Transplacental Therapy Research Articles

Mammalian target of rapamycin inhibitors: A new-possible approach for in-utero medication therapy.

The mammalian/mechanistic target of rapamycin (mTOR) is a protein kinase that plays a crucial role in regulating cellular growth, metabolism, and survival. Although there is no absolute contraindication for the use of mTOR inhibitors during pregnancy, the specific fetal effects remain unknown. Available data from the past 2decades have examined the use of mTOR inhibitors during pregnancy in patients with solid organ transplantation, showing no clear link to fetal complications or structural abnormalities. Recently, a handful of case reports and series have described transplacental therapy of mTOR inhibitors to control symptomatic and complicated pathologies in the fetus. The effect of these agents includes a significant reduction in lesion size in the fetus and a reduced need for mechanical ventilation in neonates. In this context, we delve into the potential of mTOR inhibitors as in-utero therapy for fetal abnormalities, with a primary focus on lymphatic malformation (LM) and cardiac rhabdomyoma (CR). While preliminary reports underscore the efficacy of mTOR inhibitors for the treatment of fetal CR and fetal brain lesions associated with tuberous sclerosis complex, chylothorax, and LMs, additional investigation and clinical trials are essential to comprehensively assess the safety and efficacy of these medications.

Fetal arrhythmias: Ten years' experience and review of the literature.

Fetal arrhythmias complicate 1-2% of all pregnancies. Ultrasound evaluation and Doppler technology are indispensable in both diagnosis and management. Digoxin, sotalol, flecainide and amiodarone are widely accepted antiarrhythmic agents that are frequently. We reviewed the maternal and fetal outcomes in cases with fetal arrhythmia in a tertiary care center in the last decade. Fetal arrhythmias were classified under three main groups: Irregular rhythms, tachyarrhythmia and bradyarrhythmia. Detailed anatomical evaluation and fetal echocardiography were performed in all cases to determine whether a structural cardiac and extracardiac anomaly accompanied fetal arrhythmia and the type of fetal arrhythmia. Digoxin was started primarily as first-line therapy in patients with persistent fetal tachyarrhythmia. In cases, not responding to digoxin, other antiarrhythmic agents (sotalol, flecainide) were combined with treatment without discontinuing digoxin. Fetal arrhythmia was detected in 36 cases during the study period. 50% (n=18/36) of the cases had supraventricular tachycardia, whereas 28% (n=10/36) of them were fetal bradyarrhythmia and 22% (n=8/36) of them were with various irregular rhythms. Transplacental therapy was initiated in 13 patients with persistent supraventricular tachycardia and atrial flutter regardless of the presence of hydrops. The success rate in transplacental therapy was 77% (n=10/13). Successful transplacental therapy was achieved in approximately 80% of cases and delivery could be postponed to advanced gestational weeks, confirming the crucial role of this treatment for the management of tachyarrhythmia.

The diagnosis and management of fetal cardiac arrhythmias

Key content Fetal cardiac arrhythmias are relatively common and account for up to 20% of referrals to fetal cardiologists. Arrhythmias may occur because of structural abnormalities of the fetal heart, or because of abnormal functioning of the cardiac conduction system in an otherwise structurally normal heart. Arrhythmias may be diagnosed using ultrasound and M‐mode and Doppler echocardiography. Transplacental therapy for tachyarrhythmias has been one of the success stories of fetal cardiology, and good outcomes can be expected in the absence of hydrops. Congenital heart block is most commonly caused by the transplacental passage of anti‐Ro and anti‐La antibodies and transplacental therapy is less successful in managing this. Learning objectives To enable clinicians to provide better counselling for patients about the prognosis of fetal arrhythmias. To learn how to diagnose fetal arrhythmias and know when to refer to a specialist centre if the diagnosis is suspected. To understand the treatment options available and the evidence‐based antenatal care schedule.

Supraventricular tachycardias in neonates and infants: factors associated with fatal or near-fatal outcome.

