The hydropic fetus with atrial flutter has high risk of fetal demise. In utero treatment is not as successful as SVT with 1:1 conduction. Even after conversion to sinus rhythm, close follow-up of the pregnancy is required for several reasons..
A 25 year old primigravida, at 26 wks of gestation had a fetal ultrasound which showed a tachycardic hydropic fetus with AFI 49. The rhythm was atrial flutter: AR 400 bpm and VR 200 bpm. The heart was structurally normal. Transplacental antiarrhythmic treatment with sotalol was started and 24 hours later, the fetus was still primarily in flutter with rare episodes of sinus rhythm and frequent PAC. Sotalol was increased but the mother’s QTc increased to > 500 ms, so the sotalol dose was reduced. On day 4th direct i.m. of digoxin was given and fetus was in sinus rhythm. Pharmacotherapy was continued. On the 16th day of sinus rhythm (at 33 wks), a marked change in FHR variability was seen. An US revealed the fetus was in sinus rhythm with a normal FHR. Because of the decreased FHR variability, the fetus was delivered by CS and the cord pH was 7.19, Apgars 1, 9 and 9. The neonate received no antiarrhythmic medications. On day 6 of postnatal life, an AV re-entrant tachycardia (AVRT) developed and sinus rhythm was successfully restored with sotalol and digoxin. The infant was treated for 18 months with no episodes of SVT or atrial flutter.
Iwona Strzelecka, Maria Respondek-Liberska, Maciej Słodki, Katarzyna Zych-Krekora and Bettina Cuneo
Based on fourteen case reports from various centres from 1992-2015 and three original studies in 2006-2011, 122 fetuses were subjected to analysis. In these reports, transplacental digoxin treatment was administered to different cardiac anomalies such as SVT , Ebstein’s anomaly, critical AS , absent pulmonary valve syndrome, complete heart block, in foetuses with aneurysm/diverticulum of LV, in tricuspid atresia or dysplasia, rhabdomyoma, pulmonary atresia, HLHS with fibroelastosis, in TTTS and in extracardiac anomalies such as atriovenous malformation or sacrococcygeal teratoma. There was no statistical difference to suggest (Chi-square test) that digoxin was more efficient to control fetal arrhythmias than fetal congestive heart failure in nonarrhythmic patients.
Conclusions: Foetal cardiac insufficiency may appear due to different reasons (in normal heart anatomy or in heart defects, in normal sinus rhythm or due to foetal arrhythmias: tachycardias or severe bradycardia) and may be a cause of intrauterine demise. So far, we do not have strong evidence that digoxin treatment may prevent foetal death or prematurity. More research is needed to ascertain if the prolonging of pregnancy resulted from digoxin treatment or if improvement in foetal circulatory insufficiency was influenced by spontaneous regression of foetal cardiac symptoms.
Maria Respondek-Liberska, Mark Sklansky, Dennis Wood, Maciej Słodki, Stuart Weiner, Bettina Cuneo, James C. Huhta, Ulli Gembruch, Giuseppe Rizzo, Gurleen Sharland, Reuven Achiron and Jay D. Pruetz
The first recommendations and guidelines for physicians training in fetal echocardiography (FE) were created in 1990 and later on up-dated by multiple medical associations and journals in Europe and the United States. This time advanced fetal cardiac ultrasound recommendations focused more on the organizational and logistical aspects of FE, to better define the fetal echo guidelines for practitioners in tertiary centers. Underlined is FE in 3rd trimester, with special attention to the direction of flow across the foramen ovale and ductus arteriosus.
AHA classification of heart defects in prenatal cardiology into seven major groups (from 2014) is presented as well as the Polish classification into four groups (from 2012) related to the urgency of required time to postnatal treatment/intervention based on FE findings in the 3rd trimester of pregnancy.
Current definition of fetal cardiologist in 2015 is also presented.
Katarzyna Leszczyńska, Krzysztof Preis, Maria Respondek-Liberska, Maciej Słodki, Dennis Wood, Stuart Weiner, Ulli Gembruch, Giusseppe Rizzo, Reuven Achiron, Jay D Pruetz, Mark Sklansky, Bettina Cuneo, Birgit Arabin, Isaac Blickstein and
Progress in the fields of fetal cardiology and fetal surgery have been seen not only in singleton pregnancies but also in multiple pregnancies. Proper interpretation of prenatal echocardiography is critical to clinical decision making, family counseling and perinatal management for obstetricians, maternal fetal medicine specialists, neonatologists and pediatric cardiologists. Fetal echocardiography is one of the most challenging and time-consuming prenatal examinations to perform, especially in multiple gestations. Performing just the basic fetal exam in twin gestations may take an hour or more. Thus, it is not practical to perform this exam in all cases of multiple gestations. Therefore our review and recommendations are related to fetal echocardiography in twin gestation.