Background Congenital heart disease (CHD) is the most common form of congenital anomalyand is a leading cause of neonatal morbidity and mortality. Major congenital heart disease (CHD) is defined as any congenital cardiac defect requiring immediate cardiac assessment and/or treatment within the child’s first year of life (Kirwan and FASP 2010). Major congenital heart disease occurs at a rate of approximately 5.6 per 1000 live births. An early accurate antenatal diagnosis will give parents choice, as well as the opportunity to plan the delivery and improve postnatal management and therefore outcome. The Fetal anomaly screening programme (FASP) recommends all fetuses are screened for evidence of CHD at the 18–20+6 week anomaly scan. BCCA standards set out a group of pregnancies deemed at higher risk of CHD and recommend these women are referred to a fetal cardiology specialist. Furthermore, it outlines that those with a suspected fetal cardiac abnormality on ultrasound should be seen within 5 working days, preferably <48hrs by a fetal cardiac specialist.
Aims and Objectives To review all referrals from 2011–2014 to the fetal cardiology service following implementation of the new national guidance and local teaching in 2011. We wanted to assess if this new guidance was being followed in the Southwest region, from referral criteria, gestation at referral, geography and timeliness of appointments, with a focus on referral times for urgent referrals. We also wanted to review the patients postnatally diagnosed with major CHD to quantify the number of patients missed through fetal screening in our region, highlighting any scope for additional education and training.
Methods Retrospective casenote review 2011–2014 - All patients referred to the fetal cardiology service were identified through the Heartsuite database and Fetal appointments record. Heartsuite was used to review all referral letters, patient consultations and outcomes. For postnatal review all cases of major CHD who did not have a fetal diagnosis were analysed. More detailed analysis was performed on Hypoplastic Left Heart Syndrom (HLHS), Transposition of the Great Arteries (TGA), Tetralogy of Fallot (TOF) and Atrio-ventricular septal defect (AVSD), conditions set out by FASP that should no longer be missed through routine antenatal anomaly scans.
Results A total of 2708 patients were referred to fetal cardiology over the four year period with an increase in referral number each year. Inappropriate referrals made up 2.66% of referrals, the commonest reason was non-immediate family history of CHD. Of the remaining appropriate referrals, the commonest reason for referral was suspected cardiac anomaly on a previous antenatal scan (usually 20 week anomaly scan), making up 22.6% of appropriate referrals. Mean gestation at referral was 17.1 weeks. Of the suspected cardiac anomaly referrals there was regional variation in accuracy of these suspicions. Regarding time to being seen in this subgroup, 80% were seen according to guidelines within 5 days. 17.8% were seen at greater than 5days and departmental factors may have influenced this as there was variation over the years, but an overall improvement in time to being seen so that in 2014 93% of patients were seen in less than 5 working days. From postnatal review between 2011–2014 there was a decrease in postnatal diagnosis of AVSD and TOF with a fairly static rate of TGA. Only one case of hypoplastic left heart syndrome was missed antenatally over 4 years.
Conclusions Since the introduction of the FASP and BCCA guidelines in 2010 there has been an increase in referral numbers to the Bristol Fetal Cardiology Service. Inapproprtiate referrals have slightly increased, perhaps due to heightened awareness of fetal cardiology screening. Suspected fetal cardiac anomaly makes up the largest portion of referrals. Timeliness of seeing these patients has improved over time with most cases being seen in less than 5 working days. Number of follow ups varies in line with the underlying condition and probably clinician specific factors. Our own diagnostic accuracy has proved difficult to assess due to tracking of postnatal information. Major CHD missed through fetal anomaly scanning will unfortunately always exist but our figures have shown a potential decrease in numbers of some conditions missed.
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