Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
Home Print this page Email this page
Users Online:183


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 52-55

Fetal echocardiography: A single-center tertiary care experience


1 Department of Cardiology, SKIMS, Srinagar, Jammu and Kashmir, India
2 Department of Obg/Gynae, SKIMS, Srinagar, Jammu and Kashmir, India
3 Department of Radiology, SKIMS, Srinagar, Jammu and Kashmir, India

Date of Submission01-Mar-2020
Date of Decision26-Apr-2020
Date of Acceptance07-Jun-2020
Date of Web Publication4-Aug-2020

Correspondence Address:
Dr. Aamir Rashid
House No 8, LD Colony Rawalpora, Srinagar - 190 005, Jammu and Kashmir
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartindia.heartindia_8_20

Rights and Permissions
  Abstract 


Background: Although fetal echocardiography is established screening tool for the detection of cardiac anomalies, its utility and awareness remains less in less-developed areas of the world. There is no data from our region about the usage and outcome of fetal echocardiography.
Aims and Objectives: To study the indications, referral patterns, and outcomes of fetal echocardiography.
Materials and Methods: All pregnant women referred for fetal echocardiography from January 2017 to July 2018 were included in the study.
Results: A total of 600 pregnant women underwent fetal echocardiography. The mean age of patients was 28 ± 4.2 years. The mean gestational age referred for fetal echo was 26 ± 4 weeks. Four hundred and twenty (70%) patients were more than 22 weeks of gestational age. Indications included maternal indications in 385 (64.2%) patients. The various maternal indications included bad obstetrical history in 180 (30%), pregestational diabetes in 100 (16.67%), congenital heart disease (CHD) in mother in 35 (5.83%), medication use during pregnancy in 15 (2.3%), and connective tissue disorder in mother in 55 (9.16%). Other indications included abnormal/not properly visualized cardiac chambers on anomaly scan in 50 (8.3%) and previous child with heart disease in 105 (17.5%). Different abnormalities detected included ventricular septal defect, pulmonary atresia intact septum each in 3 (0.5%); tetarology of fallot (TOF), tricuspid atresia, unbalanced atrioventricular canal defect with single ventricle, corrected the great arteries, fetal cardiac tumor, Ebstein anomaly, and total anomalous pulmonary venous connection each in 1 (0.16%); double outlet right ventricle pulmonary stenosis, hypoplastic left heart syndrome, compete heart block, fetal supraventricular tachycardia, and CoA each in 2 (0.33%) patients. Twenty-four of 600 (40 per 1000) screened fetal echos were abnormal. Seventeen (70.8%) patients were referred for an unsatisfactory/abnormal anomaly scan which were low-risk pregnancies. The highest yield of CHD was in patients who had been referred for abnormal fetal anomaly scan when compared with other referral indications (17 of 50 [34%] versus 7 of 550 [1.27%] in other indications; P = 0.0001).
Conclusion: The most common indication for which fetal scan was abnormal routine ultrasound which was mostly low-risk pregnancies. Dedicated cardiac screening should be part of the routine anomaly scan. Detailed fetal echo should be done in all patients who have any doubt on anomaly scan. Greater awareness in our community is needed for proper referral timings of fetal echo.

Keywords: Congenital heart diseases, fetal echo, referral patterns


How to cite this article:
Rashid A, Ajaz S, Rather H, Ahmed A, Khursheed R, Hafeez I, Dar I, Choh N. Fetal echocardiography: A single-center tertiary care experience. Heart India 2020;8:52-5

How to cite this URL:
Rashid A, Ajaz S, Rather H, Ahmed A, Khursheed R, Hafeez I, Dar I, Choh N. Fetal echocardiography: A single-center tertiary care experience. Heart India [serial online] 2020 [cited 2020 Dec 2];8:52-5. Available from: https://www.heartindia.net/text.asp?2020/8/2/52/291364




  Introduction Top


Fetal cardiology represents one of the most exciting and rapidly evolving areas in the field of fetal medicine. Fetal echocardiography is completely noninvasive and harmless and is the best tool in this direction.[1] Congenital heart disease (CHD) is the most common congenital anomaly found in humans. The incidence of CHD varies from about 4/1000–50/1000 live births in different studies, of which 2.5–3/1000 live births present as severely ill in the neonatal period or early infancy and need expert cardiac care.[2] Fetal echocardiography helps in delivery planning in suitable equipped center to provide immediate surgical care of newborn. Prenatal diagnosis has been suggested to impart survival advantage in the great arteries (TGA), hypoplastic left heart syndrome (HLHS), and CoA.[3],[4],[5],[6] Fetal therapy can be offered for specific defects such as critical aortic stenosis and critical pulmonary stenosis (PS), and various rhythm disturbances. Early termination can be offered if indicated which can help in reducing the incidence of complex CHDs.[2],[7] Although fetal echocardiography is established screening tool for the detection of cardiac anomalies, its utility and awareness remains less in less-developed areas of the world. There is no data from our local region about the usage and outcome of fetal echocardiography. We present analyses of the fetal echocardiography cases which were referred to a tertiary cardiac center.

