Referral for fetal echocardiography is associated with increased maternal anxiety

The Utility of Screening Fetal Echocardiograms Following Normal Level II Ultrasounds in Fetuses with Maternal Congenital Heart Disease

INTRODUCTION

Fetal echocardiograms (F-echo) are recommended in all pregnancies when maternal congenital heart disease (CHD) is present, even if there was a prior level II ultrasound (LII-US) that was normal. The goal of this study was to evaluate if any diagnosis of a critical CHD was missed in a fetus with maternal CHD who had a normal LII-US.

METHODS

A retrospective chart review of all F-echoes where the indication was maternal CHD between 1/1/2015 to 12/31/2022 was performed. Fetuses were included if they had a LII-US that was read as normal and had an F-echo. Critical CHD was defined as CHD requiring catheterization or surgical intervention < 1 month of age.

RESULTS

A total of 296 F-echoes on fetuses with maternal CHD were evaluated, of which 175 met inclusion criteria. LII-US was performed at 19.8 ± 2.9 weeks gestational age and F-echo was performed at 24.2 ± 2.8 weeks gestational age. No patient with a normal LII-US had a diagnosis of a critical CHD by F-echo (negative predictive value = 100%). Evaluating those patients that had a negative LII-US, ten patients were diagnosed with non-critical CHD postnatally (negative predictive value = 94.3%). F-echo correctly diagnosed two of the ten missed LII-US CHD.

CONCLUSIONS

Critical CHD was not missed with a normal LII-US in this at risk population. F-echo also missed the majority of CHD when a LII-US was read as normal. A cost-benefit analysis of screening F-echo in fetuses with maternal CHD should be conducted if a normal LII-US has been performed.

Associations between anxiety, depression, and weight status during and after pregnancy: A systematic review and meta-analysis

Previous work has found adverse mental health symptomology in women living with obesity, compared with those of healthy weight, around the time of pregnancy. This meta-analysis aimed to explore the association between anxiety, depression, and weight status in women living with obesity before, during, and after pregnancy. Bibliographic databases were systematically searched, and 14 studies were included, which aimed to assess the association between excess weight and anxiety or depression outcomes in women before, during, or after pregnancy. Data were analyzed via narrative synthesis and random effects multi-level meta-analyses. Scores on mental health indices were significantly greater (indicative of worse anxiety/depression) in women with obesity compared to women of a healthy weight, around the time of pregnancy (SMD = 0.21 [95% CI: 0.11-0.31; 95% prediction intervals: 0.13-0.56], I2  = 73%, p < 0.01). Depressive symptoms were greater during and after pregnancy (SMD = 0.23 [95% CI: 0.13-0.34; 95% prediction intervals: -0.12 to 0.59], I2  = 75.0%, p < 0.01), and trait anxiety symptoms were greater during pregnancy (SMD = 0.24 [95% CI: 0.01-0.47; 95% prediction intervals: -0.25 to 0.72], I2  = 83.7%, p = 0.039) in women living with obesity, compared to those of healthy weight. Narrative evidence suggests that socioeconomic status and ethnicity may modify the relationship between obesity and mental health symptomology. The findings indicate that maternal obesity is associated with greater anxiety and depression symptoms. These findings may inform the design of maternal weight management interventions.

Experiences of fetal care, social support, and emotional functioning during the COVID-19 pandemic in women carrying a fetus with CHD

OBJECTIVE

To explore how the COVID-19 pandemic affected fetal care, social support, and emotional functioning for women carrying a fetus with CHD.

METHOD

This was a single-centre qualitative study of 31 women who received a prenatal diagnosis of CHD during the pandemic. Patients completed semi-structured interviews about their experiences with fetal care, social support, and perceptions of risk to themselves and their fetus. Consistent themes regarding the impact of the pandemic were identified using an inductive thematic approach. Demographic data were collected via self-report and chart review.

RESULTS

Women generally reported consistent access to fetal care throughout the pandemic, with frequent use of telemedicine in addition to in-person care, but negative impacts resulting from restrictions on family support at appointments. Limited access to social support overall and a loss of pregnancy traditions were described. Many women reported feeling isolated and experiencing worries and fears about COVID-19 but also noted feeling supported by their healthcare team. Partner/family support during appointments and connection to peer-to-peer support were identified as recommendations to mitigate negative impacts.

CONCLUSION

Women carrying a fetus with CHD during the COVID-19 pandemic experienced unique stressors that may affect mental health. However, many also experienced unexpected supports that may mitigate effects of pandemic-related stressors. Results can inform efforts to promote positive family outcomes during and following the COVID-19 pandemic.

Utility of Screening Fetal Echocardiograms at a Single Institution Following Normal Obstetric Ultrasound in Fetuses with Down Syndrome

Fetal echocardiograms (F-echo) are recommended in all pregnancies when the fetus has Down syndrome (DS) even if there was a prior obstetric scan (OB-scan) that was normal. The utility of a screening F-echo in this high-risk population when an OB-scan is normal is unknown. Goal of this study was to evaluate if any diagnosis of a critical congenital heart disease (CHD) was missed in a fetus with DS who had a normal OB-scan. Secondary goal was to determine if any CHD was missed postnatally when an OB-scan was read as normal. Retrospective chart review of all fetuses that had a F-echo whose indication was DS between 1/1/2010 to 6/30/2022 was performed. Fetuses were included if they had an OB-scan that was read as normal and had a F-echo. Postnatal transthoracic echocardiogram (pTTE) was reviewed when available. Critical CHD was defined as CHD requiring catheterization or surgical intervention < 1 month of age. One hundred twenty-two F-echo on fetuses with DS were evaluated, of which 48 met inclusion criteria. OB-scan was performed at 20.4 ± 4.5 weeks gestational age and F-echo was performed at 24.0 ± 4.6 weeks gestational age. No patient with a normal OB-scan had a diagnosis of a critical CHD by F-echo (n = 48, negative predictive value = 100%). Evaluating those patients that had an OB-scan and a pTTE (n = 38), 14 patients were diagnosed with CHD (muscular ventricular septal defect (VSD) n = 5, perimembraneous VSD n = 3, secundum atrial septal defect (ASD) n = 2, primum ASD n = 1, transitional atrioventricular septal defect (AVSD) n = 2, and aortic valve abnormality n = 1; negative predictive value = 63.2%). F-echo correctly diagnosed 4 of the 14 missed OB-scan CHD (perimembraneous VSD n = 2, muscular VSD n = 1, and transitional AVSD n = 1). Critical CHD was not missed with a normal OB-scan in this high-risk population. F-echo also missed the majority of CHD when an OB-scan was read as normal. The cost/benefit of screening F-echo in fetuses with DS should be evaluated if a normal OB-scan has been performed, considering all these patients would have a pTTE performed per guidelines.

