Common Indications for Referral for Fetal Echo
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Common Indications for Referral for Fetal Echo

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Common Indications for Referral for Fetal Echo

Common Indications for Referral for Fetal Echo

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Common Indications for Referral for Fetal Echo Common Indications for Referral for Fetal Echo Document Transcript

  • Donofrio et al   Diagnosis and Treatment of Fetal Cardiac Disease    7 autoantibody (anti-Ro/SSA or anti-La/SSB) positivity in the general population is unknown. In prospectively examined preg- nancies of mothers with known antibodies and no prior affected child, the reported incidence of fetal CHB was between 1% and 5%. The number of affected pregnancies increases to 11% to 19% for those with a previously affected child with CHB.13–17 In addition, women with both autoantibodies and hypothyroidism are at a 9-fold increased risk of having an affected fetus or neo- nate compared with those with SSA or SSB alone.18 In addition to abnormalities in the conduction system, up to 10% to 15% of SSA-exposed fetuses with conduction sys- tem disease may also develop myocardial inflammation, endo- cardial fibroelastosis, or atrioventricular (AV) valve apparatus dysfunction.94 Because of the perception that the inflammatory effects resulting from antibody exposure may be preventable if detected and treated at an early stage, it has been recommended that SSA/SSB-positive women be referred for fetal echocar- diography surveillance beginning in the early second trimes- ter (16–18 weeks).14,16,95 The mechanical PR interval has been measured in fetuses at risk with the use of a variety of M-mode and pulsed Doppler techniques and compared with gestational age–adjusted normal values.96 Although the value of serial assessment for the detection of the progression of myocardial inflammation or conduction system disease from first-degree block (PR prolongation) to CHB has not been proved, serial assessment at 1- to 2-week intervals starting at 16 weeks and continuing through 28 weeks of gestation is reasonable to per- form because the potential benefits outweigh the risks. For women who have had a previously affected child, more fre- quent serial assessment, at least weekly, is recommended. Medication Exposure Most of the current literature implicating maternal medications in congenital abnormalities comes from retrospective patient interviews and voluntary registries and therefore may be sub- ject to bias. Nevertheless, a number of human teratogens are used clinically in women of childbearing age, and exposure to these medications in the period of cardiogenesis increases the risk of CHD. Among the most studied include anticonvul- sants, lithium, angiotensin-converting enzyme inhibitors, reti- noic acid, selective serotonin reuptake inhibitors (SSRIs), and nonsteroidal anti-inflammatory agents (NSAIDs). Anticonvulsants Anticonvulsants used in pregnancy include carbamazepine, diphenylhydantoin, and valproate. In a meta-analysis including a group of untreated epileptic women as control subjects, 1.8% of 1208 carbamazepine-exposed fetuses exhibited cardiac malfor- mations.21 This proportion was similar whether the mothers were taking carbamazepine alone or in combination with other anti- epileptic drugs. The incidence of malformations in the unmedi- cated epileptic control subjects was similar to that for the normal population. Fetal echocardiogram may be considered, although its usefulness has not been established if exposure occurs. Lithium Lithium has been reported to be associated with cardiac malformations in up to 8% of offspring in a registry study.25 However, more recent prospective case-control studies22 and literature analyses97 have suggested that the risk is not as high as initially thought, with a risk ratio for cardiac anomalies of 1.1 (95% confidence interval [CI], 0.1–16.6).22 Fetal echocar- diogram may be considered, although its usefulness has not been established if exposure occurs. Angiotensin-Converting Enzyme Inhibitors Angiotensin-converting enzyme inhibitor exposure in the first trimester is associated with increased risk for CHD, with Table 3.  Common Indications for Referral for Fetal Echocardiogram Indications with higher risk profile (estimated >2% absolute risk)  Maternal pregestational diabetes mellitus  Diabetes mellitus diagnosed in the first trimester  Maternal phenylketonuria (uncontrolled)  Maternal autoantibodies (SSA/SSB+ )  Maternal medications   ACE inhibitors   Retinoic acid   NSAIDs in third trimester  Maternal first trimester rubella infection  Maternal infection with suspicion of fetal myocarditis  Assisted reproduction technology  CHD in first degree relative of fetus (maternal, paternal or sibling with CHD)  First or second degree relative with disorder with Mendelian inheritance  with CHD association  Fetal cardiac abnormality suspected on obstetrical ultrasound  Fetal extracardiac abnormality suspected on obstetrical ultrasound  Fetal karyotype abnormality  Fetal tachycardia or bradycardia, or frequent or persistent irregular heart  rhythm  Fetal increased NT >95% (≥3 mm)  Monochorionic twinning  Fetal hydrops or effusions Indications with lower risk profile (estimated >1% but <2% absolute risk)  Maternal medications   Anticonvulsants   Lithium   Vitamin A   SSRIs (only paroxetine)   NSAIDs in first/second trimester  CHD in second degree relative of fetus  Fetal abnormality of the umbilical cord or placenta  Fetal intra-abdominal venous anomaly Not indicated (≤1% risk)  Maternal gestational diabetes mellitus with HbA1c <6%  Maternal medications   SSRIs (other than paroxetine)   Vitamin K agonists (Coumadin), although fetal survey is recommended  Maternal infection other than rubella with seroconversion only  Isolated CHD in a relative other than first or second degree ACE indicates angiotensin-converting enzyme; CHD, congenital heart disease; HbA1c , hemoglobin A1c ; NSAID, nonsteroidal anti-inflammatory drug; NT, nuchal translucency; and SSRI, selective serotonin reuptake inhibitor. by guest on April 25, 2014http://circ.ahajournals.org/Downloaded from