Uncertainty of Prenatally Diagnosed Congenital Heart Disease: A Qualitative Study

An Observational Study of Dialogue about Uncertainty in Clinician-Family Counseling Conversations Following Prenatal Diagnosis of Complex Congenital Heart Disease

Objective

Families who receive a prenatal diagnosis of complex congenital heart disease (cCHD) often experience severe psychological distress and identify uncertainty as a key source of that distress. This study examined clinician-family conversations during initial fetal cardiology consultations to identify the topics of uncertainty discussed.

Methods

In this observational, qualitative study, initial fetal cardiology consultations were audio-recorded, transcribed verbatim, and coded by two independent coders. A codebook was inductively and deductively developed and applied. This content analysis focused on uncertainty-related codes and associated themes.

Results

During 19 consultations including five clinicians, 13 different cardiac diagnoses were discussed (seven with high mortality risk). Median consultation length was 37 min (IQR: 26-51), with only 11% of words spoken by families. On average, 51% of total words spoken focused on uncertainty in relation to cardiac diagnosis, etiology, comorbidities, prognosis, childbirth, therapeutics, and logistics. Family-initiated discussion on uncertainty largely focused on childbirth and pregnancy and postpartum logistics.

Conclusions

Half of dialogue within initial fetal cardiology encounters discussed uncertainty surrounding prenatally diagnosed cCHD. Parent and clinician perspectives should be gathered on the essential content and optimal delivery of uncertainty-related topics.

Innovation

This study is conceptually and methodologically innovative as one of the first to examine audio-recorded dialogue between fetal cardiology clinicians and families.

Parents' experiences of receiving their child's diagnosis of congenital heart disease: A systematic review and meta-synthesis of the qualitative literature

PURPOSE

This systematic review aimed to synthesize qualitative research on parents' psychological experiences following their child's diagnosis of congenital heart disease (CHD).

METHODS

A systematic search of six electronic databases (CINAHL, Embase, MEDLINE, PsycINFO, PubMed and Web of Science) was completed, inclusive of all years up to May 2022. Any included articles were synthesized using thematic synthesis and appraised using the Critical Appraisal Skills Programme Qualitative Checklist.

RESULTS

Twenty-six articles were included. Four main themes, and 11 subthemes, emerged from the synthesis. Theme 1 (unpreparedness for the diagnosis) concerned parents' shock, guilt and anger regarding the diagnosis. Theme 2 (the overwhelming reality of CHD) described parental fear about decision-making and the child's prognosis, and the influence of professionals on parents' well-being. Theme 3 (mourning multiple losses) detailed parents' sadness at losing their envisioned pregnancy, birth and parenthood experiences. Theme 4 (redefining hopes to reach an acceptance of CHD) described parents' adjustment to the diagnosis.

CONCLUSIONS

Receiving a child's CHD diagnosis was a uniquely challenging situation for parents. The findings provided insight into the emotions parents experienced and how they adjusted to the diagnosis psychologically. As parents' experiences were significantly influenced by their interactions with professionals, clinicians should offer compassion, validation and clear information throughout the diagnosis process.

Initiating a Fetal Cardiac Program from Scratch in Low- and Middle-Income Countries: Structure, Challenges, and Hopes for Solutions

Although fetal cardiac programs are well established in developed countries, establishing an efficient program in low- and middle-income countries (LMICs) is still considered a significant challenge. Substantial obstacles usually face the initiation of fetal cardiac service from scratch in LMICs. The primary structural frame of a successful fetal cardiac program is described in detail, emphasizing the required team members. The potential challenges for starting fetal cardiac services in LMICs include financial, awareness-related, prenatal obstetric screening, sociocultural, psychosocial, and social support factors. These challenges could be solved by addressing these barriers, such as collecting funds for financial support, raising awareness among families and health care providers, telemedicine, building international health partnerships, modifying training protocols for fetal cardiologists and sonographers, and initiating support groups and social services for families with confirmed fetal cardiac disease. Initiating a successful fetal cardiac program requires multi-aspect structural planning. The challenges for program initiation require diverse efforts, from modified training and promoting awareness of care providers and the community to governmental and nonprofit organizations' collaborations for proper building and utilization of program resources.

