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First guideline issued on diagnosis, treatment of fetal cardiac disease
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The American Heart Association has issued a new scientific statement containing recommendations for the diagnosis and treatment of fetal cardiac disease.
Among the topics included in the guidelines are fetal cardiac evaluation, fetal echocardiogram, extracardiac assessment, fetal wellness assessment, parent counseling, fetal medical therapy, fetal intervention and specialized delivery room care.
“We now have advanced imaging technologies … enabling physicians to diagnose fetal abnormalities early and with better detail and accuracy,” Mary T. Donofrio, MD, lead statement author and director of the Fetal Heart Program and Critical Care Delivery Service at Children’s National Medical Center, Washington, D.C., said in a press release. “Despite this, more than half of babies with congenital heart disease go undiagnosed before birth. We created these guidelines to provide pediatric cardiologists, obstetricians, maternal fetal specialists, radiologists, nurses and other health care providers with the latest developments in the rapidly developing area of fetal cardiology.”
Fetal echocardiography recommended for some pregnancies
Fetal echocardiography is recommended for pregnant women with certain risk factors. This may include women with pre-gestational diabetes, poorly controlled phenylkentonuria or autoimmune diseases such as lupus; women with congenital heart disease or a family history; women who have taken nonsteroidal anti-inflammatory agents in the late second or third trimesters; women who have taken retinoic acid while pregnant; fetuses of fathers with congenital heart disease or siblings with cardiac malformations; and fetuses with a suspected cardiac abnormality detected by obstetric ultrasound.
In addition, the guideline states that fetal echocardiogram is reasonable to perform in pregnancies of assisted reproductive technologies because the risk for congenital heart disease in infants conceived through in vitro fertilization is slightly higher than that for other infants.
The guideline specifies how a fetal echocardiogram should be conducted and recommends specific techniques for specific cases.
An extracardiac assessment in fetuses with known congenital heart disease should include genetic counseling with an offer of testing for aneuploidy and a detailed fetal ultrasound anatomy survey, according to the guideline. It is also reasonable to perform a fetal brain MRI or a fetal chest/lung MRI if abnormalities in those areas are suspected.
A fetal wellness assessment for fetuses with known congenital heart disease can include fetal movement assessment by the mother and non-stress testing and/or ultrasound-determined biophysical profile for fetuses at risk for hypoxemia or acidosis.
Prenatal counseling for parents of fetuses with known congenital heart disease is essential, according to the authors.
“Counseling should help alleviate parental guilt that is commonly associated with the prenatal diagnosis of fetal malformations,” they wrote. Parents should be informed about the range of treatment and management strategies before and after birth, as well as long-term postnatal prognosis, and this information should reflect the most current data. Given the stress involved for all parties when this information is shared, “a preset algorithm of what to say and the order in which information is given can be helpful.”
Fetal CV therapy now possible
Fetal therapy for CV conditions before birth is now possible, so it is important to manage and treat the fetus as a patient, according to the guideline.
Fetal medical therapy should be offered for fetuses with the following conditions: supraventricular tachycardia; ventricular tachycardia; various sustained tachycardias; and hydropic fetuses with an arrhythmia believed to be the cause of the fetal compromise.
However, fetal medical therapy is of no benefit to fetuses with bradycardia (except that caused by SSA injuries), irregular rhythms caused by extrasystolic beats, intermittent supraventricular tachycardia without fetal compromise or hydrops, or intermittent ventricular tachycardia <200 bpm without fetal compromise or hydrops fetalis, the authors wrote.
Catheter intervention may be considered for fetuses with aortic stenosis with antegrade flow and evolving hypoplastic left heart syndrome, among other conditions.
According to the guideline, specialized delivery room care should be planned for fetuses with dextro-Transposition of the great arteries or those with sustained or uncontrolled tachyarrhythmias with HF or hydrops fetalis. It also outlines cases for which specialized delivery room care is reasonable, where it may be considered and where it is not necessary.
The scientific statement has been endorsed by the Pediatric and Congenital Electrophysiology Society and the American Society of Echocardiography.
For more information:
Donofrio MT. Circulation. 2014;doi:10.1161/01.cir.0000437597.44550.5d.
Disclosure: Some members of the writing group report financial ties with AGA Medical, GE Healthcare, Phillips Medical and Siemens Medical.