Obstetric management of 219 infants with hypoplastic left heart syndrome

Delivery Outcome of Fetuses with Congenital Heart Disease-Is It Influenced by Prenatal Diagnosis?

Objective: The objective of this study is to assess the delivery outcomes of neonates with congenital heart defects (CHD), and to explore the effect of prenatal diagnosis on these outcomes. Methods: A retrospective study including singleton deliveries between 2011 and 2020. All singleton neonates delivered at >24 weeks of gestation were included in this study. Fetuses with known prenatal anomalies other than CHD were excluded from this study. Pregnancy and neonatal outcomes were analyzed. A comparison was made between pregnancies with CHD and controls; and between pregnancies with prenatal diagnosis of CHD and postnatal diagnosis of CHD. Results: A total of 1598 neonates with CHD (688, 43.1% diagnosed prenatally) comprised the study group, compared to 85,576 singleton controls. Pregnancies with CHD had significantly increased BMI before pregnancy, suffered more from diabetes and chronic hypertension, had more inductions of labor, and had more cesarean deliveries (CD) including both elective CD and urgent CD due to non-reassuring fetal monitor (NRFHR) (OR = 1.75; 95%CI 1.45−2.14). Prenatal diagnosis of CHD is associated with a significant increased rate of induction of labor compared to postnatal diagnosis of CHD (OR = 1.59; 95% CI 1.15−2.22), but did not affect the mode of delivery including the rate of CD and CD due to non-reassuring fetal heart rate (NRFHR). Gestational age at birth and birthweight were significantly lower in pregnancies with CHD compared to controls, with no difference between prenatal to postnatal diagnosis of the anomaly. Neonates with CHD had a higher incidence of hypoxic ischemic encephalopathy and seizures compared to controls without any impact by prenatal diagnosis. Conclusion: Prenatal diagnosis of CHD is associated with an increased rate of induction of labor, with no increased rate of CD and CD due to NRFHR. The 5-min Apgar score is lower in pregnancies with postnatal diagnosis of CHD.

Neonatal outcomes in fetuses with cardiac anomalies and the impact of delivery route

BACKGROUND

Congenital fetal cardiac anomalies compromise the most common group of fetal structural anomalies. Several previous reports analyzed all types of fetal cardiac anomalies together without individualized neonatal morbidity outcomes based on cardiac defect. Mode of delivery in cases of fetal cardiac anomalies varies greatly as optimal mode of delivery in these complex cases is unknown.

OBJECTIVE

We sought to determine rates of neonatal outcomes for fetal cardiac anomalies and examine the role of attempted route of delivery on neonatal morbidity.

STUDY DESIGN

Gravidas with fetal cardiac anomalies and delivery >34 weeks, excluding stillbirths and aneuploidies (n = 2166 neonates, n = 2701 cardiac anomalies), were analyzed from the Consortium on Safe Labor, a retrospective cohort study of electronic medical records. Cardiac anomalies were determined using International Classification of Diseases, Ninth Revision codes and organized based on morphology. Neonates were assigned to each cardiac anomaly classification based on the most severe cardiac defect present. Neonatal outcomes were determined for each fetal cardiac anomaly. Composite neonatal morbidity (serious respiratory morbidity, sepsis, birth trauma, hypoxic ischemic encephalopathy, and neonatal death) was compared between attempted vaginal delivery and planned cesarean delivery for prenatal and postnatal diagnosis. We used multivariate logistic regression to calculate adjusted odds ratio for composite neonatal morbidity controlling for race, parity, body mass index, insurance, gestational age, maternal disease, single or multiple anomalies, and maternal drug use.

RESULTS

Most cardiac anomalies were diagnosed postnatally except hypoplastic left heart syndrome, which had a higher prenatal than postnatal detection rate. Neonatal death occurred in 8.4% of 107 neonates with conotruncal defects. Serious respiratory morbidity occurred in 54.2% of 83 neonates with left ventricular outflow tract defects. Overall, 76.3% of pregnancies with fetal cardiac anomalies underwent attempted vaginal delivery. Among patients who underwent attempted vaginal delivery, 66.1% had a successful vaginal delivery. Women with a fetal cardiac anomaly diagnosed prenatally were more likely to have a planned cesarean delivery than women with a postnatal diagnosis (31.7 vs 22.8%; P < .001). Planned cesarean delivery compared to attempted vaginal delivery was not associated with decreased composite neonatal morbidity for all prenatally diagnosed (adjusted odds ratio, 1.67; 95% confidence interval, 0.85-3.30) or postnatally diagnosed (adjusted odds ratio, 0.99; 95% confidence interval, 0.77-1.27) cardiac anomalies.

CONCLUSION

Most fetal cardiac anomalies were diagnosed postnatally and associated with increased rates of neonatal morbidity. Planned cesarean delivery for prenatally diagnosed cardiac anomalies was not associated with less neonatal morbidity.