Uncertainties experienced by parents of children diagnosed with severe combined immunodeficiency through newborn screening

Individuals with severe combined immunodeficiency (SCID), a group of rare, genetic conditions, are at risk for life-threatening illnesses unless diagnosed and treated early. Even after early identification through newborn screening, parents of children with SCID embark on a complex journey marked by a variety of informational and emotional support needs. This paper explored the types of uncertainties experienced by parents of a child with SCID diagnosed through newborn screening. We conducted semi-structured interviews with 26 parents to discuss the types of uncertainty experienced, including scientific, practical, personal, and existential. Each interview was recorded, transcribed, and coded. Using deductive and inductive content analysis, we describe the type of uncertainty experienced across each stage of the SCID journey. We found that uncertainties in the SCID journey were chronic and multifaceted. Some uncertainties were more prominent at certain points of the journey whereas others spanned multiple stages. Parents expressed a variety of negative emotional reactions to uncertainty, from anxiety, worry, and fear, to doubt, guilt, or grief, and even anger, frustration, and depression. The results speak to the need for healthcare providers to prepare parents for the SCID journey by providing resources to help manage and cope with uncertainty.

Nurse-guided Mobile Health Care Program to Reduce Emotional Distress Experienced by Parents of Infants Prenatally Diagnosed with Critical Congenital Heart Disease: A Pilot Study

Background

Following prenatal diagnosis of critical congenital heart disease (CCHD), parents encounter emotional distress while facing caregiving challenges. Supportive psycho-educational interventions using mobile health (mHealth) can make care more accessible.

Objectives

We tested a novel nurse-guided mHealth care program, Preparing Heart and Mind™ (PHM™), with the objectives of examining feasibility and estimating the effect of the intervention on parents' emotional distress.

Methods

This pilot study design randomized participants using a 2:1 intervention to control ratio. Analysis involved description of retention, and intervention attendance and engagement, and adjusted linear mixed models to estimate group differences in depressive (CES-D), anxiety (STAI-S), and traumatic stress (IES-r) symptoms.

Results

The sample included 55 parents (n=38 PHM™ group, n=17 control). Complete retention of 37 (67%) parents included 29 (76%) in the PHM™ group and 8 (47%) control. Most attrition was due to infant death (7 parents), transplant referral (2 parents), or postnatal diagnostic ineligibility (4 parents). For the PHM™ group, ≥96% of parents attended pre- and postnatal sessions and most (65%) messaged with the nurse. mHealth engagement was highest prenatally, with handling uncertainty the most viewed topic (average 94% pages viewed). In linear mixed models analyses, the PHM™ group had on average 4.84 points lower depression (95% CI: -10.68-1.04), 6.56 points lower anxiety (-14.04-0.92), and 6.28 points lower trauma (-14.44-1.88) scores by study end.

Conclusion

Findings suggest that a nurse-guided mHealth approach is feasible and may contribute to a clinically important reduction in parents' emotional distress.

Parental Impressions and Perspectives of Efficacy in Prenatal Counseling for Single Ventricle Congenital Heart Disease

Although commonly performed, optimal techniques, strategies, and content to achieve the most effective prenatal counseling have not been explored. We investigate the efficacy of prenatal counseling via survey feedback of parents of children with prenatally diagnosed single ventricle. Grades of counseling using a Likert scale (1-5) were solicited to assess: (1) overall impression of quantity of counseling, (2) explanation of the heart defect, (3) preparation for heart surgery, (4) preparation for hospital course and care, (5) preparation for complications and outcomes of a Fontan circulation, and (6) preparation for neurological, school-related, or behavioral problems. Impressions were solicited concerning specific providers. A comprehensive fetal counseling score was calculated for each participant. Burden of care including length of hospitalization was explored as impacting prenatal counseling grades. There were 59 survey respondents. Average age of the children at the time of survey was 4.6 ± 3.3 years (range 1-10 years). Highest grades were for explanation of the heart condition, with lowest grades for preparation for neurological, school-related, or behavioral problems. Cardiac surgeon received the highest with social worker lowest grade for provider. Negative correlation was found between the composite fetal counseling score and parental recollection of length of hospitalization (Pearson r = - 0.357, p < 0.01). Prenatal counseling for neurological, school-related, and behavioral problems in single ventricle is deficient. Further studies analyzing prenatal counseling techniques and content can help improve upon the delivery of this important aspect of prenatal care.

Prenatal Diagnosis of Congenital Heart Disease and Voluntary Termination of Pregnancy: A Population-Based Study in Qingdao, China

Objective

The outcomes of fetuses with isolated congenital heart disease (CHD) diagnosed prenatally have not been investigated in a population-based study in China. This population-based study aimed to evaluate the rate of voluntary termination of pregnancy after the prenatal diagnosis of isolated CHD in Qingdao, China.

