Fetal echocardiography

Congenital anomalies are the leading cause of infant death and congenital heart diseases accounts for 30 to 50 percent of these deaths. As the major cause of the largest single category of mortality, the identification and management of fetal cardiac abnormalities is of paramount importance. Population screening studies have shown that congenital heart disease occurs in 5/1000 to 8/1000 newborns, with about one-half causing major disease and one-half causing minor disease. Fetal echocardiography is a reasonably accurate investigation for the detection of such anomalies. The prospective parents, obstetricians and cardiologists should have some basic concepts about this extremely useful tool.

Indications for fetal echocardiography:

The common indications are divided into three categories: 1. familial 2.maternal 3.fetal. Each is elaborated below

1. Familial risk factors

●First or second degree relatives with congenital heart disease (eg, the fetus’ siblings, parents, and grandparents)

●Syndromes including congenital heart disease (eg, Noonan, tuberous sclerosis, Holt-Oram, velocardiofacial [DiGeorge] syndrome)

2. Maternal risk factors

●Maternal congenital heart disease

●Cardiac teratogen medications (e.g., lithium, methotrexate, thalidomide, drugs for seizure, isotretinoin, paroxetine, warfarin)

●Maternal medical illness (e.g., diabetes, phenylketonuria, anti Ro/SSA or anti La/SSB antibodies)

●Exposure to prostaglandin synthetase inhibitors (can cause premature closure of the ductus arteriosus in the third trimester)

●Rubella infection in the first trimester

●In vitro fertilization

3. Fetal risk factors

●Suspected cardiac anomaly during basic sonogram

●Extracardiac anomaly

●Aneuploidy

●Nonimmune hydrops

●Arrhythmia

●Abnormal fetal situs

●Increased nuchal translucency at 11 to 14 weeks of gestation

●Chromosomal abnormality

●Monochorionic twins, with or without twin-twin transfusion syndrome

What is the timing of fetal echocardiogram?

Usually between 18 to 22 weeks

How accurate is fetal echocardiography for detection of cardiac anomalies?

Studies suggest widely variable sensitivity of fetal echo ranging from 0 to 80%. A reasonable figure would be an accuracy of 40%.

How fetal echocardiography changes the outcome?

Any cardiac anomaly should be properly explained to the parents. Though parents are less interested to know the exact anatomical details of the cardiac problem. What is more important for them is the short-, mid- and long-term prognosis of the child. Also information about place of child birth, and method to be used like- normal labour, LSCS etc. Though fetal cardiac interventions have been tried , they are far from being of routine use in near future.

For doctors it is important to explain the prognosis in clear terms. One study showed that cardiac anomalies which were amenable to biventricular repair had better outcome than single ventricle physiology (Ultrasound Obstet Gynecol. 1997 Oct;10(4):237-41. PMID 9383873)

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Referral to a maternal-fetal medicine specialist, pediatric cardiologist, geneticist, and/or neonatologist to discuss prognosis, obstetrical and neonatal management, and options is recommended.

Conclusion:

The following interventions are recommended when a fetal cardiac anomaly is suspected:

•Full fetal echocardiography to evaluate cardiac structure and function, arterial and venous flow, and rhythm.

•Detailed scanning of the fetal anatomy to look for associated anomalies, particularly involving the digits and bones.

•Thorough family history to evaluate for familial abnormalities or syndromes.

•Thorough maternal medical history to identify chronic medical disorders, viral illnesses, or medications which are potential teratogens.

•Fetal karyotype, with screening for deletion in 22q11.2 when conotruncal anomalies are present

•Referral to a maternal-fetal medicine specialist, pediatric cardiologist, geneticist, and/or neonatologist to discuss prognosis, obstetrical and neonatal management, and options.

•Delivery at an institution that can provide neonatal cardiac care, if needed.

Dr. Anupam Jena
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DIABETES AND HEART DISEASE

Diabetes and heart disease are closely related. Before discussing the heart problems in diabetes we will see what is diabetes mellitus. Diabetes mellitus is basically persistent elevation of blood sugar level due to inability to produce sufficient insulin or failure to respond appropriately to insulin. International guidelines define diabetes as fasting plasma glucose ≥ 126mg/dL or nonfasting plasma glucose ≥ 200mg/dL, or glycosylated hemoglobin ≥ 6.5%. Diabetes affects more than 200 million persons worldwide and by 2030 this figure will rise to >400 million persons.

HEART DISEASE IN DIABETES

Cardiovascular disease (CVD) remains the principal cause of suffering and death in diabetes. Diabetes causes widespread disease in heart and blood vessels like

1. Coronary artery disease- involvement of blood vessels of heart

2. Carebrovascular disease- involves the blood vessels of brain causing stroke

3. Peripheral vascular disease – involves blood vessels of limbs and aorta , may lead to loss of limbs

4. Heart failure

Coronary artery disease in diabetes:

Diabetes increases the risk of coronary artery disease manifold increasing the risk of having myocardial infarction (heart attack) and angina (chest pain). The level of increasing blood sugar directly influences the development and progression of CAD. Currently CAD is the principal cause of mortality in diabetes. People with diabetes are more likely to have severe coronary artery disease like involvement of multiple coronary arteries.

Heart failure in diabetes:

The most common causes of heart failure are coronary artery disease and hypertension which go hand in hand with diabetes. Presence of diabetes increases the risk of heart failure by 3 to 5 times and also worsens the outcome of treatment

WHAT TO DO?

Reading all these things are frightening but don’t worry there are ways to counter these problems

PREVENTING HEART DISEASE IN DIABETES

The risk of heart disease in diabetes is reduced significantly by the following measures

1. Strict control of blood sugar:

The first and foremost aspect of preventing heart disease in diabetes is control of blood sugar. Proper control is blood sugar reduces the risk of Heart disease

2. Strict control of BP:

Hypertension is present in ~70% of individuals with diabetes. Hypertension increases heart disease in diabetes. So strict control of blood pressure is mandatory. Many antihypertensives like ACE inhibitors ( ramipril, enalaprol) and ARB (losartan, telmisartan) have cardio protective and kidney protective action.

3. Treatment of coronary artery disease by medication , cardiac intervention / surgery reduces morbidity and mortality risk

4. Life style modifications like

– Cessation of smoking

– Regular brisk walking for > 40 minutes per day atleast five days in a week

– Restricting salt intake , fatty foods and increasing consumption of vegetables and fruits  reduce the risk of heart disease

You can find out about the cardiovascular effects of drugs used in diabetes under the ” medications” menu

Information about choosing between percutaneous cardiac intervention vs surgery is available under ” intervention” menu.

Thank you.

Dr. Anupam Jena