Decision and outcome
The decisions taken regarding fetuses with CHD were watchful follow up
and arranging for elective delivery in any tertiary care center which
offers highly qualified cardiac and cardiothoracic services. Of the
total number of abnormal fetal echocardiography lost to follow up
occurred in 65 cases, (IUFD) in 1 cases, and elective termination in 16
case (11 cases of HLHS, 1 case of mitral atresia, 1 case of TGA intact
IVS, 3 cases of VSD PA), Total nine cases (one critical AS, two critical
PS, five PA intact IVS, one TGA intact IVS) were identified with cardiac
lesions required early post-natal intervention. but number of cases
actually underwent intervention early in post-natal life was six. Four
cases of pulmonary atresia with intact ventricular septum underwent
ductal stenting, one case of TGA with intact IVS underwent septostomy,
and one case of critical PS was underwent for neonatal BPV.
All the six cases of cardiac mass were found to be Rhabdomyoma, one of
them diagnosed as having Tuberous Sclerosis, in three cases tumors were
getting regressed in follow up, two cases were lost in follow up after
neonatal echocardiography. No cardiac mass patients required any kind of
surgery or chemotherapy. Among the four cases of complete heart block,
one was required permanent pacemaker implantation(PPI), two on oral
medication and one was lost in follow up after initial neonatal
examination. None of the PAC required any kind of treatment. Among 3
cases of DCM, two patients are on medical management and one case was
lost to follow up.
Table
4: Comparison between fetal and postnatal echocardiography
Table 4 shows the sensitivity, specificity, predictive values and
accuracy of FE in the diagnosis of each of the specific fetal cardiac
abnormalities (after excluding cases that were died which include both
IUFD and still birth, electively terminated and cases who were lost in
follow up). 65 cases out of 175 cases were lost to follow up. Four cases
with tiny muscular ventricular septal defects and two cases with
coarctation of aorta, one case of TGA with IVS and one case of large VSD
were missed by FE and were diagnosed postnatal. In case of TGA and IVS
and large VSD fetal echo was done at an advanced gestational age, so the
window was poor. The routine obstetric US scan of the case with aortic
coarctation was done at 19 weeks’ gestation and was unsuspicious of any
cardiac abnormalities. The case was referred for FE in the view of bad
obstetric history (maternal history of multiple previous abortions). FE
was done at the age of 20 weeks’ gestation and revealed mild dilatation
of the left ventricle. A second look was decided for the case to monitor
the disease progression but the mother did not return back for follow up
until after delivery when NE revealed coarctation. Another fetus with
CoA, where FE done at very early gestation, and that case was missed in
FE. One case of large VSD was missed in fetal echocardiography, in that
case fetal echo was done in very advanced (34 weeks of GA) pregnancy.
One case of DORV type of VSD with PS diagnosed by FE was turned to be
DORV type of VSD with pulmonary atresia in neonatal echocardiography,
because of progressive nature of the disease. This highlights the
importance of follow up FE in progressive cardiac lesions. Almost in all
cardiac lesions FE showed 100% sensitivity, specificity, PPV and NPV,
except in TGA IVS (sensitivity:87.5%), CoA and small VSD
(sensitivity:80%) and large VSD cases (sensitivity:95%).