Methods

This was a population-based retrospective study in which data were collected from all pregnant women in Qingdao (eastern China) from August 2018 to July 2020; fetal data, maternal data and data on pregnancy outcomes were extracted from medical records regarding prenatal diagnosis of CHD. The inclusion criteria were as follows: pregnant women or their husbands who had a household registration in Qingdao and who underwent regular prenatal screening in Qingdao. The exclusion criterion was the failure to sign an informed consent form. Counseling for all parents of fetuses with CHD was provided by a multidisciplinary team of experienced pediatric cardiologists, obstetricians, geneticists, etc. According to the type and severity of CHD, the pregnancy termination rate was analyzed.

Results

Among the 126,843 pregnant women, 1299 fetuses with a prenatal diagnosis of CHD were included in the study. Among the included fetuses, 1075 were diagnosed with isolated CHD, and the overall pregnancy termination rate was 22.8%. Termination rates varied according to the complexity of CHD (low complexity vs moderate complexity, P=0.000; low complexity vs high complexity, P=0.000; moderate complexity vs high complexity, P=0.000), with rates of 6.0% for low complexity, 54.2% for moderate complexity, and 99.1% for high complexity. The decision to terminate the pregnancy in cases of isolated CHD was unrelated to maternal age (P=0.091) but was related to gestational age (p=0.000).

Conclusion

In Qingdao, 99.1% of parents whose fetuses were diagnosed with isolated high-complexity CHD chose to voluntarily terminate the pregnancy. The pregnancy termination rate increased with increasing complexity of prenatally diagnosed CHD.

Using MRI-derived observed-to-expected total fetal lung volume to predict lethality in fetal skeletal dysplasia

BACKGROUND

Pulmonary hypoplasia is the primary cause of perinatal death in lethal skeletal dysplasias. The antenatal ultrasound correlates for lethality are indirect, measuring the thorax (thoracic circumference, TC) or femur compared to the abdomen (TC/AC, FL/AC). A single study has correlated lethality with the observed-to-expected total lung volume (O/E-TFLV) on fetal MRI in 23 patients.

OBJECTIVE

Our aim was to define a cutoff value to predict lethality more specifically using MRI-derived O/E-TFLV.

MATERIALS AND METHODS

Two large fetal center databases were searched for fetuses with skeletal dysplasia and MRI; O/E-TFLV was calculated. Ultrasound measures were included when available. Each was evaluated as a continuous variable against lethality (stillbirth or death in the first month of life). Logistic regression and receiver operating characteristic (ROC) curve analyses evaluated the prediction ability. AUC, sensitivity, and specificity were calculated. P < 0.05 was considered statistically significant.

RESULTS

A total of 80 fetuses met inclusion criteria. O/E-TFLV < 0.49 was a significant risk factor in predicting lethality, with sensitivity and specificity of 0.63 and 0.93, respectively, and an AUC of 0.81 (P < 0.001). FL/AC < 0.129 was also a strong variable with sensitivity, specificity, and AUC of 0.73, 0.88, and 0.78, respectively (P < 0.001). TC/AC and TC percentile were not significant risk factors for lethality. An O/E-TFLV of < 0.38 defines a specificity for lethality at 1.00.

CONCLUSION

MRI-derived O/E-TFLV and US-derived FL/AC are significant predictors of lethality in fetuses with skeletal dysplasia. When prognosis is uncertain after ultrasound, calculation of MRI-derived O/E-TFLV may provide additional useful information for prognosis and delivery planning.

An mHealth, patient engagement approach to understand and address parents' mental health and caregiving needs after prenatal diagnosis of critical congenital heart disease

Objective

To provide an overview of the development of the Preparing Heart and Mind™ (PHM™) care program designed for parents with a prenatal diagnosis of critical congenital heart disease (CCHD) and describe issues of parental concern, caregiving competencies, and type and timing of PHM™ topics.

Methods

Guided participation theory underpinned intervention development and a mixed methods pilot of a novel, nurse-guided mHealth intervention. Parents were enrolled from the third trimester of pregnancy-12 weeks postnatally. Online surveys, session transcripts, and app use were descriptively analyzed.

