Diagnosis and outcome of pregnancies with prenatally diagnosed fetal dextrocardia

Objective: To evaluate the incidence, associated cardiac and extracardiac malformations and clinical outcome of fetuses with dextrocardia.

Method: A retrospective review of 3556 fetal echocardiograms between 2000 and 2011 revealed 39 cases of dextrocardia. Dextrocardia was defined as right-sided positioning of the fetal heart. Prenatal and postnatal records of the fetuses were reviewed.

Results: The incidence was 1.1%. Of the 39 fetuses, 22 were primary dextrocardia and 17 were dextroposition. Diaphragmatic hernia was the most common cause of dextroposition with the incidence of 76%. Of the fetuses with dextroposition 35.5% had a cardiac anomaly. The survival rate of dextroposition was 31.2% and none of the survivors had an associated cardiac anomaly. Primary fetal dextrocardia was most common with situs solitus (45.4%), followed by situs ambiguous (36.3%) and then situs inversus totalis (18.1%). Structural cardiac malformations were found in 100%, 80% and 25% of fetuses with situs ambiguous, solitus and inversus, respectively. Of the dextroposition, 47.6% terminated pregnancy, 14.2% resulted in intrauterine death, 9.5% died after birth, and 28.5% survived.

Conclusion: A wide spectrum of complex cardiac malformations are associated with fetal dextrocardia. Fetal echocardiography enables detection of complex cardiac anomalies so that parents can be appropriately counselled.     

心脏轴测定在胎儿先天性心脏病产前超声诊断中的临床意义

目的探讨超声心动图测定心脏轴变化在胎儿先天性心脏病（先心病）产前诊断中的临床意义。方法应用Ａｃｕｓｏｎ１２８×Ｐ／１０彩色多普勒超声诊断仪检查５１８例胎龄１８～４０周的先心病高危胎儿和９０例正常胎儿,在心脏超声四腔观基础上测定胎儿心脏轴,并从多切面观察胎儿心内结构,以确定胎儿有无先心病。结果正常胎儿心脏轴为（４４．８±１０．３）度,先心病胎儿心脏轴为（５８．１±１５．７）度,两者比较,差异有显著性（Ｐ＜０．０１）。单纯四腔观检测胎儿先心病的敏感性为６８．５％,应用心脏超声四腔观加心脏轴测定检测胎儿先心病的敏感性为９１．４％,两者比较,差异有显著性（Ｐ＜０．０５）;５１８例先心病高危胎儿中,产前超声正确诊断先心病３４例,假阳性１例,假阴性１例。结论正常胎儿心脏轴范围２０～７５度,如心脏轴＞７５度,应高度怀疑胎儿先心病;心脏轴测定在胎儿先心病筛查中具有重要作用,可作为一种常规测量指标。     

Outcome for fetuses with prenatally detected congenital heart disease and cardiac arrhythmias in Taiwan.

BACKGROUND/PURPOSE: Outcome for fetuses with prenatally detected congenital heart disease (CHD) and/or cardiac arrhythmias is important for prenatal counseling and perinatal management; however, there exists little literature regarding the outcome for CHD diagnosed in utero in Taiwan. Therefore, we attempted to investigate the outcome for fetuses with CHD and/or cardiac arrhythmias diagnosed prenatally at a tertiary care medical center in Taiwan. METHODS: Between January 1995 and December 2000, 339 patients referred to the National Taiwan University Hospital for fetal echocardiography were included in this study. Medical records were reviewed retrospectively to determine the salient clinical characteristics for all fetuses. RESULTS: CHD was found in 103 fetuses. Gestational age at diagnosis ranged from 17 to 40 weeks; in 37 cases (35.9%) the diagnosis was made before 24 weeks. Mean gestational age at diagnosis was 27.8 weeks. Of the 103 cases, 15 fetuses (14.6%) had major extra cardiac malformations and 15 fetuses (14.6%) had chromosomal abnormalities (five had both) and 30 pregnancies (29.1%) were terminated. Of the remaining 73 pregnancies, three (4.1%) of the fetuses died in utero and 28 (38.4%) postnatally, with 42 (57.5%) surviving. The mortality rates were both 60% in cases with extracardiac or chromosomal anomalies. Arrhythmias were identified in 25, and two pregnancies involving hydrops fetalis were terminated. Of the remaining 23 continued pregnancies, two (8.7%) with long QT syndrome expired postnatally. CONCLUSION: Outcome for fetuses with prenatally detected CHD remains poor, with the prognosis negatively influenced by the presence of complex heart defects as well as extracardiac and chromosomal anomalies. However, prognosis is good for fetuses with cardiac arrhythmia, except with long QT syndrome or hydrops fetalis.     

