Ethical issues in fetal management: a cardiac perspective

Prenatal diagnosis of significant congenital heart disease and elective termination of pregnancy in Nevada

OBJECTIVE

We investigated the relationship between prenatal detection of significant congenital heart disease and elective termination of pregnancy over time in Nevada.

METHODS

We identified those prenatally or post-natally diagnosed with significant congenital cardiovascular malformations in Nevada with birth dates or estimated delivery dates between July 2012 and June 2021.

RESULTS

We identified 1246. Of 1246, 69 underwent fetal demise, 42 had elective termination, and 1135 were live-born. Of the 1135 live-born, 1090 had prenatal care, of which 718 (66%) overall had a prenatal diagnosis of significant congenital heart disease. However, prenatal detection statistically significantly increased over time from 45 to 82%, p = .00001. Termination of pregnancy averaged 10% of those identified within the legal timeframe, and the rate did not statistically significantly increase with increasing prenatal detection rates, p = .56. Of the 42 undergoing elective termination, 23 (55%) had syndromes or comorbidities vs. 280 (25%) of the 1135 live-births, p = .0003.

CONCLUSIONS

In Nevada, despite a statistically significant increase in prenatal detection of significant congenital heart disease over time, termination of pregnancy rates did not increase. Nevertheless, those undergoing elective termination were more likely to have associated syndromes or comorbidities.

Counseling for fetal heart disease-current standards and best practice

Congenital heart disease (CHD) is the most common cause of major congenital anomalies affecting newborns. Prenatal detection of CHD has been improving continuously during the last two decades due to technical advances and thus optimized fetal cardiac imaging. Besides the in-utero diagnosis of CHD effective parental counseling is an integral part of any Fetal Cardiology Program. However, studies on the most effective techniques are scarce, as well as data on empirical assessment of counseling and its effectiveness. In this review article, we summarize current guidelines from different international associations and societies. We provide an updated literature overview evaluating current standards of counseling with regard to parental needs. This includes ethical aspects, counseling for univentricular disease and in-utero cardiac interventions. We discuss our method to assess counseling success for fetal heart defects by exploring different analytical dimensions that may be considered helpful in order to improve efficacy. Finally, we present a proposal of how to optimize a setting for counseling based on the current literature and our own data. In summary, parental counseling for fetal heart disease is complex and multidimensional. Significant expertise in fetal cardiology and physiology, potential progression of CHD, postnatal treatment strategies and knowledge of long-term sequelae is necessary. A structured approach, together with continuous improvement of communicative skills, may lead to more effective counseling for parents following a diagnosis of CHD in the fetus.

Objective Assessment of Counselling for Fetal Heart Defects: An Interdisciplinary Multicenter Study

The objective of this study was to analyze parental counselling for fetal heart disease in an interdisciplinary and multicenter setting using a validated questionnaire covering medical, sociodemographic, and psychological aspects. n = 168 individuals were recruited from two pediatric heart centers and two obstetrics units. Overall, counselling was combined successful and satisfying in >99%; only 0.7% of parents were dissatisfied. “Perceived situational control” was impaired in 22.6%. Adequate duration of counselling leads to more overall counselling success (r = 0.368 ***), as well as providing written or online information (57.7% vs. 41.5%), which is also correlated to more “Transfer of Medical Knowledge” (r = 0.261 ***). Interruptions of consultation are negatively correlated to overall counselling success (r = −0.247 **) and to “Transparency regarding the Treatment Process” (r = −0.227 **). Lacking a separate counselling room is associated with lower counselling success for “Transfer of Medical Knowledge” (r = 0.210 ***). High-risk congenital heart disease (CHD) is correlated to lower counselling success (42.7% vs. 71.4% in low-risk CHD). A lack of parental language skills leads to less overall counselling success. There is a trend towards more counselling success for “Transfer of Medical Knowledge” after being counselled solely by cardiologists in one center (r = 0.208). Our results indicate that a structured approach may lead to more counselling success in selected dimensions. For complex cardiac malformations, counselling by cardiologists is essential. Parental “Perceived Situational Control” is often impaired, highlighting the need for further support throughout the pregnancy.