Results

The sample included 19 mothers/birthing persons and 15 caregiving partners randomized to the intervention group. In 49 sessions, mental health/wellbeing (94%) and condition-specific information (86%) were top issues. Many caregiving competencies were developed, with mothers/birthing persons often focused on feeding (86%). Regulating emotions and co-parenting consistently needed support. PHM™ topics of preparing for hospitalization (47%) and handling uncertainty (45%) were most discussed. Two cases further characterize findings.

Conclusion

Nurse-parent collaborative understanding of issues emphasized the need for mental health assessments. Prenatal intervention opportunities were underscored through discussions of caregiving issues and PHM™ topics.

Innovation

PHM™ represents an innovative approach that holds promise for supporting parents' mental health and caregiving needs outside the healthcare setting.

Families under pressure: A qualitative study of stressors in families of children with congenital heart disease

The objective of this study was to better understand the stressors in families of children with congenital heart disease (CHD) to assist with formulating targeted stress management plans for such families. A descriptive qualitative study was undertaken at a tertiary referral hospital in China. Following purposeful sampling, interviews were conducted with 21 parents of children with CHD regarding the stressors in their families. Following content analysis, 11 themes were generated from the data and categorised into six main domains: the initial stressor and associated hardships, normative transitions, prior strains, the consequences of family efforts to cope, intrafamily and social ambiguity, and sociocultural values. The 11 themes include confusion regarding the disease, hardships encountered during treatment, the heavy financial burden, the unusual growth track of the child due to the disease, normal events becoming abnormal for the family, impaired family functioning, family vulnerability, family resilience, family boundary ambiguity induced by role alteration, a lack of knowledge about community support and family stigma. Various and complex stressors exist for families of children with CHD. Medical personnel should fully evaluate the stressors and take targeted measures before implementing family stress management practices. It is also necessary to focus on the posttraumatic growth of families of children with CHD and strengthen resilience. Moreover, family boundary ambiguity and a lack of knowledge about community support should not be ignored, and further research is needed to explore these variables. Most importantly, policymakers and healthcare providers should adopt a range of strategies to address the stigma of being in a family of a child with CHD.

Fetal Anomaly: Family Experiences and Preferences for Care: An Integrative Review

BACKGROUND

The prenatal diagnosis of a fetal anomaly is unexpected, creating a family crisis. Expectant parents are at an increased risk for perinatal depression and traumatic stress. Prior reviews examined parents' experiences when terminating but not continuing the pregnancy. This review synthesized qualitative research to describe the experiences, emotional responses, and needs of families continuing their pregnancy.

METHODS

An integrative review was performed using the Whitemore and Knafl methodology and PRISMA guidelines. A systematic review of peer-reviewed articles published between 2000 and 2200 on the experiences of fetal anomaly was performed using 5 databases. Eligible articles included qualitative studies describing families' experiences with a fetal anomaly diagnosis who elected to continue their pregnancy. Methodological quality was evaluated using the Critical Skills Appraisal Program checklist.

RESULTS

Of the 678 article results, 16 met inclusion criteria. There were 298 participants from 5 countries. The major overarching theme of Response to the Diagnosis of Fetal Anomaly was identified. The major categories were emotional response, coping strategies, influences, health care experiences, and family needs. Uncertainty and grief were the most common emotions.

DISCUSSION

Parents choosing to continue pregnancy benefit from compassionate, sensitive care, and accurate, concise information, provided in tailored instruction using multiple styles.

"I Just Want You to Hear That Term": Characterizing Language Used in Fetal Cardiology Consultations

The way clinicians communicate with parents during pregnancy about congenital heart disease (CHD) can significantly influence parental understanding of and psychological response to the diagnosis. A necessary first step to improving communication used in fetal cardiology consultations is to understand and describe the language currently used, which this paper aims to do. Nineteen initial fetal cardiology consultations with parents were audio-recorded, transcribed verbatim, and coded by two independent coders. A codebook was inductively developed and applied to all transcripts. The finalized coding was used to characterize fetal cardiologists' language. We identified four discourse styles employed in fetal cardiology consultations: small talk, medical, plain, and person-centered. Plain language was used to define and emphasize the meaning of medical language. Person-centered language was used to emphasize the baby as a whole person. Each consultation included all four discourse styles, with plain and medical used most frequently. Person-centered was used less frequently and mostly occurred near the end of the encounters; whether this is the ideal balance of discourse styles is unknown. Clinicians also used person-centered language (as opposed to disease-centered language), which is recommended by medical societies. Future studies should investigate the ideal balance of discourse styles and the effects of clinician discourse styles on family outcomes, including parents' decision-making, psychological adjustment, and quality of life.