The evaluation of cardiac biometry in major cardiac defects detected in early pregnancy

The objective was to evaluate early cardiac biometry in fetuses with structural cardiac defects between 10 and 17 weeks of gestation using our normative data about fetal heart biometry. A retrospective case series, patients were selected from all cases with congenital heart disease diagnosed between 10 and 17 weeks of gestation in our prenatal unit between 1999 and 2000. A schematic sonographic examination, including nuchal translucency (NT) thickness measurements, was performed and was followed by fetal Doppler echocardiography. The transversal heart diameter, both ventricular dimensions, heart area, heart circumference, thoracic diameter, thoracic circumference, thoracic area, pulmonary trunk diameter and aortic diameter were measured and the cardiothoracic ratios were calculated. Doppler evaluation of the umbilical arteries, ductus venosus and umbilical vein was performed. Fetal karyotyping was obtained by amniocentesis or chorionic villous sampling. During the study period, 31 cases of congenital heart disease between 10 and 17 weeks of gestation were diagnosed. Of these, two fetuses presented with ectopia cordis and six with insufficient cardiac biometric measurements. In the remaining 23 fetuses, different complex abnormalities with a high rate of chromosomal abnormalities (91%) were present. Fetal heart biometry was normal in 22% and abnormal in 78%. NT thickness measurements were performed before 14 weeks of gestation and ten of 12 fetuses (83%) presented with an increased NT. Both fetuses with normal NT showed an abnormal fetal heart biometry. Venous Doppler evaluation was performed in 22 cases and 12 fetuses (55%) demonstrated an abnormal venous Doppler. There were ten fetuses (45%) with normal venous Doppler; in seven of these cases, fetal heart biometry was partly abnormal. This study shows the feasibility of first and early second trimesters' fetal echocardiography and the applicability of cardiac biometry in these instances. In this context, early fetal heart biometry and NT thickness measurements may be complementary methods for the prenatal diagnosis of some major congenital heart defects. In early pregnancy, some cardiac defects like tricuspid valve dysplasia, coarctation of the aorta, aortic stenosis, tetralogy of Fallot or pulmonary stenosis may already show similar changes in the relation of the diameters of the fetal heart and great arteries, as seen in the second trimester. Therefore, evaluating the different cardiac ratios may have a high diagnostic value in early pregnancy.     

Long-term outcome in fetuses with cardiac arrhythmias

OBJECTIVE: The objectives of this follow-up study of 292 fetuses with various cardiac arrhythmias were to estimate the incidence of structural heart defects and fetal compromise, to investigate the effects of antiarrhythmic medication, and to evaluate perinatal mortality and morbidity and long-term outcome. METHODS: The arrhythmias were classified into atrial extrasystoles (n = 200), atrial tachycardias (n = 35), atrioventricular block (n = 36), sinus bradycardia (n = 14), and ventricular extrasystoles (n = 7), and outcome of the infants was analyzed. RESULTS: The incidence of cardiac anomalies was 12% in the study population. In utero cardiac failure was noted in 11%. Among fetuses with atrial extrasystoles, 1% developed supraventricular tachycardia after birth. During antiarrhythmic therapy, sinus rhythm was achieved in 92% of nonhydropic and in 63% of hydropic fetuses. The latter had higher mortality and risk for neurologic morbidity than did nonhydropic fetuses; 38% versus 3.7% and 40% versus 12%, respectively. Among fetuses with atrioventricular block only, the survival rate was 82%, with a heart defect, prognosis was poor: 50% survived. Sinus bradycardia and ventricular extrasystoles were associated with survival rates of 75% and 67%. In the follow-up of the whole study population lasting a median 5 years, 93% are alive and 3% have a neurologic disorder. CONCLUSION: All fetal arrhythmias except atrial extrasystoles were associated with a moderately high risk for fetal distress. In cases of compromise, fetal and neonatal prognosis was poor and was an indication for perinatal medication. After the newborn period, the prognosis has been good. However, the risk for neurologic morbidity must be taken into consideration.     

