Neonatal outcomes in fetuses with cardiac anomalies and the impact of delivery route

Abstract

BACKGROUND Congenital fetal cardiac anomalies compromise the most common group of fetal structural anomalies. Several previous reports analyzed all types of fetal cardiac anomalies together without individualized neonatal morbidity outcomes based on cardiac defect. Mode of delivery in cases of fetal cardiac anomalies varies greatly as optimal mode of delivery in these complex cases is unknown. OBJECTIVE We sought to determine rates of neonatal outcomes for fetal cardiac anomalies and examine the role of attempted route of delivery on neonatal morbidity. STUDY DESIGN Gravidas with fetal cardiac anomalies and delivery >34 weeks, excluding stillbirths and aneuploidies (n = 2166 neonates, n = 2701 cardiac anomalies), were analyzed from the Consortium on Safe Labor, a retrospective cohort study of electronic medical records. Cardiac anomalies were determined using International Classification of Diseases, Ninth Revision codes and organized based on morphology. Neonates were assigned to each cardiac anomaly classification based on the most severe cardiac defect present. Neonatal outcomes were determined for each fetal cardiac anomaly. Composite neonatal morbidity (serious respiratory morbidity, sepsis, birth trauma, hypoxic ischemic encephalopathy, and neonatal death) was compared between attempted vaginal delivery and planned cesarean delivery for prenatal and postnatal diagnosis. We used multivariate logistic regression to calculate adjusted odds ratio for composite neonatal morbidity controlling for race, parity, body mass index, insurance, gestational age, maternal disease, single or multiple anomalies, and maternal drug use. RESULTS Most cardiac anomalies were diagnosed postnatally except hypoplastic left heart syndrome, which had a higher prenatal than postnatal detection rate. Neonatal death occurred in 8.4% of 107 neonates with conotruncal defects. Serious respiratory morbidity occurred in 54.2% of 83 neonates with left ventricular outflow tract defects. Overall, 76.3% of pregnancies with fetal cardiac anomalies underwent attempted vaginal delivery. Among patients who underwent attempted vaginal delivery, 66.1% had a successful vaginal delivery. Women with a fetal cardiac anomaly diagnosed prenatally were more likely to have a planned cesarean delivery than women with a postnatal diagnosis (31.7 vs 22.8%; P < .001). Planned cesarean delivery compared to attempted vaginal delivery was not associated with decreased composite neonatal morbidity for all prenatally diagnosed (adjusted odds ratio, 1.67; 95% confidence interval, 0.85–3.30) or postnatally diagnosed (adjusted odds ratio, 0.99; 95% confidence interval, 0.77–1.27) cardiac anomalies. CONCLUSION Most fetal cardiac anomalies were diagnosed postnatally and associated with increased rates of neonatal morbidity. Planned cesarean delivery for prenatally diagnosed cardiac anomalies was not associated with less neonatal morbidity.

Obstetric and Neonatal Outcomes in Congenital Isolated Cardiac Anomalies - Single Center Experience

“…3 Tanının prenatal dönemde konması değerlendirme açısından optimizasyonu sağlamış olsa da, ideal doğum şeklinin sezaryen veya vajinal doğum olması konusunda kesin sonuçlar bulunmamaktadır. 16,17 Tablo 5. Subgrup analizlerine göre doğum ağırlığı, APGAR skorları, gebelik haftaları ve maternal yaşın karşılaştırması.…”

“…[20][21][22][23] Yapılan başka bir çalışmada ise, prenatal kardiyak anomaly tanısı almış hastalarda, planlanmış sezaryen ve vajinal doğum karşılaştırılmış, sezaryen doğumun kötü neonatal sonuçlarda azalmayla ilişkili olmadığı gösterilmiştir. 17 Prenatal kardiyak anomaly tanısı alan yenidoğanların değerlendirildiği bir çalışmada, bu yenidoğanların, sıklıkla planlı sezaryen nedeni ile postnatal tanı alanlara göre daha erken doğdukları saptanmıştır. 24 Trento ve ark.…”

“…14,15 Tanının prenatal dönemde konması değerlendirme açısından optimizasyonu sağlamış olsa da, ideal doğum şeklinin sezaryen veya vajinal doğum olması konusunda kesin sonuçlar yoktur. 16,17 Hidrops ve fetal aritminin olmadığı durumlarda, yalnızca konjenital kalp hastalıklarının varlığının sezaryen ile doğum için bir endikasyon olmadığı günümüzde geniş çevrelerce kabul edilmiştir. 5 Bu çalışmada, Nisan 2013-Aralık 2019 tarihleri arasında izole kardiyak anomalisi bulunan ve İzole fetal kardiyak anomali ile doğum yapan hastalarda infantların 1. dk.…”

Impacts of prenatal diagnosis of congenital heart diseases on outcomes

“…In the EPICARD study, Laas et al found that overall preterm newborns with CHD, particularly those who were born at <35 weeks of gestational age, had a substantially higher risk of mortality than those born at term (37-41 weeks), but the same group showed that the higher risk of preterm birth in newborns with CHD, was essentially due to spontaneous labor and not scheduled delivery (35,36). The attempted route of delivery (vaginal or caesarian section) for fetal cardiac anomaly had no impact on neonatal morbidity while prenatal diagnosis reduced the need for invasive respiratory support (37).…”

Perinatal cardiology: the present and the future. Part I: congenital heart disease

“…Не рекомендуется принимать решение о преждевременном стимулировании родовой деятельности, если речь не идет о жизненных показаниях по состоянию матери или плода. К настоящему времени необходимость или потенциальные преимущества операции кесарева сечения у женщин при выявлении порока сердца у плода убедительно не доказаны (за исключением врожденных пороков сердца с внутриутробной декомпенсацией кровообращения для повышения шанса на выживание) [8]. Тем не менее данные опубликованных исследований позволяют утверждать, что решение о родоразрешении через естественные родовые пути в большинстве случаев принимается в отсутствие информации о наличии врожденного порока сердца у плода.…”