Avoiding Liability and Other Legal Land Mines in the Evolving Genomics Landscape

This article reviews evolving legal implications for clinicians and researchers as genomics is used more widely in both the clinic and in translational research, reflecting rapid changes in scientific knowledge as well as the surrounding cultural and political environment. Professionals will face new and changing duties to make or act upon a genetic diagnosis, address direct-to-consumer genetic testing in patient care, consider the health implications of results for patients' family members, and recontact patients when test results change over time. Professional duties in reproductive genetic testing will need to be recalibrated in response to disruptive changes to reproductive rights in the United States. We also review the debate over who controls the flow of genetic information and who is responsible for its protection, considering the globally influential European Union General Data Protection Regulation and the rapidly evolving data privacy law landscape of the United States.

Mapping parents' journey following prenatal diagnosis of CHD: a qualitative study

OBJECTIVE

To better understand parents' accounts of their prenatal and postnatal experience after prenatal diagnosis of CHD - particularly emotional processing and coping mechanisms - to identify strategies to improve support.

METHODS

This single-centre, longitudinal qualitative study included pregnant mothers and their support persons seen in Fetal Cardiology Clinic at Vanderbilt Children's Hospital from May through August 2019 for probable complex CHD. Twenty-seven individuals from 17 families participated in 62 phone interviews during pregnancy and postpartum: 27 conducted after the initial prenatal cardiology consultation, 15 after a follow-up prenatal visit, and 20 after birth. Applied thematic analysis approach was used to code and analyse transcribed interviews. Coding and codebook revisions occurred iteratively; intercoder reliability was >80%.

RESULTS

Patients included mothers (16 [59%]), fathers (8 [30%]), and other support persons (3 [11%]). Initial fetal diagnoses included a range of moderate to severe CHD. Prenatally, parents sought to maintain hope while understanding the diagnosis; planning for the future rather than focusing on day-to-day was more common if prognoses were better. Postnatally, with confirmation of prenatal diagnoses, parents' sense of control expanded, and they desired more active engagement in clinical decision making.

CONCLUSIONS

To enhance effective communication and support, understanding how parents conceptualise hope in relation to diagnosis and how that may evolve over time is critical. Expectant parents whose child has a significant risk of mortality may demonstrate hope by focusing on positivity. As prognostic uncertainty diminishes postpartum, the parental role on the team may shift, requiring clinicians to provide different support.

Impact of interdisciplinary counselling for parental decision-making in cases of pregnancies with prenatally diagnosed CHD

INTRODUCTION

Parental counselling after antenatal diagnosis of a congenital heart defect requires a high degree of professional and emotional competence and ultimately a sense of responsibility on the part of the consulting physicians. However, little is known about parents` perceptions and evaluation of these consultations.

MATERIAL/METHODS

Survey on 425 women who received interdisciplinary counselling after antenatal diagnosis of a complex fetal congenital heart defect in a specialized prenatal outpatient clinic with an affiliated paediatric heart centre. Two questionnaires were used to retrospectively evaluate the parental perception and impact on counselling, particularly on decision-making. Questionnaires differed between women conceiving the child and women who terminated the pregnancy.

RESULTS

400 women continued, 25 women terminated the pregnancy after diagnosis and counselling. Good quality of life was reported for 68% of the children, 15% died postnatally in the further course. 95% rated the counselling as good or very good regardless of the child´s outcome. 73% described the counselling as highly important for their subsequent decision. The possibility of termination of pregnancy was discussed with 37% of the respondents, 22% of them found it outrageous or very distressing. Of all respondents, one woman would have made a different decision regarding continuation of the pregnancy in retrospect.

CONCLUSION

Retrospectively, parents rate prenatal counselling extremely positively, irrespective of the severity of the child´s heart defect. It can be assumed that the consistent joint interdisciplinary consultation and the high reputation of the cooperating heart centre have had an influence on the below-average rate of termination of pregnancy.

