“Fetal Echocardiograms: a Heart to Heart” – with Dr. Jen Lam-Rachlin

Dr. Lam-Rachlin returns to Healthful Woman to discuss fetal echocardiograms, a procedure she describes as “one of the most fascinating part of the stuff that we do on a day-to-day basis.” She and Dr. Fox explain the differences between blood flow in a fetus vs a child or adult, congenital heart defects, and more.

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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. 

All right, Jen, welcome back to the podcast. So nice to have you here. 

Dr. Lam-Rachlin: Thank you for having me again. 

Dr. Fox: We’re doing this remotely, but for the first time, not because of COVID, just from scheduling. 

Dr. Lam-Rachlin: Yes. 

Dr. Fox: Hopefully we’ll all be together. But if scheduling doesn’t permit, we’ll do it over the phone as needed. So we’re gonna talk about fetal echocardiograms today. And we touched on this like a year ago when we had our last podcast, just in terms of your interest in it, and that we’re doing it. But I thought we’d really do a deep dive into fetal echoes, as we call them, sort of why we do them, who might need them, what do we do, just so people understand. But how has it been for you just in practice doing fetal echoes for the past several years? 

Dr. Lam-Rachlin: I might be biased, but I think it’s one of the most fascinating part of the stuff that we do on a day-to-day basis. I think the fetal heart is just amazing in terms of like the different pathology that we see. And it’s a complicated structure, but it also makes a lot of sense, which is probably why I like it so much. 

Dr. Fox: A complicated structure that makes a lot of sense. I think people have used that to describe me. It’s a very complicated structure. No, but I agree. Yeah. And the heart itself is bewildering to a lot of people, because there’s a lot of parts. And not only with a lot of parts, there’s literally a lot of moving parts, right? It’s in motion at all times. And so, it’s A, how is it built? B, how is it moving? How are these things in relation to another? There’s a rhythm that has to beat to it. Like there’s so many things that go on that it’s always fascinating, and there’s a reason cardiologists have jobs in general. But the thing that for us when we’re doing this, that we know and maybe some of our listeners don’t know is, the way the blood flows through the heart is different in the fetus from a child or adult. 

Dr. Lam-Rachlin: Right. Correct. That the moment that the baby makes his or her first cry, that entire circulation changes to what our normal circulation is, and the fetal circulation is entirely different. Which makes it very fascinating for us as prenatal diagnosis sonographers. 

Dr. Fox: Yeah. And I mean, the concept is, after birth, the way we get oxygen to our blood is we have to breathe it in. So you take a deep breath, it goes into your lungs, and then the heart has to somehow get blood to the lungs to pick up the oxygen, then spread that blood around the body to deliver it. And so that’s how the pump starts working. But fetuses don’t do that, they don’t get their oxygen through their lungs, their lungs are there, but they’re basically dormant, they’re not doing anything during pregnancy. They get their oxygen, literally, through to their belly button, and that umbilical cord. And so, the oxygen that comes to the baby is totally different way. And so the fetal heart has to sort of process that and pump it to the body in a different way. And then, right after birth, start using the lungs. And so, the system that is evolved is so fascinating that they both work, and you can literally just flip the switch and, you know, one thing closes, one thing closes, and boom, and suddenly the baby has a new circulation after birth. But part of the reason it’s so interesting for us is, the things that we’re looking at in fetuses, and what is normal or abnormal, or how things are supposed to go, and where they’re supposed to go is different from if we were cardiologists for adults or children. 

Dr. Lam-Rachlin: Correct. Things that we look at are very different than what an adult cardiologist will look at. And exactly as you said, like, the baby gets oxygen from the umbilical cord. And I think the moment that I learned about just how oxygen is shunted through these very intricate systems and how smart that vascular system is, and then all of that turns off right when the baby’s delivered and the cord is cut. And that’s like, I remember having this moment where like, oh my gosh, that’s like genius, right? How that occurs. 

Dr. Fox: It’s really crazy. And it’s like, one flap closes, another flap opens, and like, boom, suddenly the baby’s like rolling. And it works almost always right? Babies go from this…they go from underwater creatures that literally don’t have to breathe ever. And they suddenly get pulled out of the water and they start breathing and everything starts working. But again, it’s, when we’re underwater and we have like scuba gear on, we’re still breathing through our lungs, like we have equipment so we can breathe through our lungs, but when they’re underwater, they’re not, they’re like fish, they’re breathing in a totally different way. And then they suddenly turn…it’s like millions of years of evolution in like 12 seconds after birth, which is just crazy. And it really works pretty much all the time. And one of the reasons it might not work, and babies might have an issue after birth is if there is what we call congenital heart disease. And congenital basically means they’re born with it. 

