Chapters Transcript Video Fetal and Neonatal Cardiology Updates All right, thank you, Stu. Um All right. We'll try to get back on track but uh there's, there's too many good talks this morning that I we couldn't cut off. All right. So I'm gonna go over a brief summary of prenatal cardiac physiology. Uh What's involved and reasons for obtaining a fetal echocardiogram, current state of genetic screening and how it's affecting our practice prenatally and then how that translate in the newborn period. And then I'm gonna talk about some exciting advances here that we're having at Atlantic health. So, congenital heart disease, still the most commonly um diagnosed prenatal congenital disorders with about six out of 1000 live births. Traditionally, the fetal diagnosis of congenital heart disease has happened between 18 to 22 weeks gestation. But with the advancement of technology and experience in our field, we're now pushing that down to in certain, in certain cases, down to 13 to 15 weeks, prenatally, the gas exchange occurs the placenta and the majority of the right ventricular flow is diverted through the ductus arteriosus. There's a rapid drop in the pulmonary vascular resistance following delivery with the pulmonary vascular resistance, reaching adult level by about 6 to 8 weeks of age. And, and I'm fascinated every time I look at this picture, right, in terms of the flow come from the inferior vena cave and how the heart prenatal is designed to push flow away from the lungs, right? You have the IVC flow that receives flow through the ductus spinosus. It's angled across the fra in a valley on the left side of the heart. Same thing is true for the ductus arteriosus with my, how do we get the arrow up again? Is that right here? Laser pointer? OK. There we go. OK. Um That first point the flow directed across the fra in a valley. And then if you're looking at the right ventricle here, look at this how like the ductus arterio says it wants to shoot blood down through away from the lungs of the aorta. It's just, it's just fascinating to me how the the heart is designed that way and how it transitions after birth. For a fetal echocardiogram. We use two D imaging. That's the black and white pictures, color imaging which shows us the direction of flow Doppler imaging which helps us measure speed of vessels and then e mode tracings as well. So this is what we look at at about 20 weeks gestation. So this we have a two D picture here. We have black and white picture which it's only gonna run once for me. Unfortunately. Uh Let's see, we can mhm it's supposed to be on repeat. But let's see, we'll do it one more time. But in this view, what you can see are four chambers of heart. You can see squeeze, you can see outflow tracks and you can see that this is a well well developped four chamber heart with the color showing good flow across inflows and outflows. And you can see the arteries are related normally. So there, there is a ton of information that you can receive in just a few echo clips. When you can see that nice, you can rule out a large majority of forms of congenital heart disease at least once that would be significant for the neonatal period. Um Right away with just a few brief clips, we use pulse wave Doppler, this can measure the speed across, um this can measure the speed across um all heart valves. Um giving us an idea if there's any degree of obstruction or stenosis present. And then M mode one of the oldest forms of echo uh imaging. Now, we use this actually frequently in our heart rate and rhythm assessment. Uh We can judge the atrial rate, the ventricular rate. Um And here, here you can see a normal fetal heart rate of 100 and 47 beats per minute. What's new? Um So just in the past year, there have been some new updates in the guidelines in terms of when is it appropriate to obtain a fetal echocardiogram and this is appropriate or this is important to understand for how we're caring for our infants in the newborn nursery or in the in the NICU. And about a year ago, uh American Society of Echocardiography came out with new guidelines and recommendations for the performance of a fetal echo. Uh They were written by some of the most prominent fetal cardiologists uh in our field. And so there were some updates in terms of when is it appropriate to obtain one around the same time? Um IW A the which is the ultrasound of OBGYN uh came out with similar guidelines. Now, there are gonna be more most importantly, there's a lot of overlap in similarity, but there are gonna be some subtle differences. I'm not gonna go in the major, I I will expand on this, but I'm not gonna go in major detail of this, but I don't think that's what everyone primary care providers need to understand. But what, what the details of this are really just to summarize that there are various recommendations between the societies. There are gonna be some subtle differences. So what do you do when you have uh infant in the newborn nursery? When there may be something different done based on which what the OB provider chose, which guidelines