Home Monitoring for Fetal Heart Rhythm During Anti-Ro Pregnancies

Cuneo, Bettina F.; Sonesson, Sven Erik; Levasseur, Stéphanie; Moon-Grady, Anita J.; Krishnan, Anita; Donofrio, Mary T.; Raboisson, Marie‐Josée; Hornberger, Lisa K.; Eerden, Peter Van; Sinkovskaya, Elena; Abuhamad, Alfred; Arya, Bhawna; Szwast, Anita; Gardiner, Helena M.; Jacobs, Katherine; Freire, Grace; Howley, Lisa; Lam, Aimee; Kaizer, Alexander; Benson, D. Woodrow; Jaeggi, Edgar

doi:10.1016/j.jacc.2018.07.076

Cited by 75 publications

(59 citation statements)

References 22 publications

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“…As treatment of AVB‐I does not always restore a normal AV interval, a more realistic treatment goal may be to prevent progression to more advanced AVB. We suggest that fetuses with an AV interval Z ‐score of + 3 to + 4 be followed more frequently than the recommended weekly echocardiography examinations, and that adjunct fetal heart rhythm monitoring by the mother at home to detect the transition rhythm of type‐1 AVB‐II be strongly considered.…”

Section: Discussionmentioning

confidence: 99%

Assessment of atrioventricular conduction by echocardiography and magnetocardiography in normal and anti‐Ro/SSA‐antibody‐positive pregnancies

Cuneo

Bitant

Strasburger

et al. 2019

Ultrasound in Obstet & Gyne

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Objectives The objectives of this study were, first, to evaluate the association between fetal echocardiographic atrioventricular (AV) and magnetocardiographic (fMCG) PR intervals at different gestational ages (GAs) in normal and anti‐Ro/SSA‐antibody‐positive pregnancies; second, to determine if PR interval could be predicted by AV interval; and third, to assess the neonatal outcome of fetuses with prolonged AV and PR intervals, with the goal of developing criteria for fetal first‐degree AV block (AVB‐I). Methods This was a retrospective study of anti‐Ro/SSA‐antibody‐positive pregnancies (cases) and controls that underwent fMCG and fetal echocardiography at the same recording session. Cardiac cycle length, GA and AV (by mitral inflow/aortic outflow Doppler) and PR (by fMCG) intervals were measured. We tested for significant differences between AV and PR intervals using generalized estimating equations to account for repeat measurements, and assessed whether PR interval could be predicted reliably by AV interval. After delivery, infants with fetal AV or PR interval Z‐score ≥ 3 underwent 12‐lead electrocardiography. Results Thirty‐nine controls and 31 cases underwent 46 and 36 simultaneous fMCG and echocardiographic examinations, respectively; 101 controls and nine cases underwent fMCG only. AV and PR intervals increased with GA (P < 0.05 for both). Overall, AV and PR intervals were significantly different from each other (P < 0.001); this difference was not significant when compared between cases and controls (P = 0.222). PR interval could not be predicted accurately from AV interval and GA alone. Three of four cases with AV and PR interval Z‐scores > + 3 had postnatal AVB‐I despite treatment. The fourth fetus, which had predominately second‐degree AVB and rare periods of AVB‐I, progressed to third‐degree AVB despite treatment with dexamethasone. Conclusions The diagnostic threshold for AVB‐I, defined by AV interval Z‐score, is GA dependent. Based on the observed data, an AV interval Z‐score threshold of 3 (AV interval, 151–167 ms) may be appropriate. Echocardiographic AV interval was not predictive of fMCG‐PR interval. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

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Section: Discussionmentioning

confidence: 99%

Assessment of atrioventricular conduction by echocardiography and magnetocardiography in normal and anti‐Ro/SSA‐antibody‐positive pregnancies

