Foetal congenital heart disease: obstetric management and time to first cardiac intervention in babies delivered at a tertiary centre.

OBJECTIVES: The aim of this study was to determine the timing of neonatal cardiac intervention in babies with antenatally diagnosed congenital heart disease and the impact on obstetric management. METHODS: A retrospective review of all deliveries between January, 2008 and December, 2009 was conducted in a tertiary centre with foetal and paediatric cardiology, maternal-foetal medicine, and obstetric units. All live births with antenatally detected congenital heart disease were included. Data were collected from foetal, paediatric cardiology, and maternity databases and records. Induction, delivery mode, and timing of the first cardiac intervention in the neonate were studied. RESULTS: 205 deliveries were included. Induction and elective Caesarean section rates were 51.2% (105/205) and 14.1% (29/205), respectively. The vaginal delivery rate was 56% (115/205). There was a non-significant trend towards a higher rate of vaginal delivery after spontaneous labour than after induction (75% versus 66%; p = 0.234). The rate of neonatal cardiac intervention during the initial stay was 59.5% (122/205); it was 18.5% (38/205) within 48 hours and 25.8% (53/205) within 72 hours. The median time to first intervention was 4 days (interquartile range 2-8). Babies with hypoplastic left heart syndrome (median 3, interquartile range 2-6), transposition of the great arteries (median 1, interquartile range 0-4.5), and arrhythmia (median 0.5, interquartile range 0-1) had a significantly earlier time to first intervention compared with those with other conditions (p = 0.001). CONCLUSION: Vaginal delivery can be achieved in women delivering babies with major congenital heart disease at a tertiary centre. Delivery in or near a tertiary centre is recommended for patients requiring early intervention, of which many can be identified in advance.

Accuracy of prenatal diagnosis in a tertiary fetal medicine unit.

AIMS: To establish the accuracy of prenatal diagnosis in a tertiary referral fetal medicine unit by comparing those diagnoses made prenatally with diagnoses made at birth until discharge, and with postmortem information from cases that resulted in termination, intrauterine, or neonatal death. METHODS: All cases seen in the Fetal Medicine Unit between 1 June 2004 and 30 November 2005 were collected prospectively and sorted according to diagnosis. Relevant outcome data for these pregnancies were collected including postmortem information. RESULTS: 681 cases seen which accounted for 1219 visits. 198 were classified prenatally as a major abnormality, 46 cases minor, 56 with raised nuchal translucency, and 381 no abnormality. Outcome details were not available for analysis in two cases. Therefore 679 (99.7%) cases were available (711 out of 713 fetuses). Of the liveborns, 93.6% of the prenatal diagnoses were confirmed, 5.1% were resolved (predominantly soft markers), and 1.3% resulted in an additional major abnormality that had a significant clinical effect. Postmortem examinations were performed on 52% fetal or neonatal deaths with a normal or unknown karyotype. There was one new finding at postmortem that changed the fetal medicine diagnosis significantly. CONCLUSIONS: Accuracy of prenatal diagnosis in a tertiary fetal medicine unit is high. Parents and staff need to be aware that not all abnormalities will be detected prenatally, but inaccurate diagnosis is uncommon. Clinical indicators for benchmarking need to be developed.