Prenatal diagnosis and management of congenital heart disease

Thirty-two fetuses were diagnosed as having congenital heart disease (CHD). The major indications for level II echocardiography other than suspected cardiac abnormalities were fetal malformations, nonimmune hydrops and cardiac arrhythmia. Only three patients had a previous history of fetal CHD. No false-abnormal diagnosis of severe CHD was made. Aortic arch anomalies represented the major diagnostic problem among the six correct but incomplete diagnoses. Sixty-one percent of the fetuses were growth retarded, thus confirming the severity of their CHD. Chromosomal anomalies and extracardiac malformations were associated in 19% and 44% of the fetuses, respectively. Obstetric management and fetal prognosis in cases of extracardiac malformations were greatly influenced by the diagnosis of CHD. The poorest perinatal outcome was associated with heart failure. The only intrauterine deaths occurred in that group, and only one neonate survived. The outcome was more favorable in neonates without other malformations or heart failure. Four of ten (40%) of those neonates survived, while the overall perinatal survival rate was 24%.     

Chromosomal and cardiac anomalies in fetuses with intracardiac echogenic foci.

OBJECTIVE: To evaluate the prevalence of intracardiac echogenic foci (ICEF) and the association between ICEF and chromosomal and cardiac anomalies in Brazilian women. METHODS: In a cross-sectional observational study, 373 of the 23,360 genetic sonograms performed at a private maternal-fetal medicine clinic over 5 years showed intracardiac echogenic foci (ICEF). These 373 sonograms were reviewed for chromosomal and cardiac anomalies and associations were analyzed using the chi(2) test or the Fisher exact test. P<0.05 was considered significant. RESULTS: The prevalence of ICEF was 1.7%. Cardiac anomalies were detected in 10 sonograms (2.7%) and chromosomal anomalies in 14 (3.7%). There were cardiac defects in 6 (1.7%) of the 359 euploid fetuses with isolated ICEF. Of the 373 women who had fetuses with ICEF, 295 were younger than 35 years and 78 were 35 years or older. There were 6 fetuses (2.1%) with aneuploidy in the younger group and 8 (10.3%) in the older group. CONCLUSION: The prevalence of ICEF was 1.7%, and there was an association between cardiac and chromosomal anomalies. Women carrying fetuses with ICEF should be offered fetal echocardiography and karyotyping.     

Anterior abdominal wall defects--retrospective analysis of fetuses diagnosed in the Department of Obstetrics & Gynecology of the Postgraduate Center of Medical Education between 1997 & 2002

OBJECTIVES: Our objectives were to determine the risk of aneuploidy and anatomic anomalies in fetuses with different kinds of abdominal wall defects. DESIGN: We retrospectively studied ultrasound reports of the fetuses with abdominal wall defects. MATERIALS AND METHODS: We analyzed 108 cases diagnosed during the last five years in our center. All fetuses underwent a detailed ultrasonographic survey and in majority of cases (78.8%) antenatal karyotyping was performed. We also analyzed gestational age at the first examination. RESULTS: 35 cases presented gastroschisis, 60 omphalocele, 7 ectopia cordis and 6 limb-body wall complex. Associated anomalies were detected in 48.1% of all cases. It was 22.9% in gastroschisis group, 58.3% in omphalocele group, 42.9% in ectopia cordis group and in all fetuses with limb-body wall complex. Chromosomal abnormalities were present in 13% of all cases; in 2.9% of gastroschisis group, 20% of omphalocele group, 16.7% of limb-body wall complex group and none of the fetuses with ectopia cordis. The median gestational age at the first examination was 24 weeks. CONCLUSIONS: In fetuses with abdominal wall defects detailed ultrasonographic survey and in majority of cases prenatal karyotyping should be done. Furthermore patients with fetus with such a defect should be diagnosed as early as possible in the referral center.     

