R, Boos R, Babajan A, Ertan AK, Schmidt W.

Universitäts-Frauenklinik und Poliklinik mit

Hebammenlehranstalt, Homburg/Saar.

OBJECTIVES: The intrauterine growth retardation (IUGR)

contributes specially to perinatal mortality and morbidity. An
effective treatment is not yet available. The purpose of this
study is to analyse the perinatal data of a cohort with IUGR-
infants including mortality and morbidity and to describe
prematurity and IUGR as a combination of high risk. STUDY
DESIGN: We have analysed the perinatal data of a cohort of 220
patients with IUGR-infants including mortality and morbidity.
Regularly we examined fetal ultrasonographic growth, doppler
measurements of fetal and maternal vessels and CTG, as well
as indicated amniocentesis, placentesis and cordocentesis.
Entry criteria were: normal menstrual period before pregnancy,
clear gestational age, complete history of pregnancy. RESULTS:
At the Department of Gynaecology & Obstetrics, University
Hospital, Homburg/Saar, the incidence of IUGR (< 10th
Percentile) in premature babies and newborns was 13.1% over
five years (1993-1997). The percentage of premature babies
with IUGR was 18.6%. The overall mortality was 4.1%, the
perinatal mortality was 3.6% and the neonatal mortality was
2.7%. In 1.4% intrauterine foetal death was observed, all
associated with a birthweight below the 3th percentile. The
average duration of pregnancy was 34 + 4 weeks. A high
perinatal mortality of 13.1% and an overall mortality of 14.7%
was observed. 11.4% of the premature babies with IUGR
showed deformities and about 2% presented chromosome
aberrations. 46.4% of children have been transferred to the
Neonatal Intensive Care Unit. 57.1% of the postnatal
complications have been related to the lungs, 26.5% to the
cardiovascular system and 14.3% to the cerebrum. Maternal
complications were referred to: SIH/EPH-gestosis (65.4%),
HELLP-syndrome (5.8%), nicotine abuse (31.4%), pregnancy
anaemia (17.3%) and gestational diabetes with insuline therapy
(7.7%). On the placental site the most noticeable conditions
have been placental insufficiency (40.6%) and placental
 infarction (28.7%). CONCLUSION: Children with IUGR are
exposed to high perinatal mortality and postnatal morbidity.
Premature babies in association with an IUGR are at high risk.
The surveillance of the pregnant women and the new-born
children should be performed in a perinatal centre.

PMID: 11199150 [PubMed - indexed for MEDLINE]

ORIGINAL / RESEARCH

Epidemiology of Congenital Heart Disease among Hospitalised Patients

Sonali Tank, Sushma Malik, Surekha Joshi

Introduction

Congenital heart disease (CHD) occurs in approximately 0.5-0.8% of live-born children, with a higher percentage in
those aborted spontaneously or stillborn.1 To detect as many children with congenital heart disease as possible,
including those with mild lesions, very intensive studies are required which may not be available at all hospitals. 2-
dimensional echocardiography with colour Doppler has revolutionized the diagnosis and management of cardiac
malformations. It is a non-invasive investigation that can precisely diagnose most congenital heart diseases as well as
offer treatment options, whether medical or surgical.

We carried out a retrospective 4-year study to ascertain the incidence of the various congenital heart diseases in our
hospitalized patients. We also studied the symptom profile, the effect on growth and development and the
immunization status of these patients.

Material and Methods

This was a retrospective study, carried out over a 4 year period (from Jan 1996 to Dec 2000) in a public
hospital in Central Mumbai. A review of the 8893 admissions over this period revealed 165 cases admitted
for congenital heart disease. Patients were included in the study if they had clinical, laboratory and
echocardiographic proof of congenital heart disease. Basic details (name, age, sex, religion); symptoms
(breathlessness, cyanosis, cyanotic spells, respiratory tract infections, failure to thrive, refusal to feed and
symptoms related to cardiac failure) and immunization status were noted in pre-structured formats.

Whether normal or delayed were noted. General examination and cardiovascular examination in detail
were entered. Investigations, viz. X-ray chest, Electrocardiogram and 2-Dimensional Echocardiography
findings were noted as also the final outcome (survived, expired).
Results

147 children, from birth to 12 years, admitted to the paediatric wards with proven congenital heart disease
formed the study group. There were 96 males and 51 females, with a male to female ratio of 1.88:1. The
age-wise distribution is shown in Table 1. Maximum children (74) presented in the first year of life, of
which 16 were neonates, 108 patients were Hindus (73.47%), 38 were Muslims (25.85%) and there was
only 1 Christian patient.

