Prenatal Risk Stratification with Early Non-Invasive Monitoring Reduces Unnecessary Medicalization in Patients with...

To stratify by risk fetuses with prenatal coarctation of the aorta (CoA) using validated fetal echocardiographic measures, and to use non-invasive postnatal assessment to inform management in all prenatal CoA.

An original protocol to risk stratify fetuses with CoA was implemented in 2023. By the protocol, no PGE was initiated before postnatal demonstration of CoA in any prenatal risk category. A retrospective, single-center, before-and-after implementation study was performed for the era before (2018-2023, 106 neonates) and after (2023-2025, 42 neonates) protocol implementation.

There were 106 pre-protocol and 42 post-protocol neonates included. In post-protocol neonates, 14 were prenatally classified as "low risk," 9 as "moderate risk," and 19 as "high risk" for surgical CoA. The probability of surgical CoA in the low-risk group was 7% (95% CI 1-31%) and in the high-risk group was 68% (95% CI 46-85%]). The specificity of a high-risk prenatal CoA diagnosis was 77%. PGE exposure was significantly reduced in the post-protocol era (P=0.037) and eliminated in cases of false positive CoA. In post-protocol neonates with false positive prenatal CoA, there was significant reduction in the prevalence of transfer to a tertiary center (P=0.006), delay in enteral feeding (P=0.001), and central line placement (p=0.002) compared with pre-protocol neonates with false positive CoA. Two post-protocol neonates were diagnosed with CoA after newborn hospital discharge, and one post-protocol neonate developed ventricular dysfunction before initiation of PGE.

The concept of prenatal risk stratification of CoA has been previously described. Our protocol used non-invasive clinical monitoring before empiric PGE, central line placement, or hospital transfer in all prenatal risk categories. This protocol accurately identified neonates at lowest risk for CoA and significantly reduced the medicalization associated with false positive prenatal CoA diagnosis.