Doppler in fetal heart failure

Fetal echocardiography has progressed to be able to diagnose many forms of congenital heart disease (CHD) and to assess the prognosis of cardiac lesions based on their anatomy and presentation in utero. Fetal echocardiography is for pregnancies at risk of structural, functional, and rhythm-related fetal heart disease. Routine obstetrical ultrasound screening is critical in the prenatal detection of fetal heart disease/CHD. With or without CHD, fetal heart dysfunction defined as inadequate tissue perfusion may occur. Perinatal problems other than CHD can also be assessed, such as the effects of noncardiac malformations that affect hemodynamics, that is, twin-twin transfusion. Cardiac rhythm can affect cardiac function and outcome, and prenatal diagnosis can be lifesaving. A tool for the assessment of cardiac function is the Cardiovascular Profile Score that combines ultrasonic markers of fetal cardiovascular unwellness based on univariate parameters, which have been correlated with perinatal mortality. This "heart failure score" could potentially be used in much the same way as and in combination with the biophysical profile score. This study will present a summary of fetal Doppler and its place in the diagnosis and assessment of prognosis of fetal heart failure.     

Postnatal outcome of fetal cardiac echogenic foci.

BACKGROUND AND PURPOSE: Cardiac echogenic foci are found frequently during fetal echocardiographic investigations and may be related to increased mineralization of the papillary muscles. However, data from postnatal follow-up are limited. This study investigated the clinical characteristics and postnatal echocardiographic findings in infants with cardiac echogenic foci identified prenatally. METHODS: Between March 1995 and April 1998, 43 fetuses were noted to have cardiac echogenic foci during the second trimester. Postnatal evaluation was completed for 20 of these 43 fetuses. No other congenital malformations were noted during the fetal stage or after birth. Postnatal echocardiography was performed from 17 months to 4 years and 7 months after birth. RESULTS: Seven (35%) infants had persistent cardiac echogenic foci. However, only one had mild mitral valve prolapse without mitral regurgitation. All fetuses had left ventricular (LV) foci and three also had right ventricular (RV) foci. One infant who had a LV focus prenatally was noted to have a RV focus on postnatal follow-up. Among the three infants with prenatal biventricular involvement, only one had biventricular involvement on postnatal follow-up. Other cardiac echogenic foci had disappeared in all infants. The probability of persistence of foci decreased with age and reached 50% at the age of 4 years and 4 months. Thereafter, cardiac echogenic foci tended to regress and only 11% of infants had persistence at the last follow-up. No significant difference was found in the rate of persistence between children with univentricular foci and those with biventricular foci. CONCLUSIONS: Although some fetal cardiac echogenic foci may persist after birth, fetal echogenic foci were not associated with significant intracardiac or extracardiac anomalies.     

Early diagnosis of major cardiac defects in chromosomally normal fetuses with increased nuchal translucency.

OBJECTIVE: To determine the value of early ultrasound examination for prenatal diagnosis of cardiac defects in chromosomally normal fetuses with increased nuchal translucency thickness at 10-14 weeks of gestation. DESIGN: Prospective audit. SETTING: Fetal Medicine Centre. METHODS: Specialist fetal echocardiography was carried out in 398 chromosomally normal fetuses with a nuchal translucency measurement above the 99th centile (> or = 3.5 mm). In the first 75 pregnancies the cardiac scan was carried out at 17-22 weeks and the next 323 cases had one scan at 13-17 weeks and another at 20-22 weeks. Pregnancy outcome was obtained in all of the cases. RESULTS: Major cardiac defects were present in 29 (7.3% of 398) cases and in 28 of these the diagnosis was made by antenatal echocardiography. In 27 of the 29 fetuses with major cardiac defects echocardiography was carried out at 13-17 weeks and an abnormality was suspected in 24 of the cases (88%). CONCLUSIONS: Increased nuchal translucency in chromosomally normal fetuses is associated with an increased prevalence of major cardiac defects and, as such, is an indication for specialist fetal echocardiography. Most of the cardiac abnormalities are detectable on antenatal fetal echocardiography and many can be excluded by early scanning.     

Cardiac disease in pregnancy.