There were 88 cases (59.86%) of acyanotic congenital heart disease (ACHD) and 59 cases of cyanotic
congenital heart disease (CCHD). The distribution of cases is given in Table 2.

12 patients were asymptomatic and were picked up on OPD basis for their murmurs (Table 3). The
commonest symptom was breathlessness (110 patients), followed by respiratory infection (66 patients)
and failure to thrive (57 patients), the latter two symptoms were maximally seen in patients with ventricular
septal defect (VSD). 44 patients had congestive cardiac failure (PDA) and atrial septal defect (ASD) each.
Two cases of endocardial cushion defect (ECD) and 1 each of cardiomyopathy and total anomalous pulmonary
venous return (TAPVR) presented with CCF. Fifty five patients had history of cyanotic spells, which was commonest in
patients with Tetralogy of Fallot (TOF).

Five of the 16 newborns were immunized. Among the 59 cases of CCHD, 32 were completely immunized, 14 were
partially immunized and 13 were unimmunised. Of the 88 cases of ACHD, 49 patients had received complete
immunization, 27 had received partial immunization and 10 were unimmunised.

An evaluation of milestones showed that only 25/59 CCHD patients (42.37%) and 45/88 ACHD patients (51.13%) had
attained normal physical and mental milestones. A higher percentage of cases of CCHD had
delayed milestones i.e. 57.63% vs 48.86%.

It is known that 90% cases of Trisomy 18, 50% cases of Trisomy 21 and 40% cases of
Turner’s syndrome have CHD.1 In our study, 16 (10%) of cases of congenital heart disease
had syndromes and other associated somatic anomalies, among which Down’s syndrome
was the commonest (43.75%). Khalil et al noted an incidence of 17.9% of somatic anomalies,
with Down syndrome being the commonest and seen in 9.3% cases. When the outcome was
noted, 70/88 cases of ACHD were discharged, 15 expired and 3 went against medical advice.
Of the 59 cases of CCHD, 39 were discharged, 14 expired and 6 went against medical
advice.

Discussion

Congenital heart disease occurs in 8 per 1000 live births and comprises one of the major
diseases in the paediatric age group.2 CHD has become an important cause of morbidity and
mortality in infancy and accounts for two-thirds of all major birth defects along with neural
tube defects.3 We carried out this study as there are very few Indian studies stating the
epidemiology of CHD in our country.

Of the 8893 admissions, 165 children were admitted with suspected congenital heart disease.
147 children ages ranging from birth to 12 years were proven to have congenital heart
disease and formed our study group, giving an incidence of 1.65%.

Our study showed a male preponderance, which is in accordance with studies by Chadha et
al,4 Bidwai et al,5 and Jain et al.6

There are gender differences in the occurrence of specific heart lesions. TGA and left sided
obstructive lesions are slightly more common in boys (around 65%), whereas VSD, PDA,
ASD and PS are more common in girls. We also found a higher number of males with TGA
and left sided obstructive lesions (50%). Also, we found that VSD was more common among
boys, as was seen in studies by Chadha et al, Bidwai et al and Rao et al.7 Our study showed
a male preponderance among ASD cases, which was in accordance with studies by Jain et
al, Vashishta et al,8 Rao et al and Chadha et al. We found an increased number of males with
TOF, which concurs with the findings of Bidwai et al, while Vashistha et al found an equal sex
distribution and Chadha et al found a higher number of females. The difference in the gender between our study and
known literature as well as other studies could be due to the fact that we have included only indoor and
echocardiography proven cases.
When considering the age at presentation, we found that maximum number of children were picked up in infancy,
including 16 newborns, as is also seen in other studies. In the West, however, there are a higher number of patients
picked up in the neonatal period, which could be due to the fact that foetal echo-cardiography forms a part of their
routine antenatal examination. In a 5 year study (1979-1984) conducted by Udani et al9 the maximum number of
cases were seen between 5-12 years and lowest in . This may be due to the fact that increased awareness and better
facilities are freely available now and hence, more children are being picked up at an earlier age than when the study
was conducted by Udani et al 20 years ago.

On looking at the religion, we had a maximum of Hindu patients (73.47%), followed by Muslims (25.85%) and only one
Christian. This could be due to the fact that the study was conducted at a hospital that is predominantly a Hindu
populated area and has a scattering of Muslim patients.

When the symptoms were taken into consideration, we found breathlessness to be the commonest symptom, seen in
110 cases (74.83%), followed by LRTI in 66 patients (44.89%) and FTT in 57 cases (38.77%).