Prognosis of supraventricular tachycardias in neonates and infants is thought to be excellent with rare fatal outcomes. Nevertheless, initial management can be challenging. The aim of this study was to perform a retrospective analysis in neonates/infants with non-pos-toperative supraventricular tachycardias regarding risk factors for clinical outcome and type of antiarrhythmic drug therapy. The data of 157 patients aged < 1 year who presented between 2000 and 2015 with symptomatic tachycardias were retrospectively reviewed. Pharmacological therapy was successful in 151 patients (96%); 1 patient (1%) required catheter ablation and 5 patients (3%) died (1 death linked to hemodynamical reasons after effective arrhythmia control). Serious complications following acute medical therapy occurred in 4 patients of survivors. Patients with complications or death had a lower bodyweight, more frequent intrauterine tachycardia, transplacental therapy, urgent caesarian section, higher PRISM II score, longer period to control tachycardia, more frequent proarrhythmia, and major adverse event-defined as life-threatening event without a documented new arrhythmia-compared to the group without complications. There was no significant difference between the groups regarding prematurity, structural heart disease, and type of tachycardia. Proarrhythmia occurred in 6 cases and was related to intravenous drug use with class IC antiarrhythmics in 3/6 cases, digoxin in 2/6 cases, and amiodarone in 1/6 cases. ECG signs of impending proarrhythmia without new-onset arrhythmia requiring cessation of therapy were detected in 6 patients.Conclusion: Although rare, non-post-operative supraventricular tachycardia in neonates and infants might be a serious disease. Acute intravenous pharmacological treatment to control tachycardia might pose a risk for fatal or near-fatal outcome. Detection of proarrhythmia related to class IC antiarrhythmics in neonates might be especially difficult and requires alertness. What is Known • Prognosis of supraventricular tachycardias in children are thought to be excellent with fatal outcomes being rare. • Mortality is increased in the very young and in those with structural heart disease. What is New • Complicated outcome of non-post-operative supraventricular tachycardias in neonates is associated with lower bodyweight, age, prenatal tachycardia, higher PRISM II score, longer period to control tachycardia, and proarrhythmia. • Detection of class IC proarrhythmic effect is especially difficult in neonates because of their narrow QRS and warrants alertness.

Transplacental therapy of supraventricular tachycardia and hydrops fetalis in a twin pregnancy – case report and literature review

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Carl M. Macalintal J, Castillo-Cheng M, D. Cheng D. Transplacental therapy of supraventricular tachycardia and hydrops fetalis in a twin pregnancy – case report and literature review. Prenatal Cardiology. 2021;(1). doi:10.5114/pcard.2021.108875. APA Carl M. Macalintal, J., Castillo-Cheng, M., & D. Cheng, D. (2021). Transplacental therapy of supraventricular tachycardia and hydrops fetalis in a twin pregnancy – case report and literature review. Prenatal Cardiology, (1). https://doi.org/10.5114/pcard.2021.108875 Chicago Carl M. Macalintal, Joseph, Maria Rosario Castillo-Cheng, and Dexter Eugene D. Cheng. 2021. "Transplacental therapy of supraventricular tachycardia and hydrops fetalis in a twin pregnancy – case report and literature review". Prenatal Cardiology (1). doi:10.5114/pcard.2021.108875. Harvard Carl M. Macalintal, J., Castillo-Cheng, M., and D. Cheng, D. (2021). Transplacental therapy of supraventricular tachycardia and hydrops fetalis in a twin pregnancy – case report and literature review. Prenatal Cardiology, (1). https://doi.org/10.5114/pcard.2021.108875 MLA Carl M. Macalintal, Joseph et al. "Transplacental therapy of supraventricular tachycardia and hydrops fetalis in a twin pregnancy – case report and literature review." Prenatal Cardiology, no. 1, 2021. doi:10.5114/pcard.2021.108875. Vancouver Carl M. Macalintal J, Castillo-Cheng M, D. Cheng D. Transplacental therapy of supraventricular tachycardia and hydrops fetalis in a twin pregnancy – case report and literature review. Prenatal Cardiology. 2021;(1). doi:10.5114/pcard.2021.108875.

