Download - Paediatric Cardiac Pathways
Paediatric Cardiac Pathways
Dr Lindsey Hunter
Consultant Paediatric & Fetal Cardiologist
Royal Hospital for Children
Glasgow
Background
• Congenital heart disease (CHD) the most common congenital anomaly
• 0.3 - 0.6% of live births
• Most CHD occurs in ‘low risk’ pregnancies
• Detection at the FAS scan 18-21 weeks
Neonatal MCN Meeting 2017
High Risk Indications
1. Fetal Indications- Suspicion or detection of a congenital heart defect at a routine obstetric scan.- Increased nuchal translucency measurement between 11-14 weeks gestation (> 99th percentile)- Extra-cardiac abnormality (ECA) e.g. congenital diaphragmatic hernia (CDH), exompholos major,
duodenal atresia, cystic hygroma- Fetal hydrops- Arrhythmias: ectopic beats; tachycardia or bradycardia- Abnormal karyotype e.g. Trisomy 21/18/13/XO- Multiple Pregnancy e.g. risk of TTTS
2. Maternal Indications- Use of prostaglandin synthetase inhibitors e.g. ibuprofen- Teratogenic medications e.g. lithium or anti-epileptic medications- Diabetes Mellitus or other metabolic conditions e.g. PKU- Maternal Infection e.g. parvovirus- Antibody Positive Connective Tissue Disease e.g. positive anti-Ro, anti-La antibodies
3. Other- Family history of congenital heart disease - first degree relative- Increased risk of fetal heart failure e.g. absent ductus venosus, fetal anemia, fetal tumors with
large vascular supply
Background
• Congenital heart disease (CHD) the most common congenital anomaly
• 0.3 - 0.6% of live births
• Most CHD occurs in ‘low risk’ pregnancies
• Detection at the FAS scan 18-21 weeks
• Fetal cardiology is a relatively ‘new’ speciality
• Wide variation in detection rates across the UK
Neonatal MCN Meeting 2017
Neonatal MCN Meeting 2017
UK - Antenatal Diagnosis
• Only the lesions antenatally detected and requiring surgery within the 1st
year of life
• TOP/IUD or lesions not requiring surgical intervention not included
• Introduction of Fetal Anomaly Screening Programme (FASP)
• Outflow tracts and 3VV/Tracheal View
Neonatal MCN Meeting 2017
Antenatal Cardiac Detection
Neonatal MCN Meeting 2017
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Neonatal MCN Meeting 2017
Neonatal MCN Meeting 2017
Neonatal MCN Meeting 2017
Neonatal MCN Meeting 2017
Recommendations
• British Congenital Cardiac Association (BCCA)
• ‘All cases of suspected CHD should be referred to a fetal cardiology specialist’.
• ‘Fetal medicine specialist should make a detailed assessment of non-cardiac structures’.
• ‘Counselling needs to take into account the extent and implications of all associated abnormalities’.
• ‘The working relationship between fetal cardiology specialists and fetal medicine specialists is extremely important in the management of fetal congenital heart disease’.
• http://www.bcs.com/documents/Fetal_Cardiology_Standards_2012_final_version.pdf
Neonatal MCN Meeting 2017
Aims of Fetal Cardiology Service
• Detection of the majority of cardiac abnormalities and arrhythmias• Parental Counselling
• Risk stratify lesions
• Treatment of arrhythmias
• Appropriate timing of delivery/location
• Educational support for the screening sonographers and obstetriciansNeonatal MCN Meeting 2017
Neonatal MCN Meeting 2017
Neonatal MCN Meeting 2017
Neonatal MCN Meeting 2017
Parental Perceptions
• Detailed, often complex and emotional
• Prepares parents, allow time to ask questions
• Insight, understanding and acceptance of the diagnosis
• Appropriate to beliefs and life experiences
‘Parental perception of a
cardiologist’s level of compassion
was inversely linked to the
likelihood of them seeking a second
opinion’.
‘The manner in which a diagnosis
is initially presented to a family,
the information provided, and
how the family interprets the
information are all factors that
influence parental perception and
subsequent decisions’.
Neonatal MCN Meeting 2017
Neonatal MCN Meeting 2017
Cardiac Liaison Service
• Aim to meet all families with a diagnosis of CHD
• Provide ongoing support in the postnatal period• Even for families delivering locally
• Directing families to financial or emotional support
• Support families transferred to other cardiac centres
• Supporting families in their transition from paediatrics to teenage services and adult congenital services
Neonatal MCN Meeting 2017
Neonatal MCN Meeting 2017
• Local delivery v tertiary centre
• Geography
• Transport Implications
• Duct Dependent Lesions
• Extra-cardiac abnormalities
• Risk
• Immediate intervention
• Balloon atrial septostomy
• Pacing
• Cardiac surgery
Location, Location, Location
Neonatal MCN Meeting 2017
Timing of Delivery
• Obstetricians aiming for normal delivery
• Aiming for term
• Poorer outcomes associated with prematurity and CHD
• Induction usually around 39 weeks if geographically distant
• Exceptions….
• Complete heart block or tachyarrhythmia
• Tricuspid Valve Dysplasia/Ebsteins Anomaly
Neonatal MCN Meeting 2017
Neonatal MCN Meeting 2017
Neonatal MCN Meeting 2017
Neonatal MCN Meeting 2017
Neonatal MCN Meeting 2017
Neonatal MCN Meeting 2017
Neonatal MCN Meeting 2017
Neonatal MCN Meeting 2017
J Joined Up Thinking!
Neonatal MCN Meeting 2017
• Ensure the best quality of care for our
patients
• Equality in the provision of cardiac care
• Geography should not matter!
• Communication between fetal medicine;
obstetrics; neonatology and paediatric
cardiology is essential
Thank You!