to follow. These are the most common reasons that women will have a fetal echocardiogram performed IVF pregnancy is one of the main, is one of the most common ones family history of congenital heart disease, first degree relatives, autoimmune antibodies, specifically SS A or anti ro um familial inherited disorders such as 22 Q metabolic disorders, um as well as pre prenatal infections and exposures. So what do you do? You have an infant? Uh they're conceived via IVF uh pretty high prevalence uh in our area. Uh Baby is clinically doing well in the newborn nursery. Baby is doing well. But you recognize that no fetal echocardiogram was performed. So, what do we do? Um You know, maybe, maybe this, maybe this woman had an excellent uh screening done by their MFM doctor. It was felt that it was not needed. Um Do we need to do a postnatal echocardiogram because it was done? Um But no, I don't think we necessarily need to if the baby's clinically doing well, you know, now we have an infant um who you can examine um if there's any prenatal concerns or if postnatal concerns in terms of how's the baby sound on exam. Um Physical examination findings, normal and clint baby is clinically doing well, especially in the age of, of uh nursery oxygenation. Sat screening. Um I think that is, is what you need in that situation. I think this is where it gets a little bit more tricky the autoimmune antibodies, right? An I RSS A. Um these antibodies can cause fibrosis of the conduction system. The highest risk period being up to about 26 weeks, gestation uh for the past 10 years or so. You know, we've seen most of these moms where we are doing weekly fetal echocardiograms on them to assess the heart rate, rhythm and uh mechanical pr interval up to about 26 weeks gestation. But then about a year ago, up in this corner of the ring, we have the maternal fetal medicine specialist who came out really out of nowhere. I think from our perspective saying that screening for moms who have ss A antibodies is no longer recommended. Uh although they did put a little caveat in there saying outside the outside the um uh setting of a clinical trial and then the pediatric cardiologist in this corner of the ring, which I'm happy to say doctor Paul who's in the audience will be speaking soon, I believe is on this one. You're on this, right? I think it's somewhere. Um But um so she's on here for one of our new newest faculty members ped pediatric cardiologist said, wait, hold on a second. We've been doing this. We know that there's a risk in this period. Um We find this this information useful. But I think most significantly this opinion piece said that we have ongoing trials looking at this exact question. So why are we changing our recommendations before we have more information about that? Particularly when no pediatric cardiologists were given their input on this this statement. So there's a little bit of discrepancy in kind of what needs to be done right now. And what I would say about this is, it's, it's hard from the pediatric cardiologist perspective, right, because we mainly rely on the maternal fetal medicine specialist to send us their patients when the antibodies are present. So there are situations with a rheumatologist or if the mother had a prior pregnancy affected by uh uh these antibodies for which they're coming back to us. But it has led to a variation in the practice currently would point out that this is one of the trials that I'm talking about called the stop block. And what this does is it identifies moms who have these SS A antibodies and, and doing home screening and ma and fetal heart rate monitoring. Seeing if we can identify which moms you identifying early, if there's any abnormality in the heart rate dropping for, which is gonna prompt an earlier assessment by the cardiologist because traditionally catching every, seeing the mom every week in the clinic doesn't care that that mom, uh whose fetus went into heart block the day after you had that last maternal pr interval check, which is certainly possible. Um So we're trying to figure out ways that we can, we can assess um the heart rate at home more frequently because we know it's not reasonable to come in more frequently than every week. So what do you do when you have a mom who reports having a history of SS A antibodies. And I think this is an important point that it's the presence the presence of the antibodies, right? It's not the diagnosis of the lupus. You can have a diagnosis of the lupus without the antibodies, but it's the the presence of the maternal SS A antibodies that what places the fetus at risk for heart block. So when you come across an infant who has the maternal history of the SS A antibodies that may not have been followed by pediatric cardiology. What do you do if the infant is clinically doing well? Um what do we need to do for that infant in the newborn period? And you know, I think, I think we need to kind of wait and see what's happening here in terms of the stop block trial and and kind of how this discrepancy in the in the