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Screening for critical congenital heart defects in newborn babies can aid in early recognition, with the prospect of improved outcome. We assessed the performance of pulse oximetry as a screening method for the detection of critical congenital heart defects in asymptomatic newborn babies. In this systematic review, we searched Medline (1951–2011), Embase (1974–2011), Cochrane Library (2011), and Scisearch (1974–2011) for relevant citations with no language restriction. We selected studies that assessed the accuracy of pulse oximetry for the detection of critical congenital heart defects in asymptomatic newborn babies. Two reviewers selected studies that met the predefined criteria for population, tests, and outcomes. We calculated sensitivity, specificity, and corresponding 95% CIs for individual studies. A hierarchical receiver operating characteristic curve was fitted to generate summary estimates of sensitivity and specificity with a random effects model. We screened 552 studies and identified 13 eligible studies with data for 229 421 newborn babies. The overall sensitivity of pulse oximetry for detection of critical congenital heart defects was 76·5% (95% CI 67·7–83·5). The specificity was 99·9% (99·7–99·9), with a false-positive rate of 0·14% (0·06–0·33). The false-positive rate for detection of critical congenital heart defects was particularly low when newborn pulse oximetry was done after 24 h from birth than when it was done before 24 h (0·05% [0·02–0·12] vs 0·50 [0·29–0·86]; p=0·0017). Pulse oximetry is highly specific for detection of critical congenital heart defects with moderate sensitivity, that meets criteria for universal screening. None.

Screening for congenital heart defects relies on antenatal ultrasonography and postnatal clinical examination; however, life-threatening defects often are not detected. We prospectively assessed the accuracy of pulse oximetry as a screening test for congenital heart defects. In six maternity units in the UK, asymptomatic newborn babies (gestation >34 weeks) were screened with pulse oximetry before discharge. Infants who did not achieve predetermined oxygen saturation thresholds underwent echocardiography. All other infants were followed up to 12 months of age by use of regional and national registries and clinical follow-up. The main outcome was the sensitivity and specificity of pulse oximetry for detection of critical congenital heart defects (causing death or requiring invasive intervention before 28 days) or major congenital heart disease (causing death or requiring invasive intervention within 12 months of age). 20 055 newborn babies were screened and 53 had major congenital heart disease (24 critical), a prevalence of 2·6 per 1000 livebirths. Analyses were done on all babies for whom a pulse oximetry reading was obtained. Sensitivity of pulse oximetry was 75·00% (95% CI 53·29–90·23) for critical cases and 49·06% (35·06–63·16) for all major congenital heart defects. In 35 cases, congenital heart defects were already suspected after antenatal ultrasonography, and exclusion of these reduced the sensitivity to 58·33% (27·67–84·83) for critical cases and 28·57% (14·64–46·30) for all cases of major congenital heart defects. False-positive results were noted for 169 (0·8%) babies (specificity 99·16%, 99·02–99·28), of which six cases were significant, but not major, congenital heart defects, and 40 were other illnesses that required urgent medical intervention. Pulse oximetry is a safe, feasible test that adds value to existing screening. It identifies cases of critical congenital heart defects that go undetected with antenatal ultrasonography. The early detection of other diseases is an additional advantage. National Institute for Health Research Health Technology Assessment programme.

Background Preterm birth is associated with significant mortality and morbidity for mothers and babies. Women are identified as high risk for preterm birth based on either previous medical/pregnancy history or on ultrasound assessment of the cervix. Women identified as high risk can be offered a cervical cerclage (a purse string stitch) around the cervix (neck of the womb) to reduce the risk of preterm birth. In women who have a cervical cerclage, the procedure can be performed using either a monofilament (single-stranded) or braided (woven) suture material. Both suture materials are routinely used for cervical cerclage and there is uncertainty as to which is superior. Methods A multicentre, open, randomised controlled superiority trial of 2050 women presenting at obstetric units, deemed to be at risk of preterm birth and already scheduled to have a cervical cerclage as part of their standard care. Inclusion criteria include singleton pregnancies and an indication for cervical cerclage for either a history of three or more previous mid-trimester losses or premature births (≤ 28 weeks), insertion of cervical sutures in previous pregnancies, a history of mid trimester loss or premature birth with a (current) shortened (≤ 25 mm) cervix, or women whom clinicians deem to be at risk of preterm birth either by history or the results of an ultrasound scan. Exclusion criteria include women who have taken part in C-STICH previously, are aged less than 18 years old at the time of presentation, require a rescue cerclage, and are unwilling or unable to give informed consent and in whom a cerclage will be placed by any route other than vaginally (e.g. via an abdominal route). Following informed consent, women are randomised on a 1:1 basis to either monofilament or braided suture, by minimisation. The primary outcome is pregnancy loss (miscarriage and perinatal mortality, including any stillbirth or neonatal death in the first week of life), and secondary outcomes include the core outcome set for preterm birth trials. Discussion Optimising established interventions to prevent preterm birth is important in reducing perinatal mortality rates. Trial registration ISRCTN 15373349 . Registered before recruitment on 03 December 2014 prior to first recruit.