Aims and objectives

  • To study the indications, referral patterns, and outcomes of fetal echocardiography.



  Materials and Methods Top


All pregnant women referred for fetal echocardiography from January 2017 to July 2018 were included in the study after informed consent. Institutional Ethics committee clearance was obtained, and the details regarding gestational age, maternal, family history, exposure to teratogens, and reason for referral were recorded. All fetal echocardiograms were done by dedicated pediatric cardiologist with state-of-art echo machines according to the International Society of Ultrasound in Obstetrics and Gynecology guidelines for fetal echocardiography.[8] In all the cases, four-chamber view, outflow tract views, three-vessel view, and aortic and ductal arch views were done. Fetal heart rate was noted and any arrhythmia was confirmed with M-mode imaging. Color Doppler and pulse-wave Doppler were used whenever necessary. All the images were recorded and stored in a digital media.


  Results Top


A total of 600 pregnant women underwent fetal echocardiography. The mean age of patients was 28 ± 4.2 years. The mean gestational age referred for fetal echo was 26 ± 4 weeks. Four hundred and twenty (70%) patients were more than 22 weeks of gestational age as shown in [Table 1]. Indications included maternal indications in 385 (64.2%) patients. The various maternal indications included bad obstetrical history in 180 (30%), pregestational diabetes in 100 (16.67%), CHD in mother in 35 (5.83%), medication use during pregnancy in 15 (2.3%), and connective tissue disorder in mother in 55 (9.16%). Other indications included abnormal/not properly visualized cardiac chambers on anomaly scan in 50 (8.3%) and previous child with heart disease in 105 (17.5%) as shown in [Table 2]. Different abnormalities detected included ventricular septal defect [Figure 1] and pulmonary atresia intact septum each in 3 (0.5%); TOF, tricuspid atresia, unbalanced atrioventricular canal defect with single ventricle, corrected TGA, fetal cardiac tumor, Ebstein anomaly [Figure 2], and total anomalous pulmonary venous connection each in 1 (0.16%); and double outlet right ventricle PS, HLHS [Figure 3], compete heart block, fetal SVT, and CoA each in 2 (0.33%) patients [Table 3]. Twenty four of 600 (40/1000) screened fetal echos were abnormal. Seventeen (70.8%) were referred for an unsatisfactory/abnormal anomaly scan which were low-risk pregnancies. The highest yield of CHD was in patients who had been referred for abnormal fetal anomaly scan when compared with other referral indications (17 of 50 [34%] versus 7 of 550 [1.27%] in other indications; P = 0.0001).
Table 1: Gestational age at which fetal echo was done

Click here to view
Table 2: Various indications of fetal echo

Click here to view
Figure 1: Fetal echo LVOT view showing subaortic ventricular septal defect

Click here to view
Figure 2: Fetal echo apical four-chamber view showing Ebstein anomaly

Click here to view
Figure 3: Fetal echo apical four-chamber view showing hypoplastic left heart

Click here to view
Table 3: Results types of congenital heart diseases detected

Click here to view



  Discussion Top


Incidence of CHD is 5–12 per 1000 live births. CHD has become the leading cause of infant mortality, accounting for 40% of infant deaths.[9],[10] Importance of diagnosing CHD early in life cannot be overemphasized. Fetal echo plays a major role in the prenatal diagnosis of CHD, with an overall sensitivity of 70% and specificity of more than 90%.[11] It also helps to improve the pregnancy outcome of fetuses with selected CHD, and there is a clinical benefit with regard to infant outcomes.

The mean age of our patients was 28 ± 4.2 years which is comparable to other studies.[12] The main indication for referral was a bad obstetric history (BOH), followed by sibling having heart disease and pregestational diabetes. Our center being the apex center of state mostly gets high-risk pregnancies which is probable reason for high percentage of BOH patients. The referral for previous sibling having CHD was high in our study, probably due to our center being the only center in state performing pediatric cardiac surgeries and some of the next pregnancies being referred for fetal echocardiography. There is also high prevalence of pregestational diabetes in our population. Other studies[13],[14],[15] have shown abnormal fetal scan to be the most common indication for referral which was present in 8% of our patients.

The optimal timing for fetal echocardiography is 18–22 weeks of gestation;[16] as this time, window enables the evaluation of details of fetal cardiac anatomy. The mean gestational age referred for fetal echo in our study was 26 ± 4 weeks which is comparable to other studies.[13],[14] Seventy percent of patients were more than 22 weeks of gestational age. In India, the upper limit of legal termination of pregnancy is 20 weeks, though in most European countries, it is up to 24 weeks of gestation. Some of the reasons for delayed referral could be due to poor awareness among the community, late performance of anomaly scans, patients having overlooked the importance of routine ultrasound examinations, and the inability to diagnose lesions such as conotruncal anomalies in earlier scans. On correlation of our results with referral indications, the highest yield of CHD was in patients with abnormal fetal cardiac scan which were mostly low-risk pregnancies.