Associated factors with parental pregnancy decision-making and use of consultation after a prenatal congenital heart disease diagnosis

BACKGROUND

Prenatal diagnosis of congenital heart disease (CHD) often leads affected families to experience psychological stress. Pediatric cardiology consultation is important in providing parents with sufficient information and reducing their anxiety to make an informed pregnancy decision. Involving a fetal nurse coordinator may optimize fetal anomaly care. Our study aimed to identify factors associated with parental decision-making for choosing to use pediatric cardiology consultations and pregnancy termination.

METHODS

From September 2017 to December 2018, all fetal CHD cases diagnosed in the second trimester from a primary screening clinic in Taiwan were included (n = 145). Univariate and multivariate logistic regression were performed to analyze maternal, fetal, and medical factors for predictors of parental decisions for consultation use and pregnancy termination.

RESULTS

Acceptance for fetal nurse coordinator care and pediatric cardiology consultation were 84.8% (n = 123) and 83.4% (n = 121), respectively. Predictors for termination of pregnancy included the following: multiple anomalies (OR: 10.6; 95% CI: 3.6-35.7), chromosomal/genetic abnormalities (OR: 20.2; 95% CI: 3.1-395.8), severe CHDs (OR: 9.8; 95% CI: 4.3-23.4), CHDs that required surgery (OR: 32.4; 95% CI: 11.4-117.8), and physiological single-ventricle (OR: 47.3; 95% CI: 12.4-312.5). Parents who had pediatric cardiology counseling were less likely to terminate the pregnancy (OR: 0.1; 95% CI: 0.0-0.7). Parents with fetal diagnosis having multiple anomalies (OR: 0.2; 95% CI: 0.1-0.7) or chromosomal/genetic abnormalities (OR: 0.1; 95% CI: 0.03-0.9) were less likely to make use of cardiology consultation. Parents who accepted fetal nurse coordinator care were more likely to have pediatric cardiology consultation before pregnancy decision (OR: 149.5, 95% CI: 37.8-821.5).

CONCLUSIONS

Anomaly complexity appeared to be a strong predictor for termination of pregnancy beyond non-acceptability of prenatal cardiology consultation. Prenatal cardiology counseling may help support the parental decision to continue with the pregnancy. Incorporation of a fetal nurse coordinator care into the multidisciplinary fetal medicine team improved the acceptability of prenatal consultation.

Positive effects of fetal echocardiography on maternal anxiety: a prospective study in a tertiary center in Turkey

Aim: The aim of this study was to determine the anxiety levels of pregnant women who were referred to a tertiary center for fetal echocardiography (FE) and the effect of FE results on maternal anxiety.Methods: This prospective study was conducted between January 2020 and February 2021 and included 118 pregnant women. The anxiety levels of the participants were evaluated with the Spielberger State-Trait Anxiety Inventory, which evaluates state (STAI-I) and trait (STAI-II) anxiety. STAI-I and STAI-II were administered to participants at first admission using a standard interview technique prior to FE. After the FE was completed, a structured interview was performed and the state anxiety index (STAI-I-R) was re-administered to the participants.Results: Severe congenital heart disease (CHD) was detected in 63 (53.4%) fetuses. The participants' mean STAI-I scores were significantly higher than their mean STAI-II scores (44.19 ± 8.56 and 41.98 ± 5.98, respectively, t = 2.59 and p = 0.011). In pregnant women with fetuses with severe CHD, STAI-I-R scores were significantly lower compared to STAI-I scores (43.48 ± 7.97 and 46.28 ± 7.18, respectively, t = 2.13 and p = 0.037).Conclusion: Referral for FE is associated with increased maternal anxiety, and a structured interview may result in reduced anxiety levels even in those with abnormal FE.

Care of the Fetus With Congenital Cardiovascular Disease: From Diagnosis to Delivery

BACKGROUND

The majority of congenital cardiovascular disease including structural cardiac defects, abnormalities in cardiac function, and rhythm disturbances can be identified prenatally using screening obstetrical ultrasound with referral for fetal echocardiogram when indicated.

METHODS

Diagnosis of congenital heart disease in the fetus should prompt assessment for extracardiac abnormalities and associated genetic abnormalities once maternal consent is obtained. Pediatric cardiologists, in conjunction with maternal-fetal medicine, neonatology, and cardiothoracic surgery subspecialists, should counsel families about the details of the congenital heart defect as well as prenatal and postnatal management.

RESULTS

Prenatal diagnosis often leads to increased maternal depression and anxiety; however, it decreases morbidity and mortality for many congenital heart defects by allowing clinicians the opportunity to optimize prenatal care and plan delivery based on the specific lesion. Changes in prenatal care can include more frequent assessments through the remainder of the pregnancy, maternal medication administration, or, in selected cases, in utero cardiac catheter intervention or surgical procedures to optimize postnatal outcomes. Delivery planning may include changing the location, timing or mode of delivery to ensure that the neonate is delivered in the most appropriate hospital setting with the required level of hospital staff for immediate postnatal stabilization.

CONCLUSIONS

Based on the specific congenital heart defect, prenatal echocardiogram assessment in late gestation can often aid in predicting the severity of postnatal instability and guide the medical or interventional level of care needed for immediate postnatal intervention to optimize the transition to postnatal circulation.