OBJECTIVES: To evaluate the maternal and fetal outcome of pregnancies complicated by cardiac disease in a developing country. METHODS: A retrospective analysis was carried out of 207 pregnancies in women with cardiac disease who delivered at >or=28 weeks of gestation from June 1994 through December 2000 at a tertiary care center. RESULTS: Rheumatic heart disease (n=183, 88%) with isolated mitral stenosis (n=71) was the predominant cardiac problem. Septal defects were the most common form of congenital heart disease (n=24). In 28 (13.52%) women, the diagnosis of cardiac disease was made during pregnancy. Cardiac complications were noted in 62 (29.95%) and fetal complications in 42 (20.28%) pregnancies. Patients in NYHA class I/II (n=175, 84.54%) had fewer maternal complications and their babies had a higher birth weight than those in NYHA class III/IV (n=32, 15.45%). Cardiac intervention was performed prior to pregnancy in 111 (60.65%) patients with rheumatic heart disease: PTMC/CMV in 73 and valve replacement (VR) in 38. Maternal and fetal outcome was better in patients with prosthetic valves (n=38) and the majority (97.4%) of them remained in NYHA class I/II. Cardiac intervention was safely carried out during pregnancy in 10 women (PTMC in 7, CMV in l, and VR in 2). One of them developed congestive cardiac failure during labor. None of the newborns of the 41 women who had received anticoagulants had any congenital malformation. CONCLUSIONS: Rheumatic heart disease was the predominant type. Patients in NYHA class I/II had a better maternal and fetal outcome than those in NYHA class III/IV. Surgical correction of the cardiac lesion prior to pregnancy was associated with better pregnancy outcome. Pregnant women with prosthetic valves tolerated pregnancy well.     

Digoxin-like immunoreactive substance in fetuses with and without cardiac pathology

The concentration of digoxin-like immunoreactive substance was measured by immunoassay in umbilical venous blood from six normal and 19 fetuses with a variety of cardiac and noncardiac disorders. Fetal blood was obtained either by percutaneous umbilical blood sampling (n = 13) or at delivery (n = 12). Three women received digoxin for fetal indications. Healthy control fetuses had significantly less digoxin-like immunoreactive substance measured (mean concentration below the limit of the assay sensitivity) than was found in ill fetuses whose mothers received digoxin (p less than 0.005). However, the fetal concentrations of immunoreactive digoxin in fetuses with a cardiac abnormality were similar whether the mother had (0.93 +/- 0.4 ng/ml) or had not (1.27 +/- 0.4 ng/ml) received digoxin (p = 0.1452). Although there was a significant negative correlation between digoxin concentration and gestational age (R = -0.5079, p less than 0.01), the youngest fetuses examined were generally the sickest. The correlation with gestational age was not significant if the normal control fetuses were excluded. One fetus with a cardiac tachyarrhythmia was examined during and after transplacental therapy. There was no change. It is possible that previously measured "digoxin" in "treated" fetuses represents digoxin-like immunoreactive substance and that only small amounts of maternally administered digoxin actually reach the ill fetus. Our findings suggest that a randomized trial of maternal digitalization for the treatment of fetal supraventricular tachycardia is essential prior to its acceptance as effective therapy.     

Detection of congenital heart defects throughout pregnancy; impact of first trimester ultrasound screening for cardiac abnormalities

Objective: To evaluate prospectively the efficacy to screen for congenital heart defects (CHD) during the first trimester nuchal translucency (NT) ultrasound examination by assessing the four chambers’ view of fetal heart. Methods: Pregnancies that were examined prospectively by ultrasound in the first trimester (11th–14th week), the second (19th–24th week) and third trimester were included in the study. 3774 fetuses were examined and fetal heart was assessed during the NT scan by examining the four chambers view. Detailed echocardiography was performed during the anomaly and growth scans. Diagnosis of congenital heart defects (CHD) was further confirmed by a fetal cardiologist. Results: The four chambers view was obtained in 99.52% of the cases. CHD were diagnosed in 29 fetuses (0.77%). Thirteen cases (44.8%) were detected during the 11–13 weeks’ scan, 14 cases (48.3%) during the anomaly scan, 1 CHD (3.5%) during the third trimester scan and 1 case (3.5%) postpartum. Conclusion: Assessment of the four chambers of fetal heart early in pregnancy was feasible and allowed the detection of 45% of CHD. Additional parameters of fetal cardiac anatomy during the NT scan may further improve the detection rate providing pregnancy management information early in the first trimester.     