Cuneo

Bitant

Strasburger

et al. 2019

Ultrasound in Obstet & Gyne

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“…Another promising approach to diagnosing CCHB is institution of a home monitoring program in which the mother is trained to measure fetal heart rate twice a day using a simple handheld Doppler system. These studies have been shown to be feasible with up to 87% of patients completing the monitoring protocol (Cuneo et al, ; Cuneo et al, ; Cuneo et al, ). In one study, this was used to successfully identify progression to CCHB in the at‐risk fetus allowing for emergent steroid treatment and reversion to sinus rhythm in one of the patients (Cuneo et al, ; Cuneo, Ambrose, & Tworetzky, ).…”

Section: Prenatal Evaluation Of Complete Heart Blockmentioning

confidence: 99%

“…These studies have been shown to be feasible with up to 87% of patients completing the monitoring protocol (Cuneo et al, ; Cuneo et al, ; Cuneo et al, ). In one study, this was used to successfully identify progression to CCHB in the at‐risk fetus allowing for emergent steroid treatment and reversion to sinus rhythm in one of the patients (Cuneo et al, ; Cuneo, Ambrose, & Tworetzky, ). A wearable, transabdominal wireless fetal monitor has been developed which is able to differentiate maternal and fetal heart rates allowing for continuous fetal ECG monitoring for gestational ages greater than 20 weeks with decreased accuracy after 26 weeks (Graatsma, Jacod, van Egmond, Mulder, & Visser, ).…”

Section: Prenatal Evaluation Of Complete Heart Blockmentioning

confidence: 99%

Prenatal diagnosis and management of congenital complete heart block

Pruetz

Miller

Loeb

et al. 2019

Birth Defects Research

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Congenital complete heart block (CCHB) is a life‐threatening medical condition in the unborn fetus with insufficiently validated prenatal interventions. Maternal administration of medications aimed at decreasing the immune response in the fetus and beta‐agonists intended to increase fetal cardiac output have shown only marginal benefits. Anti‐inflammatory therapies cannot reverse CCHB, but may decrease myocarditis and improve heart function. Advances in prenatal diagnosis and use of strict surveillance protocols for delivery timing have demonstrated small improvements in morbidity and mortality. Ambulatory surveillance programs and wearable fetal heart rate monitors may afford early identification of evolving fetal heart block allowing for emergent treatment. There is also preliminary data suggesting a roll for prevention of CCHB with hydroxychloroquine, but the efficacy and safety is still being studied. To date, intrauterine fetal pacing has not been successful due to the high‐risk invasive placement techniques and potential problems with lead dislodgement. The development of a fully implantable micropacemaker via a minimally invasive approach has the potential to pace fetal patients with CCHB and thus delay delivery and allow fetal hydrops to resolve. The challenge remains to establish accepted prenatal interventions capable of successfully managing CCHB in utero until postnatal pacemaker placement is successfully achieved.

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“…Although we are not ready to throw the baby out with the bath water and suggest that fetal echocardiography is unnecessary for anti‐Ro/SSA‐antibody‐positive pregnancy surveillance, frequent ambulatory fetal heart rhythm (FHR) monitoring with confirmation of abnormal findings by a diagnostic echocardiogram has emerged as a technique that obviates the drawbacks of echocardiography alone. If Sonesson et al .…”

mentioning

confidence: 99%

“…We now appreciate that the phenotype of cardiac NL is variable, ranging from clinically silent AVB I that does not progress, to AVB III with cardiomyopathy that progresses to hydrops and fetal demise in < 1 week 8 . Lastly, we know that the fetal AV and the neonatal PR intervals are mutable, and that an AV interval considered to indicate AVB I may not progress to AVB II or AVB III, even in the absence of treatment [6][7][8][9][10][11][12][13][14][15][16][17][18][19] . This raises the possibility that a prolonged AV interval in humans may represent a distinct anti-Ro/SSA pathologic process, or there may be an unidentified protective genetic or environmental factor in some cases, which keeps injury in check.…”

mentioning

confidence: 99%