Utility of Screening Fetal Echocardiogram Following Normal Anatomy Ultrasound for In Vitro Fertilization Pregnancies

In vitro fertilization (IVF) is associated with a higher incidence of congenital heart disease, resulting in universal screening fetal echocardiograms (F-echo) even when cardiac structures on obstetric scan (OB-scan) are normal. Recent studies suggest that when OB-scan is normal, F-echo may add little benefit and increases cost and anxiety. We aim to determine the utility of screening F-echo in IVF pregnancies with normal cardiac anatomy on prior OB-scan. We conducted a retrospective chart review of IVF pregnancies referred for F-echo at the Seattle Children's Hospital between 2014 and 2020. OB-scan results and subspecialty of interpreting physician (Obstetrics = OB; Maternal Fetal Medicine = MFM; Radiology = Rads), F-echoes, and postnatal outcomes were reviewed. Cardiac anatomy on OB-scans was classified as complete if 4-chamber and outflow-tract views were obtained. Supplemental views (three-vessel and sagittal aortic arch views) on OB-scan were also documented. Of 525 IVF referrals, OB-scan reports were available for review in 411. Normal anatomy was demonstrated in 304 (74%) interpreted by OB (128; 42%), MFM (80; 26%), and Rads (96; 32%). F-echo was normal in 278 (91%). Of the 26 abnormal F-echo, none required intervention (17 muscular and 5 perimembranous ventricular septal defects, and 4 minor valve abnormalities). There was no difference in OB-scan accuracy for identifying normal cardiac anatomy when comparing 4-chamber and outflow-tract views vs. addition of supplemental views (91% vs 92% normal F-echo; p > 0.1). Evaluation of OB-scan accuracy by interpreting physician subspecialty demonstrated normal F-echo in 95%, 85%, and 92% (p = 0.95) as read by OB, MFM, and Rads, respectively. A majority of IVF referrals with normal cardiac anatomy visualized on OB-scan using 4-chamber and outflow-tract views resulted in normal F-echo, regardless of interpreting physician subspecialty or addition of supplemental views. Of the minority with abnormal F-echo, none required intervention. Consideration should be given to the cost/benefit of screening F-echo for the indication of IVF if normal cardiac anatomy is demonstrated on OB-scan.

Parents' Perspectives on Counseling for Fetal Heart Disease: What Matters Most?

After diagnosis of congenital heart disease (CHD) in the fetus, effective counseling is considered mandatory. We sought to investigate which factors, including parental social variables, significantly affect counseling outcome. A total of n = 226 parents were recruited prospectively from four national tertiary medical care centers. A validated questionnaire was used to measure counseling success and the effects of modifiers. Multiple linear regression was used to assess the data. Parental perception of interpersonal support by the physician (β = 0.616 ***, p = 0.000), counseling in easy-to-understand terms (β = 0.249 ***, p = 0.000), and a short period of time between suspicion of fetal CHD, seeing a specialist and subsequent counseling (β = 0.135 **, p = 0.006) significantly improve “overall counseling success”. Additional modifiers (e.g., parental native language and age) influence certain subdimensions of counseling such as “trust in medical staff” (language effect: β = 0.131 *, p = 0.011) or “perceived situational control” (age effect: β = 0.166 *, p = 0.010). This study identifies independent factors that significantly affect counseling outcome overall and its subdimensions. In combination with existing recommendations our findings may contribute to more effective parental counseling. We further conclude that implementing communication skills training for specialists should be considered essential.

A Fetal Risk Stratification Pathway for Neonatal Aortic Coarctation Reduces Medical Exposure

OBJECTIVE

To test the hypothesis that a fetal stratification pathway will effectively discriminate between infants at different levels of risk for surgical coarctation and reduce unnecessary medicalization.

STUDY DESIGN

We performed a pre-post nonrandomized study in which we prospectively assigned fetuses with prenatal concern for coarctation to 1 of 3 risk categories and implemented a clinical pathway for postnatal management. Postnatal clinical outcomes were compared with those in a historical control group that were not triaged based on the pathway.

RESULTS

The study cohort comprised 109 fetuses, including 57 treated along the fetal coarctation pathway and 52 historical controls. Among mild-risk fetuses, 3% underwent surgical coarctation repair (0% of those without additional heart defects), compared with 27% of moderate-risk and 63% of high-risk fetuses. The combined fetal aortic, mitral, and isthmus z-score best discriminated which infants underwent surgery (area under the curve = 0.78; 95% CI, 0.66-0.91). Compared with historical controls, infants triaged according to the fetal coarctation pathway had fewer delivery location changes (76% vs 55%; P = .025) and less umbilical venous catheter placement (74% vs 51%; P = .046). Trends toward shorter intensive care unit stay, hospital stay, and time to enteral feeding did not reach statistical significance.

CONCLUSIONS

A stratified risk-assignment pathway effectively identifies a group of fetuses with a low rate of surgical coarctation and reduces unnecessary medicalization in infants who do not undergo aortic surgery. Incorporation of novel measurements or imaging techniques may improve the specificity of high-risk criteria.

COVID-19 Pandemic-Related Anxiety in Pregnant Women

The COVID-19 pandemic outbreak influenced general and mental health worldwide. The objective of this study was to assess the anxiety level during the COVID-19 pandemic among pregnant women and compare it between COVID-infected and non-infected groups. We prospectively assessed the daily routine and anxiety level using a bespoke questionnaire and GAD-7 scale validated for pregnant women. With logistic regression, we established possible risk factors of generalized anxiety disorder spectrum and main causes of concern. The dataset included 439 responders of our survey. Of which, 21% had COVID-19 infection during pregnancy; 38% were screened for possible generalized anxiety disorder and the proportion was higher in women who suffered from COVID-19 (48% vs. 35%, p = 0.03). Pre-pregnancy anxiety or depression diagnosis and intentional social contact avoidance increased the risk of anxiety (aOR 3.4 and 3.2). Fetal wellbeing was the main concern for 66% of the responders. The COVID-19 pandemic and related restrictions substantially altered daily lives of pregnant women, exaggerating the prevalence of anxiety compared with the pre-COVID-19 studies (38% vs. 15%). COVID-19 infection during pregnancy was associated with increased levels of generalized anxiety scores. Patient-tailored psychological support should be a mainstay of comprehensive antenatal medical care in order to avoid anxiety- and stress-related complications.

Postpartum depression in mothers with pregnancies complicated by fetal cardiac anomaly

OBJECTIVE

To investigate factors associated with positive postpartum depression (PPD) screen in pregnancies complicated by fetal congenital cardiac anomaly.