"All in One: Fear, Happiness, Faith" A Qualitative Study on Experiences and Needs of Turkish Mothers of Infants with Congenital Heart Disease

Having an infant with congenital heart disease (CHD) may cause difficulties and changes in mothers' life. This study was aim to explore the experiences and needs of Turkish mothers of infants with CHD. The study was carried out with the descriptive phenomenological method from qualitative research. The study sample included 18 mothers having infants in the age range of 0 to 2 years with CHD. The data were collected using a sociodemographic data form and a semi-structured interview form. The data obtained from the interviews were evaluated using the content and thematic analysis methods. Four main themes and sub-themes emerged from the qualitative data. "Effect of getting a diagnosis" with two sub-themes (emotional changes and a protective mother-infant relationship), "All emotions in one" with two sub-themes (fearing of death and torn between fear and hope), "Influences on a mother's life" with three sub-themes (forgetting herself, getting away from siblings' lives and relations with spouse), and stressors with three sub-themes (loss of control, physical care and unfulfilled needs). The results of the study provide insight into how Turkish mothers subjectively experience life after CHD. Mothers expected healthcare professionals to support and understand their experiences and needs. Healthcare professionals need to create an environment for mothers to cope with emotional difficulties, gain knowledge and care skills, and adapt to their lives.

Palliative Care Across the Life Span for Children With Heart Disease: A Scientific Statement From the American Heart Association

AIM

This summary from the American Heart Association provides guidance for the provision of primary and subspecialty palliative care in pediatric congenital and acquired heart disease.

METHODS

A comprehensive literature search was conducted from January 2010 to December 2021. Seminal articles published before January 2010 were also included in the review. Human subject studies and systematic reviews published in English in PubMed, ClinicalTrials.gov, and the Cochrane Collaboration were included. Structure: Although survival for pediatric congenital and acquired heart disease has tremendously improved in recent decades, morbidity and mortality risks remain for a subset of young people with heart disease, necessitating a role for palliative care. This scientific statement provides an evidence-based approach to the provision of primary and specialty palliative care for children with heart disease. Primary and specialty palliative care specific to pediatric heart disease is defined, and triggers for palliative care are outlined. Palliative care training in pediatric cardiology; diversity, equity, and inclusion considerations; and future research directions are discussed.

What is Known About Critical Congenital Heart Disease Diagnosis and Management Experiences from the Perspectives of Family and Healthcare Providers? A Systematic Integrative Literature Review

The experience of diagnosis, decision-making and management in critical congenital heart disease is layered with complexity for both families and clinicians. We synthesise the current evidence regarding the family and healthcare provider experience of critical congenital heart disease diagnosis and management. A systematic integrative literature review was conducted by keyword search of online databases, MEDLINE (Ovid), PsycINFO, Cochrane, cumulative index to nursing and allied health literature (CINAHL Plus) and two journals, the Journal of Indigenous Research and Midwifery Journal from 1990. Inclusion and exclusion criteria were applied to search results with citation mining of final included papers to ensure completeness. Two researchers assessed study quality combining three tools. A third researcher reviewed papers where no consensus was reached. Data was coded and analysed in four phases resulting in final refined themes to summarise the findings. Of 1817 unique papers, 22 met the inclusion criteria. The overall quality of the included studies was generally good, apart from three of fair quality. There is little information on the experience of the healthcare provider. Thematic analysis identified three themes relating to the family experience: (1) The diagnosis and treatment of a critical congenital heart disease child significantly impacts parental health and wellbeing. (2) The way that healthcare and information is provided influences parental response and adaptation, and (3) parental responses and adaptation can be influenced by how and when support occurs. The experience of diagnosis and management of a critical congenital heart disease child is stressful and life-changing for families. Further research is needed into the experience of minority and socially deprived families, and of the healthcare provider, to inform potential interventions at the healthcare provider and institutional levels to improve family experience and support.

Bioethics for Neonatal Cardiac Care

BACKGROUND

Clinicians caring for neonates with congenital heart disease encounter challenges with ethical implications in daily practice and must have some basic fluency in ethical principles and practical applications.

METHODS

Good ethical practice begins with a thorough understanding of the details and narrative of each individual case, examination via classic principles of bioethics, and further framing of that translation into practice.

RESULTS

We explore some of these issues and expand awareness through the lens of a case presentation beginning with fetal considerations through end-of-life discussions.

CONCLUSIONS

We include specific sections that bring attention to shared decision-making, research ethics, and outcomes reporting. We review empirical evidence and highlight recommendations.

Practice variations for fetal and neonatal congenital heart disease within the Children's Hospitals Neonatal Consortium

BACKGROUND

Many aspects of care for fetuses and neonates with congenital heart disease (CHD) fall outside standard practice guidelines, leading to the potential for significant variation in clinical care for this vulnerable population.