recommendations pans out. But at a minimum, at a minimum, we should be getting an EKG in the newborn period. And then I think until this gets more sorted out. Um you know, at least discussing with the pediatric cardiologist of what type of follow up, you know, because these maternal antibodies do take several months uh to be cleared uh by the infant. Many of us are seeing patients back several months later to confirm the normalcy of the rhythm. Other maternal indications that you may come across in the newborn nursery, diabetes, particularly predestination, right. There's two situations where high sugar can affect the infant right when you have pre gestational diabetes with poor glycemic control, um that affects cardiac morphogenesis, right. And that can affect embryonic development including the heart. And then when you have poorly controlled diabetes later on the pregnancy, that fetal hyperinsulinemia can cause hypertrophy, the cardiac myocyte and and and uh hypertrophic cardiopathy can develop as a result of that. The good news about this though is that even though it can be quite severe, um it can be or is it should be reversible when the thickness does develop for that reason, within a few months, when they, when the baby is out of the high glucose environment. This is a patient uh that I saw initially about six actually uh probably in the fall. Um so late in gestation, poor prenatal care. And what we're seeing here in this picture right here is this, this is the entire septum and it measures I think 1.3 centimeters, right? So in a fetus who's 38 weeks, gestation, 1.3 would mean I have terrific car opathy for many Children or or or older adolescents. So we have in this picture right here, you can see the ventricular cavities are severely hypertrophied. Um but the septum is remarkably thick and so actually, uh well planned unintentionally. I saw this patient actually on Thursday in the clinic and the, and the, and the hypertrophy is actually almost resolved at three months of age other fetal cardiac indications for um for echocardiograms. If, if there's anything abnormal on the ob screening, right. So on the ob anatomy scans, uh if they suspect anything abnormal, uh seeing us, seeing us for a full fetal cardiogram is helpful. Extracardiac anomalies, fetal high drops concerns if there's a concern about the heart rate or rhythm, um as well as increased nuc translucency and mono diet or I'm sorry, mono MOOC Coric twins, PAC S not an uncommon thing, particularly later in gestation when they're happening in isolation, they're typically benign, right. There's a very low risk of developing a sustained tachycardia um SVT, but we typically don't follow moms routinely as long as they're getting routine ob heart rate checks on their routine visits. We will ask that they'll, they'll avoid caffeine. And the nice thing about once the baby is delivered, you know, if you are hearing anything abnormal on the in your examination, we can get a postnatal leakage to look at the rhythm. This is probably one of the most important slides I think, take home slides for the talk. What can't fetal echo pick up uh atrial septal defects just because of the normalcy of the fra in a valley as well as the PD A cation of the AORTA. Although we can often times pick up severe cases of aortic arch hyperplasia when the cation develops after ductal closure. That's one of the things that we can't capture prenatally. We aim to rule out total anomalous pulmonary veins return because that is a newborn emergency. Uh but however, partial anomalous pulmonary veins return can't be captured or oftentimes can't be captured. And then we're also not looking at the coronary artery anomalies. And so why this is important too, right? If you have a, you know, an older kid, you know, chest pain as we talked about earlier, you know, if they've had a normal fetal echocardiogram, it's really ir irrelevant in terms of the coronary coronary artery origins, ecogen focus uh used to be really a big thing that we would talk about uh with families and probably spend a lot of time talking with them more than some of their more significant findings because it could be scary because if you Google up, if you google ecogen focus, it'll, you know, down syndrome will come up and does not mean that the baby has Down Syndrome. We're oftentimes telling families, but that might be a slight increased risk for it. Um But that's more of a traditional approach. What's been great is that the era of non invasive prenatal testing has really helped us out in that regard that it's made ecogen focus less anxiety provoking for families. But by itself, we don't follow it up from a, from a cardiology perspective, noninvasive prenatal testing. It's a method of screening, right? I think that's important to take it's a screen, right? So it tells you a level of risk for an infant that may have genetic abnormalities, take small fragments of the DNA from the place that are placental in origin and that circulate in pregnant women's blood. So the nice thing about this is this just, just this just