STUDY DESIGN

We reviewed all records of pregnancies complicated by fetal congenital cardiac anomaly receiving prenatal, intrapartum and postpartum care at our single center, October 2016-October 2019. Maternal, obstetric, and neonatal data were compared between women with and without a positive PPD screen at the 6-week postpartum visit.

RESULTS

Out of 415 women referred for fetal congenital cardiac anomaly, 86 women had complete inclusion criteria. Twenty-four women (28%) had a positive PPD screen. The frequencies of planned future infant surgery (73.9 vs. 26.2%, p = 0.01) and neonatal death prior to postpartum visit (12.5 vs. 0%, p = 0.02) were significantly higher among women with a positive PPD screen.

CONCLUSION

In pregnancies complicated by fetal congenital cardiac anomaly, mothers of infants with planned future surgery or neonatal death are at significant risk for postpartum depression.

Maternal Depressive Risk in Prenatal versus Postnatal Surgical Closure of Myelomeningocele: Associations with Parenting Stress and Child Outcomes

INTRODUCTION

Depressive risk is higher for mothers of infants with chronic medical conditions. The present study examined maternal depressive risk and associations with parent and child outcomes among mothers of young children who were randomized to either prenatal or postnatal surgical closure for myelomeningocele.

METHODS

Using the Management of Myelomeningocele Study database, maternal depressive risk was examined at 3 time points as follows: prior to birth, 12 months, and 30 months post birth. Separate multivariate analyses examined associations among change in depressive risk (between baseline and 30 months), parenting stress, and child outcomes at 30 months.

RESULTS

Mean scores were in the minimal depressive risk range at all the time points. Post birth depressive risk did not differ by prenatal versus postnatal surgery. Mean change scores reflected a decrease in depressive risk during the first 30 months. Only 1.1-4.5% of mothers reported depressive risk in the moderate to severe range across time points. Increased depressive risk during the first 30 months was associated with increased parenting stress scores and slightly lower child cognitive scores at 30 months.

CONCLUSION

Most mothers reported minimal depressive risk that decreased over time, regardless of whether their infant underwent prenatal or postnatal surgery. Only a small percentage of mothers endorsed moderate to severe depressive risk, but an increase in depressive risk over time was associated with higher parental stress and slightly lower child cognitive development.

The impact of our images: psychological implications in expectant parents after a prenatal diagnosis

Parents are at heightened risk for perinatal depression, anxiety and traumatic stress after receiving a prenatal diagnosis of a congenital anomaly. Identifying patients at risk and implementing effective support is crucial to optimizing care in this vulnerable population. A multidisciplinary care team with embedded psychosocial support services can be utilized to evaluate and address the needs of pregnant women and their families, not only at the time of diagnosis, but throughout the course of the pregnancy and postpartum period. Provider awareness helps to facilitate expedited referral to psychosocial services to provide comprehensive care to the patient and family unit.

Fetal lower urinary tract obstruction: What should we tell the prospective parents?

Fetal lower urinary tract obstruction (LUTO), which often results in marked perinatal morbidity and mortality, is caused by a heterogeneous group of anatomical defects that lead to blockage of the urethra. The classic prenatal presentation of LUTO includes megacystis with hydronephrosis. While mild forms of the disease can be associated with favorable outcomes, more severe disease commonly leads to dysplastic changes in the fetal kidneys, and ultimately oligohydramnios, which can result in secondary pulmonary hypoplasia and renal failure at birth. The aim of this review is to provide practitioners with a general overview of the diagnosis and treatment of LUTO based on disease severity, along with some points to consider when counseling prospective parents of fetuses with this condition.

Neonatal outcome of cases with isolated prenatal ventricular disproportion with a dominant right ventricle

OBJECTIVES

Isolated prenatal ventricular disproportion with a dominant right ventricle represents a challenge in decision-making for both physicians and pregnant women. In the current study, we sought to delineate the postnatal outcomes of these cases.

METHODS

This retrospective analysis included consecutive cases of isolated ventricular disproportion identified using complete fetal echocardiography at the Fetal Heart Center of Xinhua Hospital from January 2014 to October 2017. Postnatal cardiac outcome was examined using transthoracic echocardiography within the first 6 months after birth.

RESULTS

A total of 90 fetuses were included in the final analysis. The median gestational age (GA) at diagnosis was 29 weeks (range 24 to 36). At postnatal examination, cardiac malformations were detected in 39 cases (43.3%), including 25 (27.8%) cases of congenital cardiac septal defects, eight (8.9%) of persistent left superior vena cava, four (4.4%) of left-sided obstructive diseases, and one (1.1%) case of coronary fistula. Nineteen cases (21.1%) with fetal cardiac malformations had significant lower GA at diagnosis (P = .01) and greater right to left ventricle ratio (1.38 vs 1.30, P = .02). Neonatal surgical intervention was not required in any of the cases.

CONCLUSIONS

Isolated prenatal ventricular disproportion with a dominant right ventricle comprises minor postnatal cardiac malformations and doesn't require neonatal intervention.

An assessment of awareness of mental health conditions and its association with socio-demographic characteristics: a cross-sectional study in a rural district in Bangladesh

BACKGROUND

To assess the level of awareness, knowledge and help-seeking attitudes and behaviours in relation to mental health conditions (MHCs) and associations with socio-demographic characteristics of a rural district of Bangladesh.

METHODS

We recruited 2425 adult samples (18-90 years) from a Cross-sectional study in Narial district of Bangladesh. Data on awareness, knowledge, help-seeking attitudes and practice in relation to six MHCs were collected. The MHCs were classified as common (depression, anxiety and drug addiction), and severe (psychosis, dementia and bipolar disorder). Associations of MHCs with socio-demographic characteristics were assessed using Chi-square tests. Rasch analysis was performed to transform the latent attribute (awareness) of MHCs from ordinal to interval scale. Multiple regression analysis was performed to determine how the socio-demographic characteristics contribute to the combined awareness score of MHCs.