Ebstein's anomaly: epidemiological analysis and presentation of different prenatal management

Objectives To present the crucial role of echocardiographic examination in perinatal care and analyze influence of prenatal treatment for neonatal outcome. Furthermore, the attempt to answer the question if there was any relationship between the occurrence of fetal Ebstein’s anomaly and environmental risk factors in polish population. Methods Forty-five prenatal diagnoses of Ebstein’s anomaly were compiled over the 21-year period (1998‒2018) form our single unit. The analysis included the assessment of maternal parameters (age, past obstetric history, and place of residence) and fetal parameters (sex, gestational age, anatomy, the fetal cardiovascular condition assessed by the CVPS, associated extracardiac anomalies or malformations, prenatal treatment, delivery and follow-up). Results The average age of gravida was 29.5 years (± 5.2 years) and gravidae <35 years of age accounted for 80% . There were 43 singleton pregnancies and 2 cases of multiple pregnancy. Ebstein’s anomaly was mostly (averagely) diagnosed at 28th week of gestation. Forty-three fetuses had normal karyotypes and two had trisomy 21. Cardiomegaly was present in 91% (41) of fetuses. The average heart area to chest area ratio was 0.56 (± 0.12). In 21 cases, there was only fetal monitoring – echocardiographic examinations and postnatal mortality was 44.4%. In 5 cases, transplacental digoxin treatment was administered and mortality was: 40%. In another 5 cases, only steroid therapy was applied and postnatal mortality was 100%. Steroids and transplacental digoxin treatment were administered in 11 cases and mortality was 63.6%. In 3 last cases transplacental digoxin treatment, steroids and maternal hyperoxygenation therapy were given and mortality was 0%. Cesarean section rate was 49%. Moreover, due to Ebstein’s anomaly regional peak of occurrence benzopyrene was deliberated as environmental risk factor. Conclusions Fetal Ebstein’s anomaly occurred in our population in healthy young women, expecting their first child and malformation was not related to fetus gender, nor to maternal health condition. Our data can be a new signal for the development of novel treatment strategies in therapy in fetuses with Ebstein’s anomaly.

Importance of Analysis of Arrhythmia Mechanism in Predicting Outcomes in Fetal Bradycardia: A Single-Centre Retrospective Study from a Dedicated Fetal Cardiology Unit in South India

AbstractFew studies have correlated the mechanism of fetal bradycardia to pregnancy outcomes. This study aimed to correlate the arrhythmia mechanism to pregnancy and early postnatal outcomes in fetal bradycardia. This was retrospective study (May 2013–November 2019). Fetuses with sustained bradycardia (heart rate ≤ 100 per minute) were included. Based on arrhythmia mechanism, patients were categorized into 4 groups:Group 1: blocked atrial ectopics, Group 2: second-degree atrioventricular block (AVB), Group 3: complete AVB and group 4: sinus bradycardia. Clinical presentation, need for transplacental therapy, pregnancy and early postnatal outcomes were analysed. A total of 36 patients were included. Mean gestational age was 26.2 ± 5.5 weeks. The most common arrhythmia mechanism was Group 3 (N = 24; 66.7%) followed by Group 2 (N = 5; 13.8%); groups 1 and 4 had 4 and 3 patients respectively. Maternal auto-antibodies were reported in 21 patients (58.3%); 19 were in Group 3. Transplacental therapy was needed in 15 (41.7%) cases; 14 were in Group 3. Live-birth was reported in 23 cases (63.9%), other outcomes included pregnancy termination (n = 7), intra-uterine death (n = 4) and lost to follow-up (n = 2). Live-births were most common in Groups 1 (100%) and 2 (80%), followed by Group 3 (54.2%). Postnatal mortality occurred in one patient (Group 2). Three patients (60%) in Group 2 had Long QT syndrome in postnatal evaluation. Eight patients (6 in group 3) needed pacemaker implantation after birth. Fetal bradycardia was associated with an overall favorable pregnancy and good early postnatal outcomes. Analysis of the arrhythmia mechanism should guide prognostication and decisions for transplacental therapy.

Prenatal echocardiographic diagnosis of congenital heart disease in high-risk antenatal mothers in a tertiary care center and their postnatal outcome: An experience from third world

