Institutional Evaluation of Fetal Neurology Consults and Postnatal Outcomes: A 10-Year Retrospective Cohort Review

Abstract

Background and objectives: An increasing number of centers are offering fetal neurology consultation services; however, there is limited information available in overall institutional experiences. Data are lacking on the fetal characteristics, pregnancy course, and the influence of fetal consultation on perinatal outcomes. The aim of this study is to provide insight on the institutional fetal neurology consult process and areas of strengths and weaknesses.

Methods: We performed a retrospective electronic chart review of fetal consults from April 2, 2009, to August 8, 2019, at Nationwide Children's Hospital. The objectives were to summarize clinical characteristics, agreement of prenatal and postnatal diagnoses based on best available imaging, and postnatal outcomes.

Results: Of the 174 maternal-fetal neurology consults placed, 130 qualified for inclusion based on data available for review. Of the 131 anticipated fetuses, 5 experienced fetal demise, 7 underwent elective termination, and 10 died in the postnatal period. The majority were admitted to the neonatal intensive care unit; 34 (31%) required supportive intervention for feeding, breathing, or hydrocephalus, and 10 (8%) experienced seizures during their neonatal intensive care unit (NICU) stay. Imaging results from 113 babies who had prenatal and postnatal imaging of the brain were analyzed based on the primary diagnosis. The most common malformations were as follows (prenatal % vs postnatal %): midline anomalies (37% vs 29%), posterior fossa abnormalities (26% vs 18%), and ventriculomegaly (14% vs 8%). Additional disorders of neuronal migration were not seen on fetal imaging but were present in 9% of the postnatal studies. Analysis of agreement between prenatal and postnatal diagnostic imaging for the 95 babies who had MRIs at both time points found moderate concordance (Cohen kappa: 0.62, 95% CI 0.5-0.73; percent agreement: 69%, 95% CI 60%-78%). Consult recommendations for neonatal blood tests affected postnatal care in 64 of 73 cases in which the infant survived and data were available.

Discussion: Establishing a multidisciplinary fetal clinic can provide timely counseling and create rapport with families to have continuity of care for birth planning and postnatal management. Prognosis based on radiographic prenatal diagnosis requires caution as some neonatal outcomes may vary considerably.

Figure 1. Flowchart of Distribution of Fetal Consults From April 2, 2009, to August 8, 2019, to Analyze Prenatal and Postnatal Imaging Agreement

Figure 2. Alluvial Plot Showing Flow From MRI- or US-Based Prenatal to Postnatal Diagnoses

Schema demonstrates the frequency of infants (N = 113) in the left axis, whereas the right axis indicates percentage. US = ultrasound.

Figure 3. Comparison of Prenatal Radiographic Diagnosis to the Postnatal Imaging Studies With Variable Change in Prognosis

(A) Axial T2 single shot fast spin echo (T2-SSFSE) from fetal MRI at 24 weeks of gestational age consistent with agenesis of the corpus callosum, left hemimegalencephaly, and schizencephaly. (B) Postnatal axial T2 showed extensive hemosiderosis lining the ventricles and basal cisterns and within the choroid plexus of the lateral ventricles elucidating the cause of the fetal radiographic diagnosis. (C) Axial T2-SSFSE at 33 weeks with left lateral ventriculomegaly. (D) Follow-up postnatal MRI demonstrated hemosiderin deposition within the left lateral ventricle from an old hemorrhage. (E) Sagittal T2-SSFSE MRI of a 33-week gestational age fetus suggesting cerebellopontine atrophy. (F) Reassuring postnatal sagittal T2 MRI demonstrating mega cisterna magna. (G) Fetus at 27 weeks of gestational age with cerebellar hypoplasia on sagittal T2-SSFSE, associated with mild bilateral ventriculomegaly at 12 mm. (H) Postnatal MRI on axial T2 showed extensive cortical malformations, fused thalami, hypoplastic corpus callosum, and microcephaly.

Figure 4. Disposition of Delivered Infants

(A) Frequency of disposition over time. (B) Percent, within each year, over time.