Perinatal and Delivery Management of Infants with Congenital Heart Disease

Advances in fetal echocardiography have improved prenatal diagnosis of congenital heart disease (CHD) and allowed better delivery and perinatal management. Some newborns with CHD require urgent intervention after delivery. In these cases, delivery close to a pediatric cardiac center may be considered, and the presence of a specialized cardiac team in the delivery room or urgent transport of the infant should be planned in advance. Delivery planning, monitoring in labor, rapid intervention at birth if needed, and avoidance of iatrogenic preterm delivery have the potential to improve outcomes for infants with prenatally diagnosed CHD.

Prenatal diagnosis of congenital heart disease and birth outcomes

This study was undertaken to examine the impact that prenatal diagnosis of congenital heart disease (CHD) has on birth and early neonatal outcomes. The prevalence of prenatally diagnosed CHD has risen over the past decade, but the effect that prenatal diagnosis of CHD has on peripartum decisions remains unclear. No consensus exists on the effect of prenatal diagnosis on neonatal outcomes. Between January 2004 and July 2009, a retrospective chart review of all neonates with CHD admitted to our institution's neonatal intensive care unit was conducted. Obstetric and postnatal variables were collected. Among the 993 subjects, 678 (68.3%) had a prenatal diagnosis. A prenatal diagnosis increased the odds of a scheduled delivery [odds ratio (OR) 4.1, 95% confidence interval (CI) 3.0-5.6] and induction of labor (OR 11.5, 95% CI 6.6-20.1). Prenatal diagnosis was not significantly associated with cesarean delivery when control was used for maternal age, multiple gestation, and presence of extracardiac anomaly. Mean gestational age had no impact on prenatal diagnosis, but prenatal diagnosis was associated with increased odds of delivery before a gestational age of 39 weeks (OR 1.5, 95% CI 1.1-1.9) and decreased odds of preoperative intubation (OR 0.5, 95% CI 0.3-0.6). Prenatal diagnosis did not have an impact on preoperative or predischarge mortality. Prenatal diagnosis was associated with increased odds of a scheduled delivery, birth before a gestational age of 39 weeks, and a decreased need for invasive respiratory support. Prenatal diagnosis of CHD was not associated with preoperative or predischarge mortality.

Impact of mode of delivery on markers of perinatal hemodynamics in infants with hypoplastic left heart syndrome

OBJECTIVE

To determine whether the mode of delivery of infants prenatally diagnosed with hypoplastic left heart syndrome (HLHS) affects markers of perinatal hemodynamics.

STUDY DESIGN

A retrospective review of patients diagnosed prenatally with HLHS and delivered within our institution was undertaken. Arterial blood gases, echocardiographic data, and markers of end organ function were compared based on route of delivery.

RESULTS

A total of 79 infants with HLHS were enrolled between January 2002 and December 2008. The infants delivered by elective cesarian delivery (CD) had younger gestational age compared with those delivered by vaginal delivery (VD) or by urgent CD/operative VD. Those delivered by elective CD had lower pH and higher partial pressure of CO(2) on arterial cord blood gas analysis. There were no differences in partial pressure of O(2) and base deficit among the 3 study groups. One-minute and 5-minute Apgar scores, markers of end organ function, echocardiographic parameters, length of hospitalization, and survival to discharge were similar among the groups.

CONCLUSIONS

Overall, newborns with a prenatal diagnosis of HLHS transitioned well to extrauterine life without significant acidosis regardless of the mode of delivery. Delivery of newborns with HLHS by elective CD did not demonstrate any hemodynamic advantage over VD in our cohort of patients.

Hypoplastic left heart syndrome diagnosed in fetal life: associated findings, pregnancy outcome and results of palliative surgery

OBJECTIVES

To analyze the main prenatal characteristics of hypoplastic left heart syndrome (HLHS), its association with extracardiac anomalies including increased nuchal translucency (NT) and the outcome of affected patients.

METHODS

We searched our database for classical forms of HLHS (aortic atresia, mitral and aortic atresia and critical aortic stenosis evolved to a severely hypoplastic left ventricle) prenatally diagnosed between 1998 and 2006. Data on 101 fetuses were retrieved and analyzed.