METHODS

We conducted a cross-sectional survey of site sponsors of the Children's Hospitals Neonatal Consortium, a multicenter collaborative of 41 Level IV neonatal intensive care units to assess key areas of clinical practice variability for patients with fetal and neonatal CHD.

RESULTS

We received responses from 31 centers. Fetal consult services are shared by neonatology and pediatric cardiology at 70% of centers. Three centers (10%) routinely perform fetal magnetic resonance imaging (MRI) for women with pregnancies complicated by fetal CHD. Genetic testing for CHD patients is routine at 76% of centers. Preoperative brain MRI is standard practice at 5 centers (17%), while cerebral NIRS monitoring is regularly used at 14 centers (48%). Use of electroencephalogram (EEG) after major cardiac surgery is routine in 5 centers (17%). Neurodevelopmental follow-up programs are offered at 30 centers (97%).

CONCLUSIONS

Many aspects of fetal and neonatal CHD care are highly variable with evolving shared multidisciplinary models.

IMPACT

Many aspects of fetal and neonatal CHD care are highly variable. Genetic testing, placental examination, preoperative neuroimaging, and postoperative EEG monitoring carry a high yield of finding abnormalities in patients with CHD and these tests may contribute to more precise prognostication and improve care. Evidence-based standards for prenatal and postnatal CHD care may decrease inter-center variability.

Opportunities to enhance parental well-being during prenatal counseling for congenital heart disease

Prenatal diagnosis of congenital heart disease (CHD) can be a life-altering and traumatic event for expectant parents. Parental anxiety, depression, and traumatic stress are common following a prenatal cardiac diagnosis and if untreated, symptoms often persist long-term. During prenatal counseling, parents must try to manage psychological distress, navigate uncertainty, process complex medical information, and make high-stakes medical decisions for their unborn child and their family. Physicians must deliver the diagnosis, describe the expected perinatal management plan, discuss short and long-term prognoses and introduce elements of uncertainty that may exist for the particular diagnosis. Physican training in these important skills is highly variable and many in our field acknowledge the need for improved guidance on best practices for counseling and supporting parents during pregnancy and early parenthood after prenatal diagnosis, while also sustaining physicians' own emotional well-being. We describe these challenges and the opportunities that exist to improve the current state of prenatal counseling in CHD.

Insights into Cardiovascular Defects and Cardiac Epigenome in the Context of COVID-19

Although few in number, studies on epigenome of the heart of COVID-19 patients show that epigenetic signatures such as DNA methylation are significantly altered, leading to changes in expression of several genes. It contributes to pathogenic cardiac phenotypes of COVID-19, e.g., low heart rate, myocardial edema, and myofibrillar disarray. DNA methylation studies reveal changes which likely contribute to cardiac disease through unknown mechanisms. The incidence of severe COVID-19 disease, including hospitalization, requiring respiratory support, morbidity, and mortality, is disproportionately higher in individuals with co-morbidities. This poses unprecedented strains on the global healthcare system. While their underlying conditions make patients more susceptible to severe COVID-19 disease, strained healthcare systems, lack of adequate support, or sedentary lifestyles from ongoing lockdowns have proved detrimental to their underlying health conditions, thus pushing them to severe risk of congenital heart disease (CHD) itself. Prophylactic vaccines against COVID-19 have ushered new hope for CHD. A common connection between COVID-19 and CHD is SARS-CoV-2’s host receptor ACE2, because ACE2 regulates and protects organs, including the heart, in various ways. ACE2 is a common therapeutic target against cardiovascular disease and COVID-19 which damages organs. Hence, this review explores the above regarding CHDs, cardiovascular damage, and cardiac epigenetics, in COVID-19 patients.

Resilience and Associated Factors in Mothers of Children with Congenital Heart Disease: A Cross-Sectional Study

BACKGROUND

Congenital heart disease (CHD) in children affects the parents' mental and physical health and their caring and supportive functions. Resilience is an important factor in health. This study aimed to determine resilience and its associated factors in mothers of children with congenital heart disease.

METHODS

This descriptive cross-sectional study enrolled 136 mothers of children with CHD. Samples were selected in two hospitals of Shahid Modarres and Children's Medical Center in Tehran, Iran, via convenience sampling from May to early October 2019. Data were collected using demographics questionnaire, Multidimensional Scale of Perceived Social Support (MSPSS), Life Orientation Test (LOT), and Wagnild and Young Resilience Scale (RS). Data were analyzed in statistical software SPSS-16 using independent t-test, ANOVA, Pearson and Spearman correlation, and multiple linear regression. The significance level was set at P<0.05.