Counseling for Prenatal Congenital Heart Disease-Recommendations Based on Empirical Assessment of Counseling Success

Objectives: Empirical assessment of parental needs and affecting factors for counseling success after prenatal diagnosis of congenital heart disease (CHD). Methods:Counseling success after fetal diagnosis of CHD was assessed by a validated standardized questionnaire. The dependent variable "Effective Counseling" was measured in five created analytical dimensions (1. "Transfer of Medical Knowledge-ToMK"; 2. "Trust in Medical Staff-TiMS"; 3. "Transparency Regarding the Treatment Process-TrtTP"; 4. "Coping Resources-CR"; 5. "Perceived Situational Control-PSC"). Analyses were conducted with regard to influencing factors and correlations. Results: Sixty-one individuals (n = 40 females, n = 21 males) were interviewed in a tertiary medical care center. Median gestational age at first parental counseling was 28 + 6 weeks. Parental counseling was performed four times (median), mostly by pediatric cardiologists (83.6%). Overall counseling was successful in 46.3%, satisfying in 51.9%, and unsuccessful in 1.9%. Analyses of the analytical dimensions show that counseling was less successful for TOMK (38.3%) and PSC (39%); success rates were higher if additional written information or links to web sources were provided (60 and 70%, respectively). Length of consultation was positively correlated to counseling success for ToMK (r = 0.458), TrtTP (r = 0.636), PSC (r = 0.341), and TiMS (r = 0.501). Interruptions were negatively correlated to the dimensions TiMS (r = -0.263), and TrtTP (r = -0.210). In the presence of high-risk CHD (37.5%) overall counseling success was lower (26.1%). By cross table analysis and to a low degree of positive correlation in one dimension (ToMK; r = 0.202), counseling tends to be less successful for ToMK, TrtTP, and TiMS if parents have not been counseled by cardiologists. Analyses regarding premises show a parental need for a separate counseling room, which significantly impacts ToMK (r = -0,390) and overall counseling success (r = -0.333). A language barrier was associated with lower success rates for ToMK, TiMS, and CR (21.4, 42.9, and 30.8%). Conclusions: Data from this multidisciplinary study indicate that parents after fetal diagnosis of CHD need uninterrupted counseling of adequate duration and quality in a separate counseling room. Providing additional written information or links to adequate web sources after initial counseling seems necessary. High-risk CHD needs more attention for counseling. There is a trend towards more counseling success if provided by cardiologists.

Milestones in pediatric cardiology: making possible the impossible

Pediatric Cardiology as a discipline has been proposed to have been born on August 26, 1938, when Robert Gross at the age of 33 years, successfully ligated a patent ductus arteriosus of a 7 years girl at the Children's Hospital in Boston. In November 1944, Helen Taussig convinced Alfred Blalock to anastomose the left subclavian artery to the left pulmonary artery after Robert Gross had declined to cooperate with her. About the 1950s, at the University of Minneapolis, Clarence Walton Lillehei worked on a controlled "crossed circulation" in which the cardiopulmonary bypass machine was another human, generally one of the patient's parents. In 1966 Williams Rashkind introduced ballon septostomy as a palliative approach to complete transposition of the Great Arteries, followed later by Jean Kan's balloon valvuloplasty to open the pulmonary valve. During the 1960s Giancarlo Rastelli developed a new classification of the Atrio Ventricular Canal defect which allowed to have a strikingly better surgical results. Today, even the hypoplastic left heart syndrome (HLHS), at one time a fatal condition, is operable. The completion of the Human Genome Project has been an enormous help in the understanding the genetic causes of cardiac anomalies. However, there are very few approved application for stem cells, and stem cells will not likely replace organ transplantation any time soon. Recently, the protein survivin has been described as a novel player in cardioprotection against myocardial ischemia/reperfusion injury. The science needs to be made with love to warrant the humanity of Research.

Should clinicians advise terminating a pregnancy following the diagnosis of a serious fetal cardiac abnormality?

An 18-year-old single mother presented for counseling following the diagnosis of a hypoplastic left heart syndrome in the fetus. Despite being encouraged by her family members to terminate the pregnancy, the clinicians involved endeavored to provide information in a non-directive manner in accordance with widely accepted norms for antenatal counseling. Following the consultation, however, the clinicians wondered whether they should have provided more directive advice. In this report, we review the ethics of counseling following the diagnosis of a severe fetal cardiac abnormality. We assess the general and specific arguments in favor of providing directive advice, at least in some circumstances. There may be legitimate concerns about harms to the fetus, to the mother, or to the wider community from continuing a pregnancy. While these arguments yield rare exceptions to the generally accepted practice that antenatal counseling should not be directive, they may still not apply to the more severe forms of congenital cardiac abnormalities.