Background: Congenital heart diseases (CHDs) are the most common fetal congenital defects, and until nowadays, most of them are bypassed without prenatal diagnosis. In this study, we found the incidence of fetal CHD in high-risk mothers, various indications of fetal echocardiography (FE), and their postnatal outcome in developing nation with limited resources. Materials and Methods: A total of 106 cases of antenatal mothers, who are having risk factors such as abnormal obstetric screening, diabetes mellitus, and family history, are included in the study group. The FE was done for pregnant mothers between the age groups of 20 and 40 years at different gestational ages after 20 weeks of pregnancy in the Postgraduate Department of Pediatrics, GMC, Srinagar, between January 2016 and January 2018. Results: The mean gestational age at diagnosis was 30.63 ± 4.3 weeks. The mean age of mothers at diagnosis was 29.99 ± 3.6 years. We identified indications for FE in 106 cases. The most common indication was abnormal cardiac findings in obstetrical screening sonography (30.18%). Among the 106 FE results, 80 (75.47%) were normal, eight (7.54%) were minor abnormalities, three (2.8%) were significant cardiac anomalies, eight (7.5%) were complex cardiac anomalies, and 60.7 (6.6%) were arrhythmias. The most common CHD was hypoplastic left heart syndrome (n = 4). Ninety-one neonates were examined by postnatal echo. We analyzed differences between FE and postnatal echo. There were minor differences in nine cases (9.89%) and major in only two (2.19%) cases. Transplacental fetal therapy was given in four cases. Two cases had fetal tachycardia that was reverted to sinus rhythm and two cases had complete heart block in which heart block persisted despite transplacental therapy. Conclusion: FE is a very useful tool for prenatal diagnosis of CHD. It has proven itself in the diagnosis and management of fetal arrhythmia, even in developing countries with limited resources.

Rapid Quantitation of Flecainide in Human Plasma for Therapeutic Drug Monitoring Using Liquid Chromatography and Time-of-Flight Mass Spectrometry.

Measurement of flecainide is useful to optimize dosage and minimize risks of toxicity. Furthermore, there is a need for urgent sample analysis when flecainide is used in transplacental therapy for fetal tachycardia. To this end, we have developed and validated a rapid assay for the measurement of flecainide in human plasma or serum, using a small sample volume (50 µL). After a simple deproteination with zinc sulfate and methanol, prepared samples were injected onto a short (30 mm) analytical column and eluted using a rapid gradient elution. Detection was performed using time-of-flight mass spectrometry. Flecainide was quantified using flecainide-D4 as internal standard, with both compounds extracted from the total ion chromatogram using a ±5 ppm extraction window based on the theoretical m/z values for the protonated ions. The assay was linear over a putative therapeutic range (100-1500 mcg/L). Between- and within-assay imprecision and accuracy were <4.6% and 94.8%-110.0%, respectively. Matrix effects were minimal and were compensated for by flecainide-D4. There were no effects due to hemolysis or lipemia, and no carryover was apparent. Total analysis time was just 1.2 minutes (72 seconds). We have developed and validated a rapid method for the analysis of flecainide. The method is particularly suited for flecainide therapeutic drug monitoring, when analyzing samples from mothers receiving flecainide for the treatment of fetal tachycardia.

Prenatal microRNA miR-200b Therapy Improves Nitrofen-induced Pulmonary Hypoplasia Associated With Congenital Diaphragmatic Hernia.

We aimed to evaluate the use of miR-200b as a prenatal transplacental therapy in the nitrofen rat model of abnormal lung development and congenital diaphragmatic hernia (CDH). Pulmonary hypoplasia (PH) and pulmonary hypertension determine mortality and morbidity in CDH babies. There is no safe medical prenatal treatment available. We previously discovered that higher miR-200b is associated with better survival in CDH babies. Here, we investigate the role of miR-200b in the nitrofen rat model of PH and CDH and evaluate its use as an in vivo prenatal therapy. We profiled miR-200b expression during nitrofen-induced PH using RT-qPCR and in situ hybridization in the nitrofen rat model of PH and CDH. The effects of nitrofen on downstream miR-200b targets were studied in bronchial lung epithelial cells using a SMAD luciferase assay, Western blotting and Immunohistochemistry. We evaluated miR-200b as a lung growth promoting therapy ex vivo and in vivo using lung explant culture and transplacental prenatal therapy in the nitrofen rat model. We show that late lung hypoplasia in CDH is associated with (compensatory) upregulation of miR-200b in less hypoplastic lungs. Increasing miR-200b abundance with mimics early after nitrofen treatment decreases SMAD-driven TGF-β signaling and rescues lung hypoplasia both in vitro and in vivo. Also, prenatal miR-200b therapy decreases the observed incidence of CDH. Our data indicate that miR-200b improves PH and decreases the incidence of CDH. Future studies will further exploit this newly discovered prenatal therapy for lung hypoplasia and CDH.