Breathlessness was the commonest symptom in both cyanotic as well as acyanotic heart disease. LRTI and FTT were
maximally seen in cases of VSD and these patients had large defects with evidence of pulmonary hypertension. LRTI
was also seen in other patients with a large left to right shunt, as in ASD and PDA. None of the cases of TOF had LRTI
which is a well known fact.

FTT was seen in 7 of 19 cases of ASD and 3 of 4 patients of TAPVR. FTT is a major symptom of congenital heart
disease, the reasons being low energy intake, low resting energy expenditure, inadequate food intake, and
malabsorption or feeding difficulty.10,11

Of the 44 cases with CCF, 68.2% were of VSD, 11.36% of ASD and PDA each, 4.54% of ECD and 2.27% each of
TAPVR and CMP. There were no cases of TOF as is a well known fact. Also, none of the cases of pentalogy of
Fallots, Hypoplastic heart or single ventricle had CCF.
Fifty five patients gave a history of cyanotic spells and this was commonest among patients with TOF (29.1%). Keith et
al gave an incidence of 35%.12

Our study had 88 cases of acyanotic congenital heart disease, accounting for 59.86% of cases and 59 cases of
cyanotic congenital heart disease i.e. 40.16%. The preponderance of acyanotic congenital heart disease is in
concordance with the results of other Indian and Western studies.4-11 VSD was the commonest congenital heart
disease seen in our study (36.73%), which is similar to other Indian studies. TOF was the second commonest
congenital heart disease, seen in 17.68%, and is in agreement with the results of other Indian studies,4-8 though is
higher than the incidence recorded in Western studies.1,11,12 ASD was seen in 12.24% cases in our studies, with other
Indian studies recording an incidence from 3.6-23%.4-8

When the immunization history was looked into, we found that 55.1% cases were completely immunized while 29.25%
cases were not fully immunized for age. 23 cases (15.64%) were unimmunised, however this included 16 newborns,
thereby bringing down the figure to 4.76% for unimmunised cases. The common reasons stated for incomplete
immunization were recurrent LRTI, FTT and ignorance about the importance of immunisation.

Congenital heart disease has been shown to adversely influence the neuro-developmental outcome of children though
the incidence is not known and we could not find any other study for comparison. The aetio-pathogenesis includes
chronic hypoxia, acute global and focal ischaemia and infection of the central nervous system leading to lower IQ, poor
motor skills, poor language skills and cognitive impairment.13 These complications are higher in patients with cyanotic
congenital heart disease as was seen in our study.

Normal physical and mental milestones for age were seen in 46.9% and 48.09% patients respectively, while 33.3%
patients had a delay in both physical and mental milestones. A higher percentage of cases of cyanotic congenital heart
disease had delayed milestones as compared with acyanotic congenital heart disease (57.63% versus 48.86%
respectively). Table 4 compares our echocardiographic findings with those of other studies. We had no cases of Aortic
valve stenosis or Truncus arteriosus, while most of our data compare with the other studies.

Mortality is known to be higher in CHD, more so in CCHD, the causes being subacute bacterial endocarditis, refractory
failure, arrhythmias, sepsis and complex congenital cyanotic heart disease. In our study, the mortality was 19.73%.

Conclusions

In our study, ACHD comprised 88 cases, of which VSD with or without associated heart defects accounted for 54
cases (61.36%). Among CCHD, TOF was the commonest, accounting for 26 cases (17.68%).

These children are often deprived of even basic medical care in the form of immunization. In our study, 23 patients
were unimmunised and 41 patients received incomplete immunization.

Growth and development is markedly affected in cases of CHD. 57.63% had delayed physical milestones, 48.86% had
delayed mental milestones, while 33.3% had a delay in both; related to disease and physiology, its complications,
presence of associated anomalies, coupled with inadequate medical care and facilities available.

The mortality rate in our study was 19.73%, the causes being refractory failure, complex congenital heart disease and
sepsis.

Hence, we recommend that all murmurs should be screened unless thought to be physiological. A cardiac evaluation
with echocardiography is advised in all cases of repeated lower respiratory infections and failure to thrive. All cases of
CHD should be under regular monitoring so as to permit optimal; growth and development. A high index of suspicion,
a detailed history, physical examination, chest X-ray and electrocardiogram along with the use of 2- D-
Echocardiography helps us diagnose most of the cases of congenital heart disease and early diagnosis, close
monitoring and timely intervention in cases of congenital heart disease will go a long way in reducing the morbidity and
mortality to a large extent