Fetal Cardiology

Details

Title

Fetal Cardiology

Type

Stage Two

Module code

HPS141

Requirement

Optional

Module objective

By the end of this module the Clinical Scientist in HSST will be able to analyse, synthesise, critically evaluate and apply knowledge of: (i) the changing cardiac physiology from fetus to neonate and into childhood; (ii) uniqueness of the fetal echocardiogram requiring a high level of skill and anatomical knowledge to recognise the full spectrum of simple and complex, acquired and CHD, its manifestations and natural history through gestation to understand the limitations of fetal echocardiography; (iii) the potential safety concerns of using ultrasound on a fetus and why special consideration should be given during a fetal echocardiogram; and (iv) the economic consequence of an increased survival in the CHD population and that being able to plan care allows for a smooth transition between pre- and post-natal services that allows for cost effectiveness. The Clinical Scientist in HSST will be expected to apply their knowledge in their scientific and clinical practice while consistently demonstrating the attitudes and behaviours necessary for the role of a Consultant Clinical Scientist within a patient-focused service.

Knowledge and understanding

By the end of this module the Clinical Scientist in HSST will critically analyse, synthesise, evaluate and apply their expert knowledge, including:

Fetal vs neonatal vs later cardiovascular physiology:

• the anatomy and physiology of the cardiovascular system throughout fetal development;
• maternal-fetal physiology as well as maternal conditions that may affect the fetus;
• the mechanisms of oxygen delivery to the tissues in utero;
• the changes immediately post partum to a more ‘adult’ circulation;
• the importance of neonatal heart rate for maintenance of cardiac output and blood pressure and its response to the child’s clinical condition;
• how the neonatal heart adjusts to the new pulmonary and systemic circuitry and pressures
• the vasoconstrictive response of the neonate to haemorrhage or volume depletion;
• the anatomy, function and changes to the following structures:
  • ductus arteriosis
  • ductus
  • umbilical vein
  • foramen ovale
  • umbilical arteries
  • placenta
  • lungs
  • right ventricle
  • left ventricle
• why some CHD does not present in utero;
• cardiac disease progression as the child

Screening views (advanced versus ‘standard’ imaging):

• screening views incorporated into the fetal anomaly ultrasound scan;
• additional modalities incorporated into the detailed fetal echocardiogram;
• use of a range of echo modalities, including two-dimensional, M-mode, pulse wave Doppler, continuous-wave Doppler and colour-flow mapping;
• use of advanced imaging modalities such as 3D/4D echocardiography and speckle tracking and interpretation of results;
• the position on the fetus and the left/right/anterior/posterior orientations, abdominal situs and cardiac position;
• how to achieve visualisation of each essential component (if possible) using all the conventional tomographic planes and sweeps;
• the limitations of echocardiography in terms of fetal position or activity in the uterus;
• the spectrum of fetal arrhythmias and use of the spectrum of echocardiographic modalities to demonstrate and assess them;
• the latest developments in obstetrical diagnostics, including invasive and non–invasive tests available throughout pregnancy;
• the growing field of invasive fetal intervention and its effect on the cardiovascular system;
• management strategies and current outcomes for treatment of congenital and acquired heart disease.

Risk:

The theoretical risks of:

• ultrasound energy expenditure of each modality;
• power output and time of exposure, i.e. ‘as low as reasonably achievable’ (the ‘ALARA’ principle); bioeffects of ultrasound energy, i.e. thermal or mechanical; and the parameters to monitor the effects, e.g. the Thermal Index (TI) assigned for either soft tissue (TIS) or bone (TIB);
• the evidence base underpinning these effects;
• the uncertainty with respect of the potential risks of newer modalities, including 3D/4D echocardiography and the need to continue monitoring bioeffects.

Health economics:

• the benefits and risks of screening with respect to outcome, cost-benefit ratio, mortality and long-term importance of prenatal diagnosis to optimise perinatal care;
• the limitations of cost-benefit analysis due to possible errors in diagnosis;
• how to assess the cost-benefit of further prenatal cardiac/extra-cardiac imaging in the presence of an anomaly (e.g. fetal MRI) or the need for pre-natal intervention;
• the social, psychological and emotional consequences for the family of postnatal treatment in complex CHD and the potential impact on counselling, including the ethical considerations;
• the non-surgical costs/out-of-hospital care needs of the CHD patient.

Ultrasound:

• the need for a standardised approach using recognised guidelines;
• ultrasound equipment and how to achieve high-quality scans;
• the increased demand for spatial and temporal resolution given the minute size of fetal cardiac structures and high heart rate;
• why transducers should be changed to optimise imaging.

Technical and clinical skills

By the end of this module the Clinical Scientist in HSST will be able to demonstrate a critical understanding of current evidence and its application to fetal screening programmes. They will be able to perform and master a range of techniques, adapting their response to reliably meet the varying and complex challenges that will arise and will:

• reassure the patient and their family and clearly explain the process and purpose of the fetal echocardiogram, supporting parents/carers who may be extremely anxious;
• gain informed consent, making appropriate arrangements for interpreters or senior support as required;
• take a history prior to undertaking fetal echocardiogram;
• provide a safe and clean environment for examination and appropriately clean equipment after each use;
• perform a detailed fetal echocardiogram consistent with published guidelines as efficiently as possible and recognise when to discontinue the scan due to imaging difficulties so as to avoid potential harm to the fetus;
• achieve optimum frame rates of 80–100Hz by adjusting ultrasound equipment to minimise persistence and spatial averaging; utilising Harmonic imaging when acoustic penetration is difficult (e.g. with maternal obesity);
• appropriately use all Doppler modalities, including colour, pulse, continuous, high pulse repetition frequency and tissue Doppler imaging;
• appropriately change between transducers to optimise imaging;
• adjust ultrasound equipment and optimise imaging to produce the nest images with minimal potential risk;
• appropriately use ultrasound modalities when necessary;
• interpret the findings and produce a logical and clinically relevant report;
• explain in clear and concise terms the finding of the scan and support with approved literature, and seek support from senior and counselling staff when necessary;
• accurately and concisely document findings and discussions and communicate these efficiently and effectively with team members, as well as other relevant health professionals;
• appropriately address any concerns the patient/family might have regarding fetal echocardiography safety;
• accurately and concisely document findings and discussions and communicate these efficiently and effectively with team members, as well as other relevant health professionals;
• recognise when the involvement of senior medical staff, e.g. fetal cardiologist, is required and refer appropriately;appropriately change between transducers to optimise imaging;
• convey information to parents related to scan findings according to agreed institutional policy.

Attitudes and behaviours

By the end of this module the Clinical Scientist in HSST will be expected to critically evaluate their own response to both normal and complex situations. They will consistently demonstrate the professional attributes and insights required of a Clinical Scientist in HSST working within the limits of professional competence, referring as appropriate to senior staff, and will:

• work in an empathic and calm manner to support anxious parents and families;
• adopt a conscientious approach to all aspects of practice;
• be open and have a non-judgemental approach to practice;
• contribute to the multidisciplinary team, recognising the contribution of all those involved with supporting a patient with CHD;
• communicate in an effective and timely manner with healthcare professionals, patients, parents and families;
• overcome communication barriers and consider social, cultural and religious perspectives without bias or prejudging parental views;be open and have a non-judgemental approach to practice;
• reassure patients without disregarding the potential risks and thus scanning with appropriate skill and brevity not disregarding patient concerns.