Maternal monitoring and safety considerations during antiarrhythmic treatment for fetal supraventricular tachycardia.

Fetal tachycardia is a rare complication during pregnancy. After exclusion of maternal and fetal conditions that can result in a secondary fetal tachycardia, supraventricular tachycardia is the most common cause of a primary sustained fetal tachyarrhythmia. In cases of sustained fetal supraventricular tachycardia, maternal administration of digoxin, flecainide, sotalol, and more rarely amiodarone, is considered. As these medications have the potential to cause significant adverse effects, we sought to examine maternal safety during transplacental treatment of fetal supraventricular tachycardia. In this narrative review we summarize the literature addressing pharmacologic properties, monitoring, and adverse reactions associated with medications most commonly prescribed for transplacental therapy of fetal supraventricular tachycardia. We also describe maternal monitoring practices and adverse events currently reported in the literature. In light of our findings, we provide clinicians with a suggested maternal monitoring protocol aimed at optimizing safety.

368. Current practices in maternal monitoring during antiarrhythmic treatment for fetal SVT: A scoping review

Background In pharmacologic management of fetal supraventricular tachycardia (SVT), antiarrhythmic agents are administered to the pregnant patient serving as a vehicle of transplacental delivery to the fetus. Given that antiarrhythmic therapy can have profound maternal adverse effects, administration of initial loading and dose adjustments should involve deliberate attention to pharmacologic principles with close maternal monitoring for adverse effects. We reviewed current monitoring practices and maternal complications of transplacental antiarrhythmic therapy for fetal SVT. Methods A query of the Embase database for search terms ”Fetal” or ”Foetal” and ”Supraventricular Tachycardia” or ”SVT” yielded 93 titles, of which 19 articles detailing the modalities of therapy for Fetal SVT were reviewed. Results The 19 articles represented 565 cases of fetal SVT, 111 of which had developed hydrops fetalis. Of these cases, 184 received a course of digoxin alone and 33, 56, and 5 cases received a combination therapy of digoxin with flecainide, sotalol, or amiodarone. Flecainide, Sotalol, and amiodarone were given as monotherapy in 89, 77, and 6 cases, respectively. Maternal monitoring information was available in 15 studies. Investigators performed electrocardiograms (EKGs) at baseline and during follow-up in 12 studies, and monitored electrolytes in five. Two studies reported a mandatory cardiologist consultation for all mothers and two studies considered performing echocardiography in select mothers. Digoxin and flecainide levels were measured in eight and four studies, respectively. Toxicity was reported in 5 patients: two on digoxin monotherapy, two on flecainide monotherapy, and one on combination of digoxin and flecainide. Conclusion Pharmacologic management of fetal SVT is generally safe for mothers with normal baseline cardiac assessments and close monitoring of symptoms, EKG, electrolytes, and/or drug levels. Future prospective studies on the treatment of fetal SVT should also include a systematic monitoring strategy for mothers, with consistent reporting of adverse reactions.

Ventricular Tachycardia in a Fetus: Benign Course of a Malignant Arrhythmia.

Fetal arrhythmias constitute 10 to 20% of the total referrals to fetal cardiology unit. Ventricular tachycardia (VT) is a rare form of fetal tachyarrhythmia. This report describes the clinical presentation, diagnostic features, and successful management of VT in a fetus at 32 weeks of gestation. Transplacental therapy with sotalol resulted in the termination of tachyarrhythmia in 48 h, followed by good postnatal outcome. Fetal m-mode showing ventricular rate higher than atrial rate with atrio-ventricular dissociation is suggestive of VT. Early diagnosis and institution of transplacental therapy prior to development of hydrops seem to carry a good prognosis even in malignant fetal arrhythmias like VT.

Management of Fetal Ectopic Atrial Tachycardia: What is the Best Decision?

: The prevalence of fetal arrhythmia is about 1% to 3% of all pregnancies and they are mostly benign. This report describes fetal ectopic atrial tachycardia (EAT) diagnosed in 31 weeks of gestation. The arrhythmia did not respond to transplacental therapy; therefore, cesarean section was done and arrhythmia was controlled by propranolol. This case showed effectiveness of rate control strategy by administration of propranolol.