RESULTS

The main reason for referral was suspected heart defect on a routine ultrasound scan (82%). The mean gestational age at diagnosis was 21 weeks. Most cases were detected at < or = 22 weeks (72%), the upper limit for termination of pregnancy (TOP) in our country (Spain). An intact atrial septum was diagnosed in 11 of the 58 fetuses (19%) in which pulmonary vein blood flow was assessed, and this diagnosis was proved to be correct in the six liveborn babies. Most fetuses (68%) had an isolated HLHS. Fourteen fetuses (14%) were chromosomally abnormal and all had associated extracardiac defects. NT was above the 95th centile in 21 of the 74 cases (28%) in which this measurement was available. 79% (58/73) of the cases in which HLHS was detected at < or = 22 weeks were terminated, and no differences in the rate of TOP were found through the study period. Among the 43 continuing pregnancies, seven fetuses died in utero and there were 36 live births; in 12 cases the parents opted for compassionate care and 24 chose to have the infant surgically treated. In the cohort of intention-to-treat cases, the overall survival rate was 36% (9/25). This rate improved from 18% (2/11) in the period 1998-2002 to 50% (7/14) in 2003-2006. There were no survivors in cases with intact atrial septum or when there were associated defects. At follow-up, 2/9 survivors suffered from significant neurological morbidity.

CONCLUSIONS

Fetal echocardiography allows an accurate diagnosis of HLHS, which is made in most instances in the first half of pregnancy. Despite the advantage offered by the prenatal detection of HLHS, which provides the opportunity to plan perinatal management, our up-to-date results show that the outlook for these fetuses is still poor, and highlight the importance of presenting these figures when counseling parents with affected fetuses.

Safeguarding precarious survival: parenting children who have life-threatening heart disease

The purpose of this study is to describe the process of parenting a child with life-threatening heart disease. Despite advances in pediatric cardiac sciences, hypoplastic left heart syndrome remains difficult and controversial to treat. The Norwood surgical approach is a developing technology, and little is known about how mothers and fathers experience parenting a child who survives this treatment. Constructivist grounded theory informed this Canadian study that involved multiple interactive interviews with 9 mothers and 7 fathers of children with hypoplastic left heart syndrome who were at various stages of treatment. Extraordinary parenting in a context of uncertainty was evident as parents simultaneously safeguarded their child's precarious survival as well as their own survival. As technologically advanced treatment contributes to the survival of children with complex health conditions, health care professionals must consider how to promote and support parenting strategies that benefit the new survivors of technology as well as their families.

Risk-stratified approach to hybrid transcatheter-surgical palliation of hypoplastic left heart syndrome

We prospectively employed a risk-stratified approach to first-stage palliation of hypoplastic left heart syndrome. High-risk features included severe tricuspid insufficiency, severe right ventricular dysfunction, a severely restrictive or intact atrial septum, an ascending aortic diameter < or = 2 mm, late presentation, weight < 2 kg, or significant extracardiac issues, Infants without high-risk features underwent a Norwood procedure (with Sano modification), whereas infants with high-risk features underwent a hybrid procedure consisting of bilateral pulmonary artery banding, ductal stenting, and atrial septostomy or a Norwood/Sano. Operative survival for 10 infants without high-risk features undergoing a Norwood/Sano procedure was 90%. Operative survival for 5 infants with high-risk features undergoing hybrid palliation was 100%, compared to 29% in 7 infants with high-risk features undergoing the Norwood/Sano procedure. Although only short-term data are available, this hybrid palliative procedure may have a role for infants with hypoplastic left heart syndrome and high-risk features.

Pregnancy outcome of fetuses with a diagnosis of hypoplastic left ventricle on prenatal sonography

OBJECTIVE

The goal of our study was to assess the pregnancy outcome of fetuses with a diagnosis of hypoplastic left heart syndrome (HLHS) on prenatal sonography to determine the frequency of intrauterine fetal demise (IUFD) and any factors associated with IUFD.

METHODS

We reviewed all cases with the diagnosis of HLHS on prenatal sonography at our institution from 1992 through 2003. Data collected included gestational age at diagnosis, sonographic findings, karyotype testing, and pregnancy outcome.

RESULTS

Our study included 176 fetuses with HLHS. One hundred thirty-four fetuses were liveborn; 32 pregnancies were terminated; 3 IUFDs occurred; and outcome was unknown in 7. Of the 134 liveborn fetuses, 2 had abnormal karyotypes and 30 had other anomalies. Two of the 3 fetuses with IUFD had abnormal karyotypes, 1 with trisomy 13 and 1 with trisomy 18, and both had other anomalies on sonography. The third fetus with IUFD had no other anomalies but was 1 of triplets, and the karyotype was unknown.

CONCLUSIONS

Fetuses with HLHS diagnosed prenatally who have normal chromosomes are unlikely to die in utero.

Congenital heart disease and aneuploidy

Congenital heart disease (CHD) is one of the commonest prenatal diagnoses made on routine ultrasound screening. Overall, up to 33% of CHD are associated with fetal aneuploidy. However, some specific cardiac lesions have a significantly greater association with particular chromosomal abnormalities. The majority of fetuses with CHD and aneuploidy also have extra-cardiac anomalies and are best managed by a multidisciplinary team where the management and prognosis of the cardiac defect can be discussed in the context of the baby as a whole. It is therefore important for clinicians involved in the management of fetuses with CHD to be aware of the association of aneuploidy as well as the prognosis and management of these cases, so that they can appropriately counsel the parents. In this chapter, we review the frequency and types of aneuploidy associated with the commonly diagnosed CHD and discuss their management.