RESULTS

Of 2425 participants, 17 (0.7%) were cognizant of all the awareness construct of MHCs, and 1365 (56.28%) were not aware of any of MHCs. The prevalence of awareness of MHCs such as depression (8.5%), anxiety (6.2%), psychosis (3.5%), and bipolar disorder (3.3%), was found to be very low. Awareness was significantly lower in older adults, and in women. Higher levels of education (β 1.77, 95% confidence interval (CI): 1.58-1.97) associated with common MHCs and (β 0.81, 95% CI: 0.67-0.95) those associated with severe MHCs contributed significantly to increased awareness as opposed to having no or primary level of education. Availability of sufficient funds when applied to common MHCs (β 0.43, 95% CI: 0.26-0.61) and severe MHCs (β 0.25, 95% CI: 0.13-0.38) appeared to be more effective in boosting awareness compared to unstable financial situations. Almost 100% of the participants who were aware of the MHCs demonstrated positive attitudes towards seeking medical or psychological counselling.

CONCLUSIONS

Awareness of MHCs appeared to be very limited. However, knowledgeable participants were found to be very receptive to medical or psychological counselling. For improving awareness of MHCs need to conduct various intervention programs in particular those campaigns that focus on women, older adults, low SES and people up to the primary levels of education.

Systematic error and cognitive bias in obstetric ultrasound

Linked Comment: Ultrasound Obstet Gynecol 2019; 53: 454-464.

Parents' experiences of receiving an antenatal versus postnatal diagnosis of complex congenital heart disease

BACKGROUND

The time point at which parents receive a diagnosis of congenital heart disease (CHD) has changed over the years due in part to advances in fetal ultrasound. However, CHD remains undiscovered until after birth in some cases. The psychological effect of time of diagnosis on parents' experiences has not been well researched.

AIM

To explore parents' experiences at the time of diagnosis of complex CHD and to compare if experiences differ when receiving an antenatal versus postnatal diagnosis.

METHOD

Descriptive and thematic analysis of primary mixed qualitative and quantitative data, collected in 2012-2013, from an online survey of parents ( n =22) whose infants had undergone stage one surgery for a functionally univentricular heart.

FINDINGS

Four themes emerged: parents' understanding of the condition at the time of diagnosis; parents' emotions at the time of diagnosis; sources of support at the time of diagnosis; and additional sources of information after the diagnosis.

CONCLUSION

There are implications for practice in terms of who provides the diagnosis and, more importantly, how well it is explained. Professionals need to assess parents' emotional status, information needs and level of understanding irrespective of time of diagnosis, so that support is individualised, sensitive and time appropriate.

The Pediatric Cardiac Intensive Care Unit Parental Stress Model: Refinement Using Directed Content Analysis

This descriptive, qualitative study used directed content analysis to explore and clarify specific foci of parental stress for mothers of infants with complex congenital heart disease in the pediatric cardiac intensive care unit (PCICU). The PCICU Parental Stress Model was used as the guiding theoretical framework. Three focus groups were conducted with 14 mothers of infants who were being cared for in a PCICU at a large mid-Atlantic children's hospital. Data provided themes to support and refine the PCICU Parental Stress Model that can be used to guide practice, education, and future research in this unique population and setting.

Isolated Single Umbilical Artery and Fetal Echocardiography: A 25-Year Experience at a Tertiary Care City Hospital

OBJECTIVES

To review our 25-year experience with a single umbilical artery and fetal echocardiography to estimate the need for this test in cases of an isolated single umbilical artery.

METHODS

We conducted a retrospective review of 436 patients with a diagnosis of a single umbilical artery at our institution between 1990 and 2015. Two hundred eighty-eight women had both an anatomic survey and a fetal echocardiogram. Pregnancies with concurrent extracardiac anomalies or aneuploidy were excluded. The study population was divided into 3 groups based on cardiac views on the anatomic survey: normal, incomplete, and suspicious. Echocardiographic results were compared among the 3 groups. The primary outcome measure was the incidence of cardiac anomalies in the normal group at fetal echocardiography. The data were analyzed by the χ² test or Fisher exact test.

RESULTS

The mean maternal age ± SD of the group was 29.2 ± 6.2 years; 44.1% were primiparas. The mean gestational age at diagnosis was 22.6 ± 5.2 weeks, and the mean gestational age at fetal echocardiography was 25.1 ± 3.6 weeks. In the normal group, 99.1% (230 of 232) of women had a normal fetal echocardiogram; the 2 abnormal cases were ventricular septal defects. Normal echocardiograms were obtained in 81.8% (36 of 44) and 25.0% (3 of 12) of the "incomplete" and "suspicious" groups, respectively.

CONCLUSIONS

Fetuses with a single umbilical artery, in the absence of structural abnormalities, and with normal cardiac views at the time of the anatomic survey do not warrant an echocardiogram.

Clinical yield of fetal echocardiography for suboptimal cardiac visualization on obstetric ultrasound

OBJECTIVE

Suboptimal cardiac imaging on obstetric ultrasound is a frequent referral indication for fetal echocardiography, even in the absence of typical risk factors for fetal cardiac disease. The clinical profile of patients and findings of examinations performed for such an indication are not well defined. Given the increased cost, time and resource utilization of fetal echocardiography, we sought to determine the clinical findings of such referrals.

STUDY DESIGN

We performed a single-center review of such referrals from January 2010 to June 2016. Patients with commonly accepted indications for fetal echocardiography were excluded. Demographic variables and echocardiogram findings were collected. Findings were classified as (1) "normal," (2) "probably normal," if minor pathology could not confidently be excluded, or if minor findings were noted that were expected to resolve, or (3) "abnormal." Rates of pathology were determined with comparison of nonobese and obese populations.

RESULTS

A total of 583 gestations in 562 women were included (median gestational age 23.3 weeks, range 19.0-38.4). The median body mass index (BMI) was 34.6 kg/m² (range 17.2-66.3 kg/m² ). The majority of women were obese (BMI ≥ 30 kg/m² in 74.6%). Overall, 574 of 583 examinations (98.5%) were normal or "probably normal." Pathology was noted in 9 fetuses (1.5%), 3 of whom required intervention (0.5%). No ductal dependent lesions were diagnosed. There was no significant difference in pathology rates between nonobese and obese mothers.

CONCLUSIONS

We found a low fetal cardiac anomaly rate in studies performed for suboptimal views on obstetric ultrasound. The majority of women referred for this indication were obese. The practice of routine referral for this indication deserves further evaluation.

Coping with the Stress in the Cardiac Intensive Care Unit: Can Mindfulness Be the Answer?

