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Fetal echo – why bother?

Dr Luke Eckersley

Disclosures

• I have no disclosures

History of Fetal Echo

• 1957 Tom Brown invents first B-mode scanner

• 1958 Ian Donald, Glasgow – Fetal heads scanned

• 1980 Lindsay Allen

History of Fetal Echo

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

What can we treat in utero?

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.

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

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

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

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

Does it change outcomes?

Does it change outcome?

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

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

Does it change outcomes?

Does it change outcomes?

Does it change outcomes?

ALL CASES OF MORTALITY POSTNATAL DIAGNOSIS

Does it change outcomes?

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

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

Does it change prevalence?

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

How are we doing?

98% of referrals due to abn. OFT or OFT not well seen on obstetric screening study

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

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