ABSTRACT
Background: Prenatal diagnosis of congenital heart disease (CHD) is a stressful event that leads to anxiety, depression and traumatic stress in expectant parents. Cortisol is elevated in times of stress, and when present in mothers, crosses the placenta and leads to suppression of the fetus' own production of cortisol. When those neonates go on to require stressful procedures in the first months of life, some are unable to effectively mount a cortisol mediated stress response which can lead to poor outcomes and even death. We sought to investigate the relationship between maternal stress during pregnancy, and neonatal outcomes. Methods: We conducted a retrospective chart review of pregnancies complicated by a fetal diagnosis of critical CHD (including transposition of the great arteries, tetralogy of Fallot, total anomalous pulmonary venous return, and coarctation) who were born between 5/1/2019 and 5/1/2021. Maternal data included demographics and medical comorbidities. Composite maternal prenatal stress score (PSS) was calculated based upon 1) prenatal mental health diagnoses, 2) housing/food insecurity 3) income insecurity, 4) social support/child care, 5) legal involvement, 6) transportation issues and 7) other stressors. Categories ranged from 0 (no concerns) to 3 (significant concerns). Infant charts were reviewed for postnatal, and post-operative outcomes including infection, inotropic support, and exogenous steroid treatment. Results: 41 maternal-fetal dyads met inclusion criteria. Demographic and catheter based intervention at a median of 8 (2-54) days of life. 13 patients had single ventricle anatomy (8 initial surgical palliation, 5 catheterization). Mothers with higher composite PSS were more likely to have infants that required steroids after CHD surgery compared to mothers with lower scores (p=.01) (figure 1). Surgical patients needing bypass were more likely to require post-operative steroids than those not requiring bypass (18/22 vs 0/4, p<.005). None of the catheter-based interventions (including those with high risk single ventricle anatomy) required steroids (p <.0001). Maternal individual stress sub-categories, severity of prenatal CHD diagnosis, and counseling during the COVID-19 era did not correlate with steroid treatment. Finally, PSS did not correlate with individual outcomes such as birthweight, inotropic support, infection or hypoglycemia. Conclusion: Maternal prenatal stress is multifactorial and higher composite maternal prenatal stress scores are correlated with post-bypass steroid requirements, suggesting that a stressful intrauterine environment can be associated with worse postoperative outcomes for the neonate.
ABSTRACT
Introduction: Comprehensive prenatal care of congenital heart disease (CHD) relies on a multidisciplinary approach that includes timely prenatal counseling and individualized care plans for the pregnancy, delivery and neonatal period. With the COVID-19 pandemic our fetal therapy clinic (FTC) approach to patient care was altered to accommodate restrictions, including the use of telehealth visits. We investigated whether counseling and access to care for fetal patients with CHD was negatively impacted by COVID-19. Hypothesis: Fetuses with CHD would experience a delay in timing of diagnosis and referral;parents would receive a shorter counseling session during the COVID-19 pandemic. Methods: Retrospective chart review of all fetal cardiology patients seen in our multidisciplinary FTC both before (5/1/19-12/31-19) and during the COVID-19 pandemic (5/1/20-12/31/20). Data collected included gestational age (GA) at referral, GA at first fetal echo, use of telehealth, total time counseled, number of sub-specialty consults, and total number of fetal cardiology visits. Results: A comparable number of dyads were seen before and during the pandemic (Table 1). GA at initial diagnosis was similar, but GA at referral and first visit was earlier during the pandemic. Additionally, families seen during the pandemic had longer counselling across all disciplines with significant differences in pediatric cardiology and neonatology. There was no difference in total number of consults or access to care based on insurance. Conclusions: While prenatal counseling and referral to FTC is multifaceted, we demonstrated that COVID-19 and alterations in care delivery did not in fact lead to delays in referrals for patients across a large geographical catchment. Moreover, with telemedicine we were able to ensure our families continued to receive multidisciplinary care and families were able to spend more time with our care team developing comprehensive individualized plans.