Correspondence to Professor Andrew K Ewer, Department of Neonatal Unit, Birmingham Womens Hospital, Birmingham B15 2TG, UK; a.k.ewer@bham.ac.uk Routine pulse oximetry screening (POS) of newborn babies before discharge from hospital has been shown to identifying cases of critical congenital heart disease (CCHD) with consistent test accuracy1 and to reduce mortality from these conditions by one-third.2 There is increasing uptake of POS in high-income and middle-income countries1–4; in July 2018, after several years of state-by-state introduction, POS became mandatory across the USA2 which means that almost 4 million babies a year will undergo the test in that country alone. Some babies (particularly those with defects that obstruct left ventricular outflow such as coarctation of the aorta [CoA] and interrupted aortic arch [IAA]) are missed by POS and other routine screening tests4 and Searle and colleagues quite rightly ask if an additional screening tool—perfusion index (PI)—could have identified such defects earlier.5 As Searle et al describe, PI is an assessment of pulse strength—measured at the same time as oxygen saturations by a pulse oximeter which calculates the ratio of pulsatile to non-pulsatile blood. Association of US state implementation of newborn screening policies for critical congenital heart disease with early infant cardiac deaths.

Routine newborn pulse oximetry screening identifies babies with critical congenital heart defects that would otherwise have been missed by antenatal ultrasound and postnatal examination.1 Pulse oximetry screening reduces mortality from critical congenital heart defects2 and identifies babies with other important conditions, such as respiratory disorders and sepsis. In 2017, 78 (40%) of the 193 neonatal units in the UK used pulse oximetry screening (an increase from 15 [7%] of 224 neonatal units in 2010).4 Following a public consultation on pulse oximetry screening by the UK National Screening Committee in 2019, during which opinions from clinicians, parents, and members of the public were sought on the decision not to make pulse oximetry screening a routine practice, we surveyed all UK neonatal units to see if practice had changed. Between Jan 26 and May 12, 2020, lead clinicians from all 189 neonatal units in the UK were invited to complete an online questionnaire, with a telephone follow-up for non-responders. 189 neonatal units (100%) responded (appendix).

ObjectivesTo evaluate the continued impact of pulse oximetry screening (POS) in a regional neonatal unit (NNU) and identify trends in screening outcomes in comparison with our previous experience.DesignRetrospective review of admissions between April 2013 and March 2019 (the current study) and comparison with previously published data (the 2014 study).PatientsAll infants >34 weeks completed gestation admitted to NNU as a result of positive POS.Outcome measuresIndication for admission, diagnosis, investigations and management.ResultsThere were 49 375 livebirths and 253 NNU admissions as a result of positive POS (0.5% of livebirths; compared with 0.8% in 2014). 247/253 (97.6%) of those admitted had a significant diagnosis requiring medical intervention (compared with 79% in 2014) and the proportion of healthy babies (with transitional circulation) admitted decreased from 21% to 2.4%.22 (9%) babies admitted as a result of a positive POS were found to have a previously undiagnosed congenital heart defect (CHD) of which eight were critical CHDs (CCHDs). This accounted for 73% of all undiagnosed CCHD undergoing POS. The antenatal detection rate of CCHD was 75% compared with 46% in 2014. No baby died or collapsed on the postnatal ward during the study period. The proportion of babies with CCHD identified before discharge improved from 94% to 99%.ConclusionsRoutine POS, in addition to antenatal screening and postnatal examination, continues to contribute to the improvement of our overall CCHD detection rates. We have demonstrated an overall reduction in the admission of healthy babies and therefore workload following a positive test.

Fetal hematometrocolpos is a rare finding with an incidence of 1 in 16 000 female births. We present a case of fetal hematometrocolpos managed exclusively by prenatal and postnatal ultrasound scans allowing for effective immediate postnatal surgical treatment. Our case highlights that cross‐sectional imaging is not mandatory for successful management of fetal hematometrocolpos. This is of great significance in low resource healthcare settings, where access to fetal MR may not be readily available.

In high-income countries, examination and, increasingly, antenatal ultrasound have formed the basis of screening, but test accuracy of these procedures is variable and many babies with critical congenital heart defects are discharged before diagnosis.1,2 Screening with pulse oximetry to detect hypoxaemia associated with most critical congenital heart defects has already been introduced in the USA3 and some Scandinavian countries, and is being considered by European countries including the UK.4 In The Lancet, Qu-ming Zhao and colleagues5 publish the results of a large study including 122 738 babies (120 707 asymptomatic and 2031 symptomatic), from 13 provinces in China. Because China does not have a national screening policy for congenital cardiac defects, individual clinicians were trained to undertake both a clinical assessment and pulse oximetry measurement in all eligible babies as part of the study.

Objectives (i) To evaluate the impact of routine early pulse oximetry screening on the rate of unexpected neonatal unit (NNU) admissions and the need for echocardiography. (ii) To review the outcomes of babies admitted as a result of a positive pulse oximetry screening test. Design Retrospective review over a 40-month period. Setting Level 3 NNU. Patients All babies admitted as a result of positive pulse oximetry screening. Main outcome measures Indication for admission, clinical diagnosis and management were collated. Results 3552 babies were admitted during the study period. Of these, 1651 were unexpected admissions and 208/1651 (12.6%) were as a result of positive pulse oximetry screening. 165/208 babies (79%) had a significant clinical condition which required further intervention including 17 with congenital heart defect (CHD) (nine critical), 55 with pneumonia, 30 with sepsis and 12 with pulmonary hypertension. No baby died or collapsed on the postnatal ward during the study period. 61/208 babies (29%) had echocardiography and CHD was detected in 28%. Conclusions Routine use of pulse oximetry screening identifies babies with CHD and other illnesses, which, if not identified early could potentially lead to postnatal collapse. It does not appear to overload clinical services, resulting in appropriate admission in the majority and a modest increase in the number of echocardiograms performed.