Fetal echo – why bother ? Dr Luke Eckersley
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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
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