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%).