Fetal cardiac asymmetry: a marker for congenital heart disease

Objective: To determine the sensitivity of prenatally detected fetal cardiac asymmetry as a sonographic marker for congenital heart disease.Methods: The normal ratios of pulmonary artery to aorta diameters and of right ventricle to left ventricle diameters were derived from normal fetuses scanned at 17 weeks or more in a 65-month period. Cross-sectional diameters of cardiac ventricles and great arteries were measured at the level of the valves at the time of the scan. Fetuses with confirmed cardiac anomalies detected prenatally during the study were examined to identify how many had cardiac asymmetry, determined by abnormal ratios.Results: Linear regression analysis of the group of 881 normal fetuses showed the normal pulmonary artery to aorta diameter ratio remained constant throughout pregnancy and the normal right ventricle to left ventricle ratio increased slightly with progressing gestational age. The 90% confidence intervals were 0.79, 1.24 for the right ventricle to left ventricle ratio and 0.84, 1.41 for the pulmonary artery to aorta ratio. Of the 73 fetuses with abnormal hearts, 66% had either ventricular or great artery asymmetry (at least one of the two ratios was abnormal). However, if no asymmetry was present, the cardiac defect was more likely to be a minor one.Conclusion: Cardiac asymmetry was present in two-thirds of fetuses with cardiac anomalies diagnosed prenatally. If cardiac asymmetry is found, a more thorough examination of the fetal heart is indicated.     

Congenital heart disease and fetal thoracoabdominal anomalies: associations in utero and the importance of cytogenetic analysis.

We examined the frequency with which congenital heart disease (CHD) and cytogenetic abnormalities were found associated with omphalocele, gastroschisis, duodenal atresia and posterior diaphragmatic hernias. We performed fetal echocardiograms on 80 patients with these diagnoses and found congenital heart disease in 13 of 37 with omphalocele (35%), 2 of 17 with gastroschisis (12%), 4 of 15 with duodenal atresia (27%), and 2 of 11 with posterior diaphragmatic hernia (18%). Karyotypes were obtained in 74 and were abnormal in 24 (32%). Although most fetuses with these extracardiac malformations and abnormal karyotypes had associated CHD, many did not. Normal karyotypes were found in 69% of fetuses with CHD and omphalocele, and 50% of fetuses with CHD and duodenal atresia. We conclude that CHD may be present in fetuses with extracardiac malformations whether or not the karyotype is normal and that the prenatal evaluation of fetuses with these lesions should include both karyotype and fetal echocardiography. Although karyotypes play an important role in prenatal diagnosis, they are not predictive of normal cardiac structure when normal in the abnormalities studied. Even when the karyotype is normal in the presence of these abnormalities, fetal echocardiography is indicated.     

Isolated left-sided congenital diaphragmatic hernia: cardiac axis and displacement before fetal viability has no role in predicting postnatal outcome

OBJECTIVES: The purpose of this retrospective study was to determine whether objective assessment of cardiac shifting on two-dimensional ultrasonography can predict postnatal outcome in fetuses with isolated left-sided congenital diaphragmatic hernia (CDH). MATERIALS AND METHODS: Still images at the level of the four-chamber view were obtained in 23 fetuses with left-sided CDH. A group of 12 fetuses (3 non-survivors and 9 survivors) were examined at two periods, between 20 and 30 weeks and between 31 and 40 weeks. A further 11 fetuses (2 non-survivors and 9 survivors) were examined between 31 and 40 weeks. Fetal heart axis and position were determined manually and associated with postnatal outcome. RESULTS: The cardiac axis remained constant in the 9 survivors (15.5 +/- 3.2 versus 17.2 +/- 3.3, p = 0.71) and 3 non-survivors (19.0 +/- 11.5 versus 18.5 +/- 11.8, p = 0.97). There was no statistical difference between the 9 survivors and 3 non-survivors at the two periods. Cardiac displacement remained constant in the 9 survivors (0.2 +/- 0.02 versus 0.2 +/- 0.02, p = 0.32) but increased significantly in the 3 non-survivors (0.2 +/- 0.04 versus 0.4 +/- 0.02, p = 0.015). The difference between survivors and non-survivors was statistically significant between the18 survivors and 5 non-survivors examined between 31 and 40 weeks of gestation (0.2 +/- 0.02 versus 0.4 +/- 0.02, p = 0.037). CONCLUSION: This study does not support the hypothesis that objective assessment of mediastinal shift in fetuses with left-sided CDH has a role in predicting postnatal outcome before fetal viability, which is when it would be more useful for counseling patients regarding whether to continue with the pregnancy or to opt for termination.     