RESULTS

Mothers' total mean score of resilience was 94.08±12.81, while 14.7%, 66.2%, and 19.1% had low, moderate, and high resilience, respectively. Regression analysis showed that two variables of social support (B=2.20, P<0.001) and optimism (B=0.76, P=0.003) were associated with resilience in mothers. The duration of the child's disease was positively correlated with the mothers' resilience but did not predict it (B=-0.72, P=0.22).

CONCLUSION

The level of resilience in most mothers was moderate. Social support in the dimension of significant others and optimism were associated with mothers' resilience. Therefore, holistic care and providing educational training programs that enhance these variables could be effective in promoting resilience in mothers of children with CHD.

Factors That Influence Parents' Decision-Making Regarding Termination of Pregnancy After Prenatal Diagnosis of Fetal Congenital Heart Disease

OBJECTIVE

To explore factors that influence parents' decisions regarding the termination of pregnancy after the detection of fetal congenital heart disease (CHD).

DESIGN

A prospective descriptive study.

SETTING

The Institute of Pediatric Cardiology in the Schneider Children's Medical Center.

PARTICIPANTS

One hundred twenty couples (240 participants) with fetuses prenatally diagnosed with CHD, which was defined as conditions requiring surgical treatment.

METHODS

We obtained data from a structured questionnaire for the pediatric cardiologist, the medical records, and structured self-report questionnaires for the participants.

RESULTS

Thirty-six of 120 couples (30%) decided to terminate the pregnancy after a prenatal diagnosis of fetal CHD. The main factors associated with the decision to terminate were low gestational age (OR = 0.83 per week, 95% confidence interval [CI] [0.75, 0.96]), severe cardiac malformation (OR = 2.23, 95% CI [1.40, 3.53]), religious affiliation (OR = 10.0 for secular participants vs. others, 95% CI [4.61, 22.46], population group (OR = 2.96 for Jewish participants vs. others, 95% CI [1.63, 11.3]), and education (OR = 1.34 per year of education, 95% CI [1.15, 1.55]).

CONCLUSIONS

Our findings describe the profiles of couples who decided to terminate their pregnancies after a prenatal diagnosis of fetal CHD. Early identification of the couple's decision can help health care providers provide adequate support, counseling, and guidance. Future research is needed to understand parents' needs for support through the process of decision-making, with attention to their religious and cultural values and contexts.

The parental journey of fetal care: a systematic review and metasynthesis

OBJECTIVE

This study aimed to synthesize the qualitative literature on parental experiences of fetal care to reflect events that happened across the continuum of care and to better understand parents' positive and negative experiences with care delivery.

DATA SOURCES

Eligible studies published until June 2020 were retrieved from MEDLINE, Embase, Cochrane Central Register of Controlled Trials, EBSCO CINAHL, Web of Science, and ProQuest.

STUDY ELIGIBILITY CRITERIA

Studies must have been: (1) published in English in a peer-reviewed journal or in ProQuest, (2) available in full text, (3) contained a qualitative component, and (4) focused on expectant parents' experiences of tertiary, coordinated, multidisciplinary prenatal diagnosis and care related to a fetal anomaly.

STUDY APPRAISAL AND SYNTHESIS METHODS

Researchers used the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. A metastudy and an interpretive description approach was taken to synthesize the events that happened across the continuum of care and the themes associated with a positive care experience.

RESULTS

The metasynthesis included 13 studies and 217 patients from 11 different multidisciplinary fetal diagnosis and intervention practices across North America and Europe. We identified key events that influenced parental experience of fetal care across the continuum. The themes associated with a positive care experience are parents (1) gaining understanding and feeling understood, (2) realizing agency and control, and (3) finding hope and meaning. We identified aspects of healthcare delivery that served as barriers or facilitators to these positive experiences.

CONCLUSION

Understanding the commonalities of the parental experience of fetal care across diverse settings creates a foundation for improving care and better meeting the needs of parents undergoing a painful and life-defining event. Although health outcomes are not always positive, a positive experience of care is possible and can assist parents to cope with their grief, manage their expectations, and engage in their care. The findings of this study illustrate the ways in which healthcare delivery can facilitate or obstruct a positive care experience.