Jodi I. Pike

Specialized Delivery Room Planning for Fetuses With Critical Congenital Heart Disease

Improvements in fetal echocardiography have increased recognition of fetuses with congenital heart disease (CHD) that require specialized delivery room (DR) care. In this study, care protocols for these low-volume and high-risk deliveries were created. Elements included (1) diagnosis-specific DR care plans and algorithms, (2) a multidisciplinary team with expertise, (3) simulation, (4) checklists, and (5) debriefing. The purpose of this study was to assess the accuracy of fetal echocardiography to predict the need for specialized DR care and determine the effectiveness of the care protocols for the treatment of patients with critical CHD. Fetal and postnatal medical records and echocardiograms of fetuses with CHD assigned to an advanced level of care were reviewed. Safety and outcome variables were analyzed to determine care plan and algorithm efficacy. Thirty-four fetuses were identified: 12 delivered at Childrens National Medical Center and 22 at the adult hospital. Diagnoses included hypoplastic left heart syndrome, aortic stenosis, d-transposition of the great arteries, tetralogy of Fallot with absent pulmonary valve, complex pulmonary atresia, arrhythmias, ectopia cordis, and conjoined twins. Delivery at Childrens National Medical Center was associated with a shorter time to specialty care or intervention. Measures of physiologic stability and survival were similar. Need for specialized care was predicted in 84% of deliveries. For hypoplastic left heart syndrome, intervention was predicted in 10 of 11 deliveries and for d-transposition of the great arteries in 10 of 12 deliveries. Care algorithms addressed most DR events. Of the unanticipated events, none were unrecoverable. DR survival was 100%, and survival to discharge was 83%. In conclusion, fetal echocardiography predicted the need for specialized DR care in fetuses with critical CHD. Algorithm-driven protocols enable planning such that maternal and infant risk is minimized and outcomes are good.

Ineffective Therapy, Underpowered Studies, or Merely Too Little, Too Late? Risk Factors and Impact of Maternal Corticosteroid Treatment on Outcome in Antibody-Associated Fetal Heart Block

It is estimated that 2% to 3% of pregnant women carry the anti-SSA/Ro antibody, which can be found in various autoimmune disorders, including Sjogren syndrome (SS), systemic lupus erythematosus, rheumatoid arthritis, and mixed connective tissue disorder.1,2 In addition, many women are asymptomatic carriers, with less than one third of anti-SSA/Ro–positive women diagnosed with a rheumatological disorder preceding the discovery of advanced heart block in the fetus.3,4 Prospective studies have demonstrated that, in the absence of a previously affected pregnancy, the fetuses of these women bear up to a 3% risk of developing cardiac manifestations of neonatal lupus (NL), including cardiac conduction abnormalities, structural cardiac defects, and isolated cardiomyopathies.5–7 In women with a previously affected pregnancy, the recurrence rate of congenital heart block can reach as high as 17%.8,9 Articles see p 1919 and p 1927 The cardiac conduction manifestations of NL are thought to result from a pathological response to the transplacental acquisition of anti-SSA/Ro whereby an immune-mediated inflammatory pathway triggers injury and eventually fibrosis of the atrioventricular (AV) node.10 In addition, anti-SSA/Ro antibodies appear to inhibit activation of the cardiac L-type calcium channels, which are essential to normal AV node conduction.11 The role of anti-SSB/La antibodies is less clearly defined. Although anti-SSB/La alone has not been associated with conduction abnormalities, some evidence suggests that it may potentiate the effects of anti-SSA/Ro–mediated injury.12 Antibody-exposed infants without cardiac involvement at birth have little risk of later developing AV block; however, complete AV block can evolve in fetuses with second-degree AV block in utero or neonates born with first- or second-degree AV block.9 Jaeggi and colleagues3 reported that the timing of initial presentation of complete AV block correlated with mortality. Among the 29 cases diagnosed …

Fetal and neonatal atrial arrhythmias: an association with maternal diabetes and neonatal macrosomia

To determine if the incidence of maternal diabetes mellitus or neonatal macrosomia is more frequent in fetuses and neonates with atrial arrhythmias than the general population.

Early fetal echocardiography: congenital heart disease detection and diagnostic accuracy in the hands of an experienced fetal cardiology program

Evaluate the utility of early fetal echocardiography in the hands of an experienced fetal cardiology program for detection of congenital heart disease (CHD) in high‐risk pregnancies.

Bassinet Use and Sudden Unexpected Death in Infancy

OBJECTIVE To analyze risk factors in infants who die suddenly and unexpectedly in bassinets. STUDY DESIGN A retrospective review of all deaths of infants involving bassinets reported to the Consumer Product Safety Commission (CPSC) between 1990 and 2004. RESULTS For the 53 deaths analyzed, the mean age at death was 84 days. The cause of death was recorded as anoxia, asphyxiation, or suffocation in 85% and sudden infant death syndrome (SIDS) in 9.4%. In terms of position, 37% were placed prone for sleep, and 50% were prone when found dead. Additional items in the bassinet, including soft bedding, were noted in 74% of cases. Specific mechanical problems with the bassinets were noted in 17% of cases. CONCLUSIONS The risk of sudden unexpected death in infants who sleep in bassinets can be reduced by following American Academy of Pediatrics guidelines, including positioning infants supine and avoiding soft bedding in bassinets. In addition, parents must ensure that the bassinet is mechanically sound and that no objects that can lead to suffocation are in or near the bassinet.