Prenatal diagnosis and management of fetal cardiovascular malformations

Impact of fetal counseling on outcome of antenatal congenital surgical anomalies

AIM

To analyze the impact of counseling on antenatal congenital surgical anomalies (ACSA).

METHODS

Cases presenting with ACSA for fetal counseling and those presenting in post-natal period following diagnosis of ACSA (PACSA) for surgical opinion were analyzed for spectrum, presentation and outcome.

RESULTS

117 cases including ACSA(68);PACSA(49) were analyzed. Gestational age at diagnosis of ACSA;PACSA was 17-37;17-39 weeks (median 24;32 weeks). Diagnoses in ACSA;PACSA included urological (26;31), neurological (10;5), congenital diaphragmatic hernia (CDH)(5;1), gastrointestinal (5;5), lung and chest anomalies (5;1), intraabdominal cysts (4;1), abdominal wall defects (4;0), tumors (3;3), limb anomaly (1;1), esophageal atresia (1;1), conjoint twins (1;0), hepatomegaly (1;0), and major cardiac anomalies (2;0). Two antenatal interventions were done for ACSA; vesicoamniotic shunt and amnioinfusion for oligohydramnios. 17;24 ACSA;PACSA required early surgical intervention in post-natal period. Nine ACSA underwent medical termination of pregnancy and 4 had intrauterine demise. Nine ACSA babies died including two CDH, one gastroschisis, one duodenal atresia, one conjoint twins, one megacystitis with motility disorder and three posterior urethral valves. All PACSA babies survived.

CONCLUSION

Fetal counseling for CSA portrays true outcome of ACSA with 32.3% (22/68) mortality versus 0% for PACSA due to selection bias. However, fetal counseling ensures optimal perinatal care.

Echocardiography in Early Pregnancy

Within the last decade, two significant events have contributed to the increasing interest in early fetal echocardiography. First, the introduction of high frequency vaginal ultrasound probes allows detailed visualization of cardiac structures at early stage of gestation, making early detection of fetal malformations possible. Second, the close relationship observed between some first trimester sonographic and Doppler markers and congenital heart defects allows an early identification of a high-risk group at 11 to 14 weeks of gestation. In this context, from the early 1990s, many authors have examined the potential role of the transvaginal approach to obtain earlier diagnosis of fetal cardiac malformations. Further studies have appeared in the literature showing that early transvaginal echocardiography in experienced hand is a fairly sensitive investigative tool. Although some malformations are detected as early as 11 weeks’ gestation, the optimal gestational age to perform the early scan is at least 13 weeks’ gestation. Transvaginal ultrasound is the preferred approach, although most of the authors agree that results can be improved if transabdominal ultrasound is also incorporated. The further application of color Doppler enhances visualization. The sensitivity and specificity of early fetal echocardiography for the detection of heart anomalies is acceptable compared to the ones obtained by mid-gestational echocardiography, showing a slight reduction in detection rates and an increase in false positive and negative rates. The cardiac anomalies detected at this early stage of pregnancy are mainly defects involving the four-chamber view, indicating that defects solely affecting the outflow tracts are difficult to diagnose in the first trimester of pregnancy. Heart defects diagnosed early in pregnancy tend to be more complex than those detected later, with a higher incidence of associated structural malformations, chromosomal abnormalities and spontaneous abortions. The neonate follow-up or postmortem examination in case of termination of pregnancy (TOP) is essential to assess the actual role of early fetal echocardiography. At present, early fetal echocardiography is a promising technique, which can be of considerable value for patients at high-risk. This technique is, however, currently limited to a few specialized centers.

The aim of this review is to explore the possibilities of examining the fetal heart at this early stage of pregnancy. This article also present our experience in the first multicenter trial in early fetal echocardiography performed in Spain. In accordance with other studies, this experience stresses the usefulness of early echocardiography when performed by expert operators on fetus specifically at risk for cardiac defects. Our review of these additional 48 cases contributes to the expanding literature on the ability of transvaginal ultrasonography to detect fetal heart defects in early pregnancy.

How to cite this article

Gabriel CC, Rodriguez PP. Echocardiography in Early Pregnancy. Donald School J Ultrasound Obstet Gynecol 2013;7(2):168-181.

Critical heart disease in the neonate: presentation and outcome at a tertiary care center

OBJECTIVE

To define the modes of presentation, incidence of major organ dysfunction, predictors of hospital mortality, and adverse outcomes in neonates with critical heart disease admitted to a tertiary care center.

DESIGN

Retrospective chart review.

SETTING

A tertiary care pediatric cardiac intensive care unit and neonatal intensive care unit.

PATIENTS

The medical records for all neonates (< or = 30 days of age) with heart disease admitted to the cardiac intensive care unit or neonatal intensive care unit between October 1, 2002, and September 30, 2003, were reviewed.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 190 neonates met inclusion criteria during this 1-yr period, of which 146 (77%) had at least one surgical procedure. Single ventricle heart disease was present in 42%. The most common mode of presentation was following a prenatal diagnosis (53%), followed by diagnosis in the newborn nursery (38%) and diagnosis after newborn hospital discharge (8%). The most common presenting findings in the newborn nursery were isolated murmur (38%) or cyanosis (32%), while circulatory collapse (38%) was the most common presentation after discharge. For the entire study cohort, 13% had a known genetic syndrome, 23% had a major noncardiac congenital anomaly, and 16% weighed < 2.5 kg. The hospital mortality for the entire cohort was 7.4%. Risk factors associated with an increased risk of hospital mortality included younger age at admission, higher number of cardiopulmonary bypass runs, and need for postoperative cardiopulmonary resuscitation. Total hospital length of stay was > 1 month in 17% of neonates.

CONCLUSIONS

In patients with complex congenital heart disease, including nearly half with single ventricle heart disease, neonatal hospital mortality was 7%. These patients have a high frequency of multiple congenital anomalies, genetic syndromes, low birth weight, and prolonged length of stay.

Genetic counseling throughout the life cycle

As the definition of genetic counseling continues to evolve, so does the application of genetic counseling services in all areas of medicine and throughout the human life cycle. While governmental policy, economics, ethics, and religion continue to influence society's views regarding the necessity of testing germ cells for mutations to prevent the birth of an affected child or predicting whether healthy adults will develop future life-threatening illness, patient autonomy in the choice of whether to know, or not know, one's genetic make-up remains a core principle of genetic counseling.