Heart disease in pregnancy: cardiac and obstetric outcomes

Background

A retrospective analysis of the records of all the patients of heart disease with pregnancy at AIIMS, New Delhi, India, to find out the maternal and fetal outcome.

Materials and methods

A retrospective analysis was carried out of 100 pregnancies in women with heart disease who delivered at ≥28 weeks of gestation from July 2009 through August 2012.

Results

Cardiac disease was found to complicate 3.8 % of pregnancies. Rheumatic heart disease (n = 64, 64 %) was the predominant cardiac disease. Congenital heart disease was found to complicate 36 pregnancies (n = 36, 36 %).Cardiac complications were seen in 32 (32 %) and fetal complications in 18 (18 %) pregnancies. Fewer cardiac and postpartum complications were present in NYHA class I/II patients compared to NYHA III/IV patients (P < 0.05). Pregnancy outcome was better in rheumatic heart disease patients who had undergone cardiac intervention prior to pregnancy (n = 29, 45.2 %) compared to those whose heart disease remained uncorrected (n = 35, 54.8 %) but the difference was not statistically significant. There was one maternal mortality in a patient with Eisenmenger syndrome. Two of the newborns of the 17 women who had received anticoagulants had features of warfarin embryopathy.

Conclusion

Pregnancy in women in NYHA class III/IV is associated with significantly higher maternal morbidity and cardiac interventions before pregnancy, when indicated may improve pregnancy outcome.     

Accuracy and limitations of transabdominal fetal echocardiography at 12-15 weeks of gestation in a population at high risk for congenital heart disease

Objective Evaluation of transabdominal fetal echocardiography at 12–15 weeks of gestation.
Design Retrospective analysis.
Setting Tertiary fetal cardiology unit.
Sample Two hundred twenty-nine consecutive fetuses imaged at 12–15 weeks of gestation over a 45-month period.
Methods Retrospective analysis of echocardiography and autopsy reports.
Main outcome measures Accuracy of early echocardiography for the detection of abnormalities of the cardiac connections.
Results Diagnostic images were obtained in 226/229 fetuses (98.7%). Abnormalities of the cardiac connections were detected in 13 fetuses (5.7%) on the initial scan. Where information was available (   n = 11  ), the echocardiographic findings were confirmed at autopsy or postnatally. In two of the 13 cases of congenital heart disease, repeat echocardiography was necessary to provide additional cardiological information. Of the 213 cases in whom a normal initial report was issued, four (1.7%) had congenital heart disease diagnosed later in pregnancy (   n = 3  ) or postnatally (   n = 1  ). Three of these fetuses had haemodynamically insignificant ventricular septal defects and one developed a dilated cardiomyopathy later in gestation.
Conclusions Transabdominal fetal echocardiography can be performed at 12–15 weeks of gestation permitting accurate early detection of major congenital heart defects in a high risk population. Some forms of congenital heart disease, usually minor, may not be detectable at such an early stage.     

Early diagnosis of major cardiac defects in chromosomally normal fetuses with increased nuchal translucency

Objective To determine the value of early ultrasound examination for prenatal diagnosis of cardiac defects in chromosomally normal fetuses with increased nuchal translucency thickness at 10–14 weeks of gestation.
Design Prospective audit. Setting Fetal Medicine Centre.
Methods Specialist fetal echocardiography was carried out in 398 chromosomally normal fetuses with a nuchal translucency measurement above the 99th centile (2 3.5 mm). In the first 75 pregnancies the cardiac scan was carried out at 17–22 weeks and the next 323 cases had one scan at 13–17 weeks and another at 20–22 weeks. Pregnancy outcome was obtained in all of the cases.
Results Major cardiac defects were present in 29 (7.3% of 398) cases and in 28 of these the diagnosis was made by antenatal echocardiography. In 27 of the 29 fetuses with major cardiac defects echocardiography was carried out at 13–17 weeks and an abnormality was suspected in 24 of the cases (88%).
Conclusions Increased nuchal translucency in chromosomally normal fetuses is associated with an increased prevalence of major cardiac defects and, as such, is an indication for specialist fetal echocardiography. Most of the cardiac abnormalities are detectable on antenatal fetal echocardiography and many can be excluded by early scanning.