Clinical presentation, management, and postnatal outcomes of fetal tachyarrhythmias: A 10-year single-center experience.

Background:Limited information is available regarding the prevalence and outcomes of fetal tachyarrhythmias from the developing countries.Aims:This study aims to report referral patterns, management protocols, and pregnancy outcomes of fetuses with tachyarrhythmias reporting to a single center in South India.Methods:All fetuses with documented sustained fetal tachyarrhythmia during the study period (2008–2017) were included. Arrhythmia characterization and hemodynamic evaluation were done using fetal echocardiography. Patients were grouped into supraventricular tachycardia (SVT) and atrial flutter (AF) groups. Patient characteristics, transplacental therapy (TPT), pregnancy, and postnatal outcomes were analyzed.Results:Total of 19 fetuses included; 11 had SVT and 8 AF. Mean gestational age at referral was higher for AF (32.5 ± 3.2 vs. 29.6 ± 3.3 weeks; P = 0.05). Hydrops fetalis was present 8 (42%) fetuses; 4 in each group. TPT was instituted in 18 fetuses; 12 (66.7%) received combination therapy; 4 (21%) received direct fetal therapy. Eighteen fetuses (91%) were born alive with one intrauterine death in a fetus with SVT and severe hydrops. Seven (87.5%) fetuses with hydrops survived. Twelve patients (66.7%) were delivered in sinus rhythm. Six babies (33.3%) had tachycardia at birth requiring anti-arrhythmic therapy. All patients survived the neonatal period. Duration of trans-placental therapy (3.8 + 3.3 vs. 7.3 + 3.4 weeks) was shorter in the AF group.Conclusions:Aggressive TPT using combination of drugs achieves excellent pregnancy and postnatal outcomes in fetuses with tachyarrhythmia. Early diagnosis and prompt referral before hemodynamic decompensation is critical for ensuring optimal outcomes.

Fetal Atrial Flutter and Hydrops Successfully Treated with Transplacental and Direct Fetal Therapy

Abstract The hydropic fetus with atrial flutter has high risk of fetal demise. In utero treatment is not as successful as SVT with 1:1 conduction. Even after conversion to sinus rhythm, close follow-up of the pregnancy is required for several reasons.. Case Report: A 25 year old primigravida, at 26 wks of gestation had a fetal ultrasound which showed a tachycardic hydropic fetus with AFI 49. The rhythm was atrial flutter: AR 400 bpm and VR 200 bpm. The heart was structurally normal. Transplacental antiarrhythmic treatment with sotalol was started and 24 hours later, the fetus was still primarily in flutter with rare episodes of sinus rhythm and frequent PAC. Sotalol was increased but the mother’s QTc increased to &gt; 500 ms, so the sotalol dose was reduced. On day 4th direct i.m. of digoxin was given and fetus was in sinus rhythm. Pharmacotherapy was continued. On the 16th day of sinus rhythm (at 33 wks), a marked change in FHR variability was seen. An US revealed the fetus was in sinus rhythm with a normal FHR. Because of the decreased FHR variability, the fetus was delivered by CS and the cord pH was 7.19, Apgars 1, 9 and 9. The neonate received no antiarrhythmic medications. On day 6 of postnatal life, an AV re-entrant tachycardia (AVRT) developed and sinus rhythm was successfully restored with sotalol and digoxin. The infant was treated for 18 months with no episodes of SVT or atrial flutter.

Placenta chorioangioma: a rare case and systematic review of literature

Objectives: Placental chorioangioma is a relatively rare condition that often results in serious prenatal complications and adverse pregnancy outcome. We report a case of a large chorioangioma that was prenatally diagnosed at 23 weeks with polyhydramnios and fetal anemia. With prenatal monitoring, transplacental therapy with a COX-2 inhibitor and intrauterine transfusion, the pregnancy resulted in the live birth at 30 weeks. Due to the paucity of evidence relating to the management protocols in cases of placental chorioangiomas, we have conducted a systematic review of the literature.Methods: All reported cases in the English language were captured using the electronic databases. Bibliographies of relevant articles were manually searched.Results: Sixty-four articles were included reporting 112 cases of placental chorioangioma. In 79, there was no prenatal treatment and in 33 there was in-utero treatment. A systematic comparison of antenatal complications and pregnancy outcomes was performed. No strong conclusion could be made due to the low number and quality of the reported cases.Conclusion: Placenta chorioangioma represents a challenge with its potentially serious complications adversely affecting pregnancy outcome. An international registry of pregnancies with this rare complication and documentation of pregnancy outcomes will improve the evidence base for prospective management.

