A comparison of fetal echocardiography in university and health maintenance organization settings

Fetal echocardiographic findings, and decisions to continue or to terminate affected pregnancies, may differ between university (UNIV) and health maintenance organization (HMO) settings. The aim of this study was to review the fetal echocardiographic experience at a combined university/health maintenance organization program over a 4-year period. Imaging and counseling for affected pregnancies were provided by the same, single investigator at both sites. Out of a total of 1382 studies (940 UNIV, 442 HMO), 127 abnormals were identified (94 UNIV, 33 HMO). Among the 127 pregnancies with fetal heart disease, 24 (19%) underwent elective termination, 16% at UNIV and 27% at HMO (p = 0.2). Mean gestational age at the time of diagnosis was 25.2 weeks at UNIV compared with 22.3 weeks at HMO (p = 0.002). At UNIV, only 51% of diagnoses were made before 24 weeks compared with 79% at HMO (p = 0.003). Screening fetal sonograms, performed between 18 and 20 weeks on every pregnancy at HMO but not at UNIV, enabled earlier detection of congenital heart disease (CHD) and allowed more women with severely affected pregnancies the option to terminate. In both settings, indications with the highest yields for CHD included a right-sided stomach, abnormal four-chamber view, sustained bradycardia, abnormal fetal karyotype, fetal omphalocele, and maternal indomethacin. An echogenic reflector was identified in 86 pregnancies (7%) and did not represent a risk factor for CHD. No major differences in CHD were found between UNIV and HMO. In summary, this study found a significantly earlier diagnosis of CHD at HMO than at UNIV. This discrepancy between programs may explain, at least in part, the trend toward a higher frequency of decisions to terminate affected pregnancies at HMO than at UNIV, despite similar fetal findings.