Issues related to prenatal diagnosis of congenital heart disease

Enhanced technology and professional expertise are making the diagnosis of congenital heart disease possible with increasing frequency during the prenatal period. This article describes the process of prenatal diagnosis of congenital heart disease and the many personal issues families face when they receive news of this condition. Ethical and legal considerations of prenatal diagnosis are reviewed. Brief vignettes describe what families experience when they receive the diagnosis. The role of the nurse in educating parents, assisting them in sorting out options for treatment, and providing ongoing care and support is discussed, and implications for nurses in obstetric, neonatal, and pediatric settings are reviewed. Finally, the need for further research on this topic is explored.

Indications for caesarean section

Caesarean section rates are rising. Caesarean section confers an increase in maternal mortality and morbidity as well as having considerable financial implications. Caesarean section is usually justified by the assumed benefit for the fetus. These benefits are often unquantified and based on scanty evidence. The changing trends in the rates of caesarean section for various indications may be explained partly by improved anaesthetic and neonatal techniques. Cultural changes and expectations in the general population and obstetricians' fear of litigation may have made the changing rate and indications for caesarean section seem more acceptable. There is little research evidence in this area. The evidence that caesarean section is the optimal mode of delivery for various major indications is critically examined. The obstetrician is under an obligation to share the evidence that caesarean section is the optimum mode of delivery with the pregnant woman and her birth attendants to allow the woman to make wise decisions about her management.

Structural cardiac anomalies

Although it is unrealistic to expect that all major structural cardiac anomalies will be detected at the time of routine prenatal ultrasound, an increase in prenatal diagnosis is anticipated as accreditation of ultrasound practices takes place nationwide. Following the diagnosis of congenital heart disease, evaluation for extracardiac anomalies and chromosomal abnormalities is important because these are found in up to 62% and 38% of prenatally identified cases, respectively. Although the literature is limited, counseling parents based on the prenatal experience gives them realistic information about frequency, diagnosis, associated findings, and prognosis of the heart defect found in their fetus. A multidisciplinary team of perinatologists, pediatric cardiologists, geneticists, pediatric cardiac surgeons, and neonatologists should be assembled to assist patients in making informed decisions about their pregnancies and to establish a reasonable management plan for ongoing pregnancies with congenital heart disease.

Outcome after prenatal diagnosis of hypoplastic left-heart syndrome: a case series

BACKGROUND

Traditionally, after prenatal diagnosis of hypoplastic left-heart syndrome (HLHS) couples have been offered termination of pregnancy or comfort care. Success of postnatal surgical options such as the Norwood procedure have been associated with survival of up to 60%. Whether survival is affected by the congenital anomaly being identified prenatally or postnatally remains uncertain.

METHODS

We reviewed all cases of prenatally diagnosed HLHS referred to the Fetal Medicine Unit at Birmingham Women's Hospital over 6 years between 1994 and 1999.

FINDINGS

87 cases of HLHS were referred at a median gestational age (95% CI) of 23 (19-37) weeks. Of these, 53 (61%) chose prenatal karyotyping. The overall frequency of abnormal karyotype was found in seven of 59 cases (12%) and associated structural anomalies in 18 of 87 (21%). After counselling, 38 of 87 couples (44%) chose termination of pregnancy. Of the remaining 49 fetuses, 11 (23%) were not considered for postnatal surgery because of parental choice and they died after compassionate care. Of the 36 babies who had surgery postnatally, 12 survived (33%). We recorded a survival rate of 38% for the stage-1 Norwood procedure in the prenatally diagnosed HLHS in our centre. These data suggest that at the point of prenatal detection, the overall survival rate for fetuses with HLHS is 25% (if terminated pregnancies are excluded).

INTERPRETATION

Fetal echocardiography allows early diagnosis of HLHS and gives clinicians the opportunity to triage this group dependent on prenatal findings, including karyotyping and the exclusion of other structural anomalies. These prospective data provide up-to-date information on the basis of which parents can make decisions.

Prenatal diagnosis and management of fetal cardiovascular malformations

Screening for fetal cardiovascular malformations is widely performed. Its accuracy is not yet satisfactory, but better training of ultrasonographers and extension from the four-chamber view to the study of the outflow tract are probably clues to an improvement. The main impact of prenatal diagnosis is still the termination of pregnancy for severe malformations and for those associated with chromosomal or extracardiac anomalies. There is now evidence that prenatal diagnosis improves perinatal morbidity or mortality for some malformations. New information about the molecular genetic basis of congenital heart disease will help in management and counselling.