Transplacental fetal therapy for junctional ectopic tachycardia

Junctional ectopic tachycardia (JET) is a rare type of tachyarrhythmia. A 39-year-old woman was transferred to our hospital for fetal tachyarrhythmia at 32 weeks' gestation. Fetal cardiac sonography revealed atrial and ventricular rates of 120-130 and 175-230 bpm, respectively, without 1:1 atrioventricular relationship. As ventricular tachycardia was considered to be the most probable diagnosis, transplacental therapy with digoxin and sotalol was done with partial response. Diagnosis of JET was made after birth. Although fetal JET is rare and prenatal diagnosis and treatment of this condition is still a challenge, differential diagnosis of fetal tachyarrhythmia should include this disorder.

Transplacental digoxin therapy for fetal tachyarrhythmia with multiple evaluation systems

Background. Sustained fetal tachyarrhythmia may result in congestive heart failure, hydrops fetalis, and fetal/neonatal death, which requires timely and appropriate therapy.Aim. To determine the value of transplacental digoxin therapy for fetal tachyarrhythmia with multiple evaluations.Methods. Four cases of fetal tachyarrhythmia were diagnosed with fetal echocardiography and treated with transplacental digoxin therapy with an initial dosage of 0.25 mg qd. Fetal echocardiography and measurement of maternal serum digoxin concentrations were performed every 5–7 days. Echocardiographic information was further used for the calculation of three evaluation systems including, Tei index, cardiovascular profile score (CVPS), and umbilical artery resistance index (UARI). The dosage of digoxin was adjusted according to the serum concentration, as well as results from three evaluation systems.Results. During the course of digoxin treatment, our patients show an increase of CVPS and decrease of Tei index and UARI, suggesting the recovery of heart function. Sinus rhythm was restored in 3–10 days in three cases and 42 days in one case. At the time of delivery, the placental transportation efficiency (neonate/mother ratio of serum digoxin concentration) was 76.45–84.31%. Following delivery, the general conditions of neonates were favorable. During the 4- to 14-month follow-up, reoccurrence of arrhythmia, neurological deficit, and retarded growth and development were not observed.Conclusions. Transplacental digoxin therapy with combined evaluation of Tei index, CVPS, and UARI systems is useful for treating fetal atrial flutter (AF) and supraventricular tachycardia (SVT).

Current Status of Fetal Cardiac Intervention

The potential benefits of fetal cardiac intervention (FCI) have been realized for many years. In 1975, Eibschitz et al1 reported intrapartum treatment of fetal ventricular tachycardia by administering propranolol to the mother, and as early as 1986, in utero pacing was attempted for complete heart block in a human fetus.2 Recently, however, interest in FCI has accelerated.3–18 As with other fetal interventions,19,20 FCI can only become a highly useful clinical tool if it is applied to conditions in which a feasible mode of therapy is available and either the fetus is at risk for demise as a result of the condition or intervention may alter the evolution of the condition such that the severity of the postnatal disease is substantially reduced (Table 1). For conditions in which the fetus is at high risk for prenatal or neonatal death, the rationale for FCI is obvious, to improve survival. If death is not imminent but the disease is likely to have major lifelong morbidity, the rationale is that FCI will modify the course of cardiac growth, function, and/or development in utero sufficiently to alter postnatal outcome and justify the potential risks of the procedure. Prenatal intervention may also allow the fetus to recover in the supportive in utero environment, during a developmental period when there is enhanced wound healing and the capacity for myocyte proliferation.21,22 View this table: Table 1. Congenital Cardiovascular Anomalies Potentially Amenable to FCI This construct rightfully emphasizes death or significant morbidity as therapeutic targets. FCI can entail substantial short-term risk to the fetus, uncertain long-term risk to the fetus and child, and at least some risk to the mother. There are no known medical benefits to the mother. With that risk profile, FCI will not be embraced by the maternal-fetal medicine and cardiology communities unless it …