BACKGROUND

Mothers of infants with complex congenital heart disease are exposed to increased stress which has been associated with numerous adverse health outcomes. The coping mechanisms these mothers use critically effect the familial illness adaptation and most likely infant outcomes. Currently no data-based strategies have been developed for mothers to facilitate their coping, and proactively promote their adaptation in the critical care settings. A potential strategy is mindfulness which is currently used in other clinical settings with stress-reduction effects.

PURPOSE

(1) To investigate coping mechanisms of mothers whose infant with complex CHD is admitted in the CICU, and (2) to explore the acceptability and feasibility of mindfulness as a potential stress-reduction intervention for these mothers.

DESIGN AND METHODS

A descriptive qualitative study obtained perspectives from 14 mothers during three focus groups. A qualitative conventional content analysis was performed using ATLAS.ti.

RESULTS

In congruence with the Stress and Coping framework, themes identified mostly emotion-regulatory coping mechanisms including both active and passive strategies such as positive thinking, denial, distraction, relying on support systems, and focusing on baby. Mindfulness was an acceptable and feasible approach for most participants, however, practice unfamiliarity, time and space concerns, and personal preferences were identified as potential barriers for future dissemination.

CONCLUSIONS

Mindfulness can potentially promote illness adaptation by utilization of active coping mechanisms. Early interventions can provide immediate, and potentially long-term stress relief. Intervention settings, format, and time-frame should be flexibly tailored to the trajectory of parental distress and familial adjustment.

Parenting Stress in Parents of Infants With Congenital Heart Disease and Parents of Healthy Infants: The First Year of Life

While we know that the parents of infants with congenital heart disease (CHD), the most prevalent group of congenital anomalies, experience increased parenting stress, the stress levels throughout infancy have yet to be studied. Stress experienced by parents beyond the normative stress of parenting can interfere with parenting processes, and bear adverse family outcomes. This prospective cohort study was conducted to describe and compare parenting stress levels during infancy between parents of infants with complex CHD and parents of healthy infants. The Parenting Stress Index-Long Form was distributed to parents of infants with complex CHD and parents of healthy infants (N = 129). T-tests were used to compare stress between groups at 3, 6, 9, and 12 months of age. Parents of infants with complex CHD had higher parenting stress than parents of healthy infants on multiple subscales on the Child and Parent Domains, at 3 months of age. The stress remained higher on the demandingness subscale throughout infancy. Parents of CHD infants also demonstrated significantly higher stress scores on the life stress subscale at 12 months of age. Findings highlight stressful periods related to parenting infants with CHD, which may increase existing psycho-social risk for parents of infants with CHD. Early family intervention may promote parental adaptation to the illness, and help establishing healthy parenting practices.

Identifying expectant parents at risk for psychological distress in response to a confirmed fetal abnormality

The aim of the study was to determine the incidence of psychological distress among expectant women carrying fetuses with prenatal diagnosed abnormalities and their partners. A 2-year retrospective medical chart review was completed of 1032 expectant mothers carrying fetuses with a confirmed anomaly, and 788 expectant fathers, who completed the CFDT Mental Health Screening Tool. Furthermore, 19.3 % of women and 13.1 % of men reported significant post-traumatic stress symptoms, and 14 % of men and 23 % of women scored positive for a major depressive disorder. Higher risk was noted among expectant parents of younger age and minority racial/ethnic status, and women with post-college level education and current or prior use of antidepressant medications. Heightened distress was noted within fetal diagnostic subgroups including neck masses, sacrococcygeal teratomas, neurological defects, and miscellaneous diagnoses. Incorporating screening tools into prenatal practice can help clinicians better identify the potential risk for psychological distress among expectant parents within high-risk fetal settings.

Parent's experiences of counselling and their need for support following a prenatal diagnosis of congenital heart disease--a qualitative study in a Swedish context

BACKGROUND

Prenatal screening for foetal cardiac abnormalities has been increasingly practiced in Sweden during the last 25 years. A prenatal diagnosis may have medical benefits but may also cause sustained parental psychological distress. The aim of this study was to explore pregnant women's, and their partner's, experiences of counselling and need for support during continued pregnancy following a prenatal diagnosis of a cardiac defect. A second aim was to use this information to propose a structured follow-up programme for continued support after the first counselling.

METHOD

DESIGN

Qualitative study, using interviews performed 5-9 weeks after a prenatal diagnosis of congenital heart disease.

SETTING

A tertiary foetal cardiology unit in Sweden Sample: Six pregnant women and their 6 partners, consecutively recruited after a prenatal diagnosis of an isolated and significant cardiac defect.

DATA ANALYSIS

Qualitative content analysis.

RESULTS

The analysis resulted in three themes. 1/ Counselling and making a decision--the importance of knowledge and understanding: Short waiting time for specialist evaluation together with clear and straightforward information was essential. Parents called for written information together with a high-quality website with relevant information about congenital heart disease. 2/ Continued support during pregnancy: Continued and easy access to health care professionals, including a paediatric specialist nurse, throughout pregnancy, was important. Contact with couples with similar experiences and social media were also considered valuable sources of support. 3/ Next step--the near future: Practical and economical issues during the postnatal hospital stay and the initial period following the hospital stay were common concerns.

CONCLUSIONS

The following aspects should be considered in a structured follow up program during pregnancy after a prenatal diagnosis of CHD; written information, access to a safe web-site with information of high quality in their native language, support from parents with similar experiences and continued contact with a specialist liaison nurse with experience of paediatric cardiology.

Pediatric prenatal diagnosis of congenital heart disease

PURPOSE OF REVIEW

Fetal cardiology is a rapidly evolving field. Imaging technology continues to advance as do approaches to in-utero interventions and care of the critically ill neonate, with even greater demand for improvement in prenatal diagnosis of congenital heart disease (CHD) and arrhythmias.

RECENT FINDINGS

Reviewing the advances in prenatal diagnosis of CHD in such a rapidly developing field is a broad topic. Therefore, we have chosen to focus this review of recent literature on challenges in prenatal detection of CHD, challenges in prenatal counseling, advances in fetal arrhythmia diagnosis, and potential benefits to patients with CHD who are identified prenatally.

