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Findings, Hx Flag Need for Fetal Echocardiogram. (Fetal Hydrops, Maternal Cardiac Disease).

PALM BEACH, FLA. - Although few obstetricians will ever do a fetal echocardiogram themselves, knowing when to ask for one and how to guide their patients through the results is a valuable asset, according to one expert.

If an anomaly is detected, the referring physician is encouraged to continue the necessary monitoring and antenatal testing to track its progression until delivery "Our goal is to not exclude the referring physician and, in fact, to have them go ahead and do the delivery when the time comes," Dr. Deward Voss said at an ob.gyn. meeting sponsored by the University of Chicago.

Congenital cardiac anomalies occur in 411 of every 1,000 live births, said Dr. Voss, a maternal-fetal medicine specialist at Good Samaritan Hospital in Cincinnati.

Physicians should suspect a higher risk of cardiac anomalies in women with metabolic disorders such as diabetes mellitus or phenylketonuria; exposure to a known cardiac teratogen such as alcohol, anticonvulsants, retinoic acid, or lithium; exposure to viral teratogens such as rubella, parvovirus, or Coxsackie virus; or maternal autoantibodies as in lupus erythematosus or Sjobgren's syndrome.

If the mother has cardiac disease, the risk of a cardiac defect in the fetus may be as high as 12%, whereas it's 5%-10% if the father has heart disease or the mother has borne an affected child or fetus.

Certain findings on routine obstetric sonograms are definite indications to order a fetal echocardiogram. These findings include any extracardiac malformation, the presence of fetal hydrops, omphalocele, diaphragmatic hernia, duodenal atresia, nuchal edema, single umbilical artery tracheoesophageal fistula, and cystic hygroma.

"We can do an abdominal fetal echocardiogram as early as 18 weeks in a thin patient and earlier if we do it transvaginally," Dr. Voss said in an interview. But he pointed out that often the test is done too late to! make a decision about therapeutic abortion.

When a cardiac defect is detected, "the obstetrician is going to have a lot of counseling o do with the parents long before delivery, because they are going to have a lot of unanswered questions about the problems their baby is going to face," he said.

The main goal of the fetal echocardiogram is to obtain a good four-chamber view, which shows 60% of pulmonary diseases. The addition of a good view of both the left and right outflow tract can exclude 80%-85% of disease. "If the fetal echocardiogram has not achieved this, you might consider repeating the study in 2-4 weeks," he advised.

Most fetuses with cardiac anomalies can be delivered vaginally The few exceptions are those with fetal hydrops, congenital heart block, or arrhythmia; these conditions make it very difficult to monitor the fetus' well-being during labor.

The only reason the primary obstetrician might not perform the delivery is if the patient needs to deliver at another institution. "Depending on the nature of the cardiac anomaly, the patient might have to be in a tertiary care center where her baby will get immediate intensive care, Dr. Voss said.
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Author:Johnson, Kate
Publication:OB GYN News
Date:Oct 15, 2001
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