Fetal echo – why bother? - Home - Pediatric and Fetal...
Transcript of Fetal echo – why bother? - Home - Pediatric and Fetal...
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Fetal echo – why bother?
Dr Luke Eckersley
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Disclosures
• I have no disclosures
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History of Fetal Echo
• 1957 Tom Brown invents first B-mode scanner
• 1958 Ian Donald, Glasgow – Fetal heads scanned
• 1980 Lindsay Allen
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History of Fetal Echo
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What we have learned about fetuses
Why a fetus can survive independently with most heart problems
01Progression of congenital heart disease before birth
02Differences from post-natal disease
03
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What can we treat in utero?
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Rhythm abnormalities• Supraventricular tachycardia
• Atrial Re-entrant tachycardia• Ectopic atrial tachycardia• Atrial flutter
• Natural history: • Without hydrops - 2-3% mortality • With hydrops - 14% intrauterine fetal death, 10% neonatal death, risk of neurological injury• With hydrops and no control of arrhythmia – up to 45% mortality!• With hydrops and control of arrhythmia - <10% mortality
• Simpson et al, Heart, 1998
• Maternal treatment with anti-arrhythmic medication can reduce risk of hydrops, fetal demise.
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Rhythm abnormalities
• Complete heart block• Related to maternal autoantibodies – 15% mortality
• Related to congenital heart disease – 85% mortality
• Can delay delivery by giving beta-blockers
• Can improve function and outcomes by giving steroids and IVIg
• If getting into trouble, can deliver early
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Complete heart blockImproved Perinatal Morbidity & Mortality
0 1 2 3 4 5 6 7 8 9 10 11 120
10
20
30
40
50
60
70
80
90
100
fetal therapy
no therapy
n = 13
n = 20
P < 0.01
follow-up (years)
Survival (%)
Therapy with maternal dexamethasone, ß sympathomimetics, and more aggressive perinatal management
Jaeggi, Hornberger et al Circulation 2004
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Congenital heart disease
• Transposition of the great arteries – Balloon atrial septostomy
• Tetralogy with absent pulmonary valve – Respiratory support
• Conditions that can be treated in utero
• Aortic stenosis
• Pulmonary stenosis
• Restrictive atrial septum
Conditions that may need emergency intervention / support
• Pulmonary atresia, critical pulmonary stenosis
• HLHS / critical aortic stenosis
• Critical coarctation of the aorta
Ductus-dependent conditions
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Conditions with cardiac involvement
• Twin-to-twin transfusion syndrome • Ventricular hypertrophy
• Diastolic dysfunction
• Right outflow tract obstruction
• Teratomas• High output cardiac failure
• Fetal Anemia• High output cardiac failure
laser therapy
in utero resection, early delivery
fetal transfusion
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Does it change outcomes?
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Does it change outcome?
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Percentage of prenatally and postnatally diagnosed (Dx) patients who were found to have tricuspid regurgitation
of mild or greater degree, right ventricular dysfunction, or a significantly (needing intervention) restrictive
interatrial septum on first postnatal echocardiogram and who needed preoperative bicarbonate or inotropic
medications.
Wayne Tworetzky et al. Circulation. 2001;103:1269-1273Copyright © American Heart Association, Inc. All rights reserved.
HLHS
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Data only from patients who underwent surgery depict difference between those who survived
and those who did not.
Wayne Tworetzky et al. Circulation. 2001;103:1269-1273
Copyright © American Heart Association, Inc. All rights reserved.
HLHS
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Does it change outcomes?
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Does it change outcomes?
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Does it change outcomes?
ALL CASES OF MORTALITY POSTNATAL DIAGNOSIS
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Does it change outcomes?
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Impact of prenatal diagnosis on parents
• 75% of parents had clinically significant psychological distress
• No difference in psychological distress either at diagnosis or at birth between pre and postnatal diagnosis
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Impact of prenatal diagnosis on parents
• 92% would have fetal echo for next pregnancy
• Increased anxiety, but
• Increased closeness to baby and partner
• 14% termination rate
• 23% of normal fetals would have considered termination
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Does it change prevalence?
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Does it improve hospital costs?
Neonates presenting with critical CHD amenable to a 2 ventricle repair
Prenatal dx Postnatal dx
* p < 0.05
Length of stay 10.06.0days 13.02.4days
Cost (US$)* 30,27716,869 64,6169441
Neonatal
survival*
96% 76%
Copel et al UOG 1997
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How are we doing?
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98% of referrals due to abn. OFT or OFT not well seen on obstetric screening study
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IMPROVING RATE OF FETAL DIAGNOSIS OF COARCTATION OF THE AORTA IN ALBERTA. DOES IT RELATE TO OBSTETRIC SCREENING GUIDELINES?
Luke Eckersley, Mehdi Houshmandi, Lisa K Hornberger
29%33%
29%
39%
49%54%
INFANT INTERVENTION
NEONATAL INTERVENTION
2004 - 2009 2010 - 2012 2013 - 2015
14%
33%
57%
44%
REGIONAL METROPOLITAN
2008-2011 2012-2015
p<0.01 ns
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Conclusions - Fetal Echocardiography
• Has taught as a lot about the fetal heart
• Allows for parental decisions and preparation
• Has a huge impact for conditions with• High risk of pre-operative mortality – TGA, Coarctation
• Risk of intrauterine fetal death – SVT, heart block
• Opportunity to intervene in utero – arrhythmia, aortic and pulmonary stenosis