SUMMARY

As methods and tools to diagnose and manage CHD and arrhythmias in utero continue to improve, future generations will hopefully see a reduction in both prenatal and neonatal morbidity and mortality. Prenatal diagnosis can and should be used to optimize location and timing of delivery and postnatal interventions.

Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association

BACKGROUND

The goal of this statement is to review available literature and to put forth a scientific statement on the current practice of fetal cardiac medicine, including the diagnosis and management of fetal cardiovascular disease.

METHODS AND RESULTS

A writing group appointed by the American Heart Association reviewed the available literature pertaining to topics relevant to fetal cardiac medicine, including the diagnosis of congenital heart disease and arrhythmias, assessment of cardiac function and the cardiovascular system, and available treatment options. The American College of Cardiology/American Heart Association classification of recommendations and level of evidence for practice guidelines were applied to the current practice of fetal cardiac medicine. Recommendations relating to the specifics of fetal diagnosis, including the timing of referral for study, indications for referral, and experience suggested for performance and interpretation of studies, are presented. The components of a fetal echocardiogram are described in detail, including descriptions of the assessment of cardiac anatomy, cardiac function, and rhythm. Complementary modalities for fetal cardiac assessment are reviewed, including the use of advanced ultrasound techniques, fetal magnetic resonance imaging, and fetal magnetocardiography and electrocardiography for rhythm assessment. Models for parental counseling and a discussion of parental stress and depression assessments are reviewed. Available fetal therapies, including medical management for arrhythmias or heart failure and closed or open intervention for diseases affecting the cardiovascular system such as twin-twin transfusion syndrome, lung masses, and vascular tumors, are highlighted. Catheter-based intervention strategies to prevent the progression of disease in utero are also discussed. Recommendations for delivery planning strategies for fetuses with congenital heart disease including models based on classification of disease severity and delivery room treatment will be highlighted. Outcome assessment is reviewed to show the benefit of prenatal diagnosis and management as they affect outcome for babies with congenital heart disease.

CONCLUSIONS

Fetal cardiac medicine has evolved considerably over the past 2 decades, predominantly in response to advances in imaging technology and innovations in therapies. The diagnosis of cardiac disease in the fetus is mostly made with ultrasound; however, new technologies, including 3- and 4-dimensional echocardiography, magnetic resonance imaging, and fetal electrocardiography and magnetocardiography, are available. Medical and interventional treatments for select diseases and strategies for delivery room care enable stabilization of high-risk fetuses and contribute to improved outcomes. This statement highlights what is currently known and recommended on the basis of evidence and experience in the rapidly advancing and highly specialized field of fetal cardiac care.

Comparison of method of conception in fetuses undergoing echocardiography at a tertiary referral center

OBJECTIVES

We compared the proportion of conception with and without in vitro fertilization (IVF) in fetuses with and without congenital heart disease (CHD).

METHODS

This was a retrospective review of fetal echocardiograms at Columbia University from 2007 to 2010, to identify the mode of conception.

RESULTS

Echocardiography was performed on 2828 fetuses, and 2761 (97.6%) had the method of conception documented. CHD was diagnosed in 22.4%, consisting predominantly of complex CHD. The proportion of IVF conception was lower in fetuses with CHD (6.9% CHD vs 10.3% no CHD, OR = 0.65 [95% CI 0.46-0.92], p = 0.01). IVF fetuses were conceived by elder mothers and were more likely part of a multiple gestation than those without IVF. In a multivariate model controlling for maternal age and multiple gestation, IVF was not associated with CHD diagnosis (OR = 1.1 [95% CI 0.77-1.7], p = 0.51).

CONCLUSION

At a tertiary referral center, fetuses with CHD were not more likely to be conceived by IVF after controlling for maternal age and multiple gestation. These results differ from those of several previous reports, which may be related to our study population, and the exclusion of isolated atrial shunts and patent ductus arteriosus, which are normal fetal findings.

Psychological correlates of decision-making during prenatal diagnosis: a prospective study

OBJECTIVE

Decision-making during prenatal diagnosis has not been extensively studied. We aimed to determine psychological correlates and level of decisional conflict following prenatal diagnosis.

METHOD

A total of 159 pregnant women were consecutively enrolled. All participants completed three questionnaires (the Hospital Anxiety and Depression scale, the Berlin Social Support scales and the Decisional Conflict scale) at three time points (T1 - waiting period between prenatal testing and disclosure of the results; T2 - decision phase within 3 days from test result disclosure; T3 - digestion period within 3 weeks from disclosure).

RESULTS

Women with fetal anomaly who terminate pregnancy were significantly more anxious and depressed than controls at each time point. Additionally, women with a normal fetus who terminate pregnancy presented higher level of anxiety and depression compared with controls at T2. Women who terminated pregnancy showed increased uncertainty scores at T2 and T3. Anxious and depressed individuals at T2 (decision period) were more uncertain about their choice at T3 compared to women with normal levels of anxiety and depression.

CONCLUSION

The decision to terminate pregnancy, irrespective of test results, may determine emotional distress and psychiatric morbidity. Women who were anxious and depressed at decision appeared to be more uncertain about their choices as time passed by. A careful assessment of women during prenatal diagnosis should be useful to identify women who may benefit from psychological support.

Maternal psychological stress after prenatal diagnosis of congenital heart disease

OBJECTIVE

To determine whether prenatal diagnosis of congenital heart disease (CHD) increases maternal stress.

STUDY DESIGN

Self-report instruments were administered to mothers carrying a fetus with CHD. Domains included: (1) traumatic stress (Impact of Events Scale-Revised); (2) depression (Beck Depression Index II); and (3) anxiety (State-Trait Anxiety Index). Modifiers included: (1) coping skills (COPE Inventory); (2) partner satisfaction (Dyadic Adjustment Scale); and (3) demographics. Multivariate linear regression models were used to assess relationships between stress measures and modifiers.

RESULTS

Fifty-nine mothers (gestational age 27 ± 3 weeks) completed all measures. Clinically important traumatic distress was seen in 39%, depression in 22%, and state anxiety in 31%. Lower partner satisfaction was associated with higher depression (P < .01) and higher anxiety (P < .01). After controlling for partner satisfaction and income, "denial" was most associated with increased traumatic stress, anxiety, and depression (P < .01).