requires a, a blood draw for the mom, right? And we can get a lot of information from that on the risk for the infant for, for genetic conditions. This at the late about a year ago, a year and a half ago and what they talked about, which they were pretty, pretty spot on about is that although, although it's good at picking up try somebody 2113 and 18 when you start to look for, for more um expanded conditions, things like even like things like 22 Q and one or Turners, you have a lot of high false positive rates and it, and it was causing a lot of anxiety. At le at least in my practice, I feel like I've seen less of these expanded screening referrals. I don't know if this in part, they've recognized that um it's less helpful in those regards. But several years ago, I was seeing many more patients for abnormal screening tests that end up the fetus ended up being ok. These are the benefits of prenatal counsel, uh prenatal diagnosis, prenatal counseling, preparing parents for expecting a child with Conal heart disease, genetic testing. So understanding it, is it just the heart or is there something else? Going on, uh gives parents the option to continue a pregnancy. If there's a severe anomaly, we can optimize the delivery site and timing when necessary and then plan for fetal or postnatal intervention. Now, the future of cardiology, I'm happy that we've been making progress in the Hirsch fetal diagnostic and testing, uh testing center. Um I'll get to that in a second. We're expanding our simulation training and we're doing more early gestational fetal echocardiograms. And I specifically put fetal intervention in small print. Here. It is very rare. There's very rare indications that where it's actually uh going to be indicated and even questionable of utility. At that point. At least at this era, we have been working diligently um the whole department hospital and department of pediatrics and developing the Hirshfield Diagnostic and treatment Center. Um What we're envisioning is a multidisciplinary approach for women um who whose infants are fetuses are diagnosed with a congenital heart problem or not just congeal heart problem, but any congenital anomaly and including the heart and what's going to be done it in the, in our location of 55 Madison is having um all prenatal, um all prenatal uh specialists including MFM uh cardiologists, uh pediatric surgeons, pediatric neurosurgeons, meeting together with families to help guide their treatment. So they understand the disorder and what's gonna be needed for the infant um after they've been born. And what we need to do this is to uh train our echo technicians who are fabulous in taking care of Children, but then also to expanding them to um uh pregnant women and doing feel echocardiograms, you know, we, we couldn't um do what we do without the exceptional support of our team, many of whom are in the audience today. Um Our Ecotech NICS do so much of the work before we even go and see the family, right? That all of that work is done before we add a few pictures at the end of a study. Um The answers are oftentimes figured out by them so that we can just go in and talk to the families about what it means. So we're very appreciative for the hard work that they put in for our patients. But what in what is involved in training a pediatric echo technician on fetal, there's a lot of work to be done beforehand and it's different, it's different, having a fetus swimming around and trying to follow them. Um So fortunately, we have now funding to obtain this, this fetal echocardiography simulation module that I've used it under my prior institution. Hopefully we'll be acquiring soon too. Um That will be able to uh train uh trainees as well as echo technicians are interested in who will be working in the HFD DC. Um They will be able to learn on a mannequin in a simulation model uh before ever uh scanning a uh a pregnant woman. And then lastly, I'll finish up here, um, early fetal echocardiograms and we're pushing the envelope in terms of when we can start scanning women and, and giving them useful information. Uh We're pushing it down to 13 to 15 weeks. Um I think we're starting with 16, we'll, we'll be down even lower soon. Uh, but we're reserving this for really, for uh really high risk indications that there's an a if, if an early anatomy scan was done by the MFM team for which they found an anomaly, we'll see them. Certainly. Um If there's a high risk for genetic conditions such as Down Syndrome, um in which there's such a high incidence of Conal heart disease, we'll fit them in. And, but the, the negative part of this is that because the imaging is often times limited at 13 to 15 weeks, those moms will be coming back again, uh around 20 for a full study again as well. So, um try to get through as much as I could. Um That was what I wanted to cover in falco. I'm, I'm very excited about the opportunities here. Uh Please grab me at one of any of the breaks or email me. I'm happy to talk to you more about any of these things. Thank you very much. Published Created by