  Conclusion Top


Fetal echo has opened a new horizon in accurate diagnosis of CHD. Most common indication for which fetal scan was abnormal was abnormal routine ultrasound which was mostly low-risk pregnancies. Dedicated cardiac screening should be part of the routine anomaly scan. Detailed fetal echo should be done in all patients who have any doubt on anomaly scan. The main concern in our scenario is the late referrals. Greater awareness in our community is needed for proper referral timings of fetal echo.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Ethical Approval

The study was approved and cleared by Institutional Ethical Committee of the Institute.



 
  References Top

1.
Allan LD, Sharland GK, Milburn A, Lockhart SM, Groves AM, Anderson RH, et al. Prospective diagnosis of 1,006 consecutive cases of congenital heart disease in the fetus. J Am Coll Cardiol 1994;23:1452-8.  Back to cited text no. 1
    
2.
Hoffman JI, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol 2002;39:1890-900.  Back to cited text no. 2
    
3.
Bonnet D, Coltri A, Butera G, Fermont L, Le Bidois J, Kachaner J, et al. Detection of transposition of the great arteries in fetuses reduces neonatal morbidity and mortality. Circulation 1999;99:916-8.  Back to cited text no. 3
    
4.
Khoshnood B, De Vigan C, Vodovar V, Goujard J, Lhomme A, Bonnet D, et al. Trends in prenatal diagnosis, pregnancy termination, and perinatal mortality of newborns with congenital heart disease in France, 1983-2000: A population-based evaluation. Pediatrics 2005;115:95-101.  Back to cited text no. 4
    
5.
Mahle WT, Clancy RR, McGaurn SP, Goin JE, Clark BJ. Impact of prenatal diagnosis on survival and early neurologic morbidity in neonates with the hypoplastic left heart syndrome. Pediatrics 2001;107:1277-82.  Back to cited text no. 5
    
6.
Simpson JM. Fetal arrhythmias. Ultrasound Obstet Gynecol 2006;27:599-606.  Back to cited text no. 6
    
7.
Daubeney PE, Sharland GK, Cook AC, Keeton BR, Anderson RH, Webber SA. Pulmonary atresia with intact ventricular septum: Impact of fetal echocardiography on incidence at birth and postnatal outcome. UK and Eire Collaborative Study of Pulmonary Atresia with Intact Ventricular Septum. Circulation 1998;98:562-6.  Back to cited text no. 7
    
8.
International Society of Ultrasound in Obstetrics and Gynecology. Cardiac screening examination of the fetus: Guidelines for performing the basic and extended basic cardiac scan. Ultrasound Obstet Gynecol 2006;27:107-13.  Back to cited text no. 8
    
9.
Donofrio MT, Moon-Grady AJ, Hornberger LK, Copel JA, Sklansky MS, Abuhamad A, et al. Diagnosis and treatment of fetal cardiac disease: A scientific statement from the American Heart Association. Circulation 2014;129:2183-242.  Back to cited text no. 9
    
10.
Rosano A, Botto LD, Botting B, Mastroiacovo P. Infant mortality and congenital anomalies from 1950 to 1994: An international perspective. J Epidemiol Community Health 2000;54:660-6.  Back to cited text no. 10
    
11.
Zhang YF, Zeng XL, Zhao EF, Lu HW. Diagnostic value of fetal echocardiography for congenital heart disease: A systematic review and meta-analysis. Medicine (Baltimore) 2015;94:e1759.  Back to cited text no. 11
    
12.
Garg S, Sharma P, Sharma D, Behera V, Durairaj M, Dhall A. Use of fetal echocardiography for characterization of fetal cardiac structure in women with normal pregnancies and gestational diabetes mellitus. J Ultrasound Med 2014;33:1365-9.  Back to cited text no. 12
    
13.
Sharony R, Fejgin MD, Biron-Shental T, Hershko-Klement A, Amiel A, Levi A. Who should be offered fetal echocardiography? One center's experience with 3965 cases. Isr Med Assoc J 2009;11:542-5.  Back to cited text no. 13
    
14.
Li M, Wang W, Yang X, Yan Y, Wu Q, et al. Evaluation of referral Indication for fetal echocardiography in Beijing. J Ultrasound Med 2008;27:1291.  Back to cited text no. 14
    
15.
Vaidyanathan B, Kumar S, Sudhakar A, Kumar RK. Conotruncal anomalies in the fetus: Referral patterns and pregnancy outcomes in a dedicated fetal cardiology unit in South India. Ann Pediatr Cardiol 2013;6:15-20.  Back to cited text no. 15
    
16.
Rychik J, Ayres N, Cuneo B, Gotteiner N, Hornberger L, Spevak PJ, et al. American Society of Echocardiography guidelines and standards for performance of the fetal echocardiogram. J Am Soc Echocardiogr 2004;17:803-10.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed871    
    Printed31    
    Emailed0    
    PDF Downloaded91    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]