CONCLUSIONS

Posttraumatic stress, depression, and anxiety are common after prenatal diagnosis of CHD. Healthy partner relationships and positive coping mechanisms can act as buffers.

Anxiety and depressed mood in obese pregnant women: a prospective controlled cohort study

BACKGROUND

The psychological health in obese women during pregnancy has been poorly studied.

OBJECTIVE

To compare levels of anxiety and depressed mood during pregnancy in obese versus normal-weight women.

METHODS

63 obese pregnant women and 156 normal-weight controls were included prospectively before 15 weeks of gestation. Levels of state and trait anxiety and depressed mood were measured during the first, second and third trimester of pregnancy. A linear mixed-effect model with repeated measures was used to evaluate group differences.

RESULTS

The levels of state anxiety significantly increased from trimester 1 to trimester 3 in obese pregnant women (beta = 3.70; p = 0.007), while this parameter remained constant throughout pregnancy in normal-weight women. Levels of trait anxiety and depressed mood significantly decreased from trimester 1 to trimester 2 in controls, but not in obese pregnant women. Variables such as maternal education, ethnicity, marital state, psychological history and miscarriages, parity and smoking behaviour had significant effects on anxiety and/or depressed moods during pregnancy. Obese pregnant women show higher levels of anxiety and depressive symptomatology compared to normal-weight pregnant women.

CONCLUSION

Interventional programmes aiming at preventing the deleterious influence of maternal obesity on perinatal outcomes should include a psycho-educational program specifically tailored to this high-risk group.

Fetal cardiac screening and variation in prenatal detection rates of congenital heart disease: why bother with screening at all?

Antenatal screening for fetal cardiac abnormalities was introduced over 25 years ago, yet detection of congenital heart disease before birth remains a challenge. While experienced tertiary centers report a high level of diagnostic accuracy, with most major forms of congenital heart disease being detectable before birth, the overall detection rate remains low. Pregnancies at increased risk of having an affected baby are referred to tertiary centers for fetal ECG, but most cases of congenital heart disease will occur in low-risk pregnancies. These cases will only be detected by screening the low-risk population at the time of routine obstetric scanning. Many obstetric ultrasound units have learnt to successfully obtain, and correctly interpret, views of the heart, including the four-chamber view and outflow tract views. However, standards for doing this are not uniform, nationally or internationally, so there is a significant variation in detection rates across individual countries and between different countries. Early diagnosis of babies with lesions that can result in cardiovascular collapse and death, could improve their survival as well as reducing morbidity. In addition, detection of a cardiac abnormality during pregnancy allows time to prepare parents for the likely course of events after birth. It also facilitates detection of other abnormalities in the baby and gives parents a choice, even if the choice is difficult and unwelcome. As well as providing parents with accurate and up-to-date information regarding the their baby’s abnormality, it is vital to provide continuing support to help them deal with the problem, regardless of what decisions they make. Much work remains to establish a uniform standard for antenatal detection of cardiac abnormalities. More recent national guidelines for examining the fetal heart along with formalized auditing processes should help to achieve this, although considerable time and effort will be required, particularly with regard to the teaching and training required.

Fetal and post-natal diagnosis of major congenital heart disease: implications for medical and psychological care in the current era

AIM

The fetal or post-natal diagnosis of major congenital cardiac abnormality has important medical and psychological consequences.

METHODS

We reviewed infants who underwent cardiac surgery in the first year of life at the Heart Centre for Children, The Children's Hospital at Westmead during 2009. The aims of this study were to: (i) examine the key features of cardiac diagnosis and clinical outcome, and (ii) consider how these data can inform priorities for the delivery of clinical services.

RESULTS

Over the 12-month study period, a first cardiac surgical procedure was performed on 195 infants, with 85 infants (44%) diagnosed in the antenatal period. Of the total sample, a subset of 90 babies (46%) underwent their first procedure in the neonatal period, with 62% having had a fetal diagnosis. Major intracardiac lesions including truncus arteriosus (100%), single ventricular lesions (83%), pulmonary atresia with ventricular septal defect (78%) and transposition of the great arteries (53%) were diagnosed prior to birth. Improved haemodynamic stability at initial presentation was found in those with a fetal diagnosis. The overall mortality rate for all patients was 6.1% at 12 months, with a higher mortality in infants with single ventricle.

CONCLUSIONS

The contemporary paradigm of care for infants with major congenital heart disease requires a multidisciplinary approach to care, with improvements in clinician-clinician and clinician-family communication, and psychological support and education for families. Changes in the allocation of resources are required to meet this model of best practice.

Unfractionated heparin for second trimester placental insufficiency: a pilot randomized trial

OBJECTIVE

To conduct a pilot randomized controlled trial of unfractionated heparin (UFH) in women considered at high risk of placental insufficiency in the second trimester.

METHODS

Women with either false-positive first trimester (pregnancy-associated placental protein-A [PAPP-A] < 0.35 MoM) or second trimester (alpha-fetoprotein [AFP] > 2.0 MoM, inhibin > 3.0 MoM, human chorionic gonadotropin > 4.0 MoM) serum screening tests or medical/obstetric risk factors were screened for placental insufficiency by sonographic evaluation of the placenta and uterine artery Doppler between 18 and 22 weeks. Thrombophilia screen-negative women with two or three abnormal test categories were randomized by 23+6 weeks to self-administration of subcutaneous unfractionated heparin (UFH) 7500 IU twice daily until birth or 34 weeks, or to standard care. Maternal anxiety and other maternal-infant outcomes were determined.

RESULTS

Thirty-two out of 41 eligible women consented, with 16 women randomized to UFH and 16 to standard care. There was no statistically significant difference identified between the two treatment groups (standard care vs. UFH) for the following: maternal anxiety score (mean [standard deviation]), 14.2 [± 1.6] vs. 14.0 [± 1.8]; birth weight (median [range]), 1795 [470-3295]g vs. 1860 [730-3050]g; perinatal death, 3 vs. 0; severe preeclampsia, 2 vs. 6; placental weight < 10th percentile, 7 vs. 4; or placental infarction, 4 vs. 3.

CONCLUSION

Our study design identified women at high risk of adverse maternal-infant outcomes attributable to placental insufficiency. Women with evidence of placental insufficiency were willing to undergo randomization and self-administration of UFH without increased maternal anxiety.