Dr. Lam-Rachlin: Correct. Yeah. Just basically like, something was malformed in the heart system that was developed in-utero at birth, and that may need correction after delivery. And it’s kind of a summary of congenital heart defects. And the reason why it’s so important to talk about is it’s the most common birth defect in the fetus. So, when we do these anatomy scans, and we see anomaly on the baby, the most common anomaly that we see is something in the heart system. And it could be about 1%, depending on what definition, it is about 1% of all live born babies. 

Dr. Fox: Right. Because some of those may be more concerning or more, in terms of prognosis, might be worse than others. And so it’s sort of where do you draw the line? It’s like a tiny little hole in the heart, and it’s gonna close up on its own, and it doesn’t really matter, you can categorize that as a birth defect and add it into the number, but you might not because it’s not as relevant, so to speak. 

Dr. Lam-Rachlin: Correct. I mean, the good thing about congenital heart defects is that the vast majority of them are non-critical, is the term that they’ve been using, the newer terminology. So 25% are critical heart defects, which are the major connection issues where this baby for sure will need surgery after delivery, maybe stages of surgery. And then these are the worst prognosis. But the majority of heart defects are less critical or non-critical, where they may or may not need any surgery. And they usually have a very good prognosis. 

Dr. Fox: Right. And we’re talking about, now, structural heart defects, meaning, where the heart is sort of built differently or incorrectly, so to speak. There are other heart issues related to like the rhythm of the heart, if the electrical wiring is off. I mean, the heart itself is structurally normal but it’s not beating in the correct fashion, that is technically like congenital heart disease but it’s not a congenital heart defect in terms of just how people think of these things. 

Dr. Lam-Rachlin: Correct. Majority of what we look for will be structural. But yes, you’re correct. Like, the structure could be normal, meaning, all the chambers are where they’re supposed to be, all the connections are where they’re supposed to be. But functionally, it’s not acting normal, whether it’s because the rhythm is abnormal, or it’s not pumping the way that they’re supposed to, something is just off with that normal flow that we mentioned. 

Dr. Fox: Right. And as you said, overall, it’s about 1% of births, you know, 1 in 100 babies will have one of these congenital heart defects. And it is also one of the leading causes of neonatal death after birth, like, why would babies suddenly die after birth, it’s very rare, but one of the leading causes or the leading cause is because of heart disease. And it can also, even for babies who survive and don’t obviously do well, it can be associated with genetic syndromes, it can be associated with also neurodevelopmental outcomes. So it’s not just the heart, the heart is sometimes a window into more global issues with the baby. And so we look very closely at the heart during pregnancy, A, to look at the heart itself, to make sure it’s functioning properly. But B, if a heart looks great, it also gives you clues as to the likelihood of other issues going on with the baby. 

Dr. Lam-Rachlin: That’s correct, yeah. If we see a, let’s say an abnormal heart, part of the counseling is that this could be part of, as you said, a genetic syndrome or it could be even outside of a genetic syndrome. Congenital heart defects can be associated with neurodevelopmental delay. So there’s a lot of important sequelae after a diagnosis like that. So having a normal heart doesn’t exclude out all those possibilities, but it’s obviously reassuring. 

Dr. Fox: I think one of the things that surprises a lot of people when they first think about congenital heart defects, or maybe they have it themselves in one of their children or a family, or friend is the idea that almost never are we “fixing it” during pregnancy. I mean, people think, “Oh, you see, this is so advanced, can you fix it during pregnancy?” And there are rare instances when there’s things you can do, certain rhythm abnormalities you can possibly fix. There are some very specialized procedures for very specific conditions that might be helpful in sort of an experimental way. But for the vast majority of these, there’s really nothing that we do to the baby before delivery. And so, the question comes up, why would we even care to know before delivery? If there’s nothing we can do about it before delivery, like, what’s the big deal? Why don’t we just find out after birth? 

Dr. Lam-Rachlin: That’s a very common question that we get. And you’re right, for the vast majority of these heartbeat defects, we make the diagnosis, and there’s really nothing we do differently in-utero. There’s no, or rarely a fetal surgery that’s necessary. But I usually tell patients, it’s always good obviously to know beforehand in terms of prognosis, right? Like you don’t wanna have a surprise at the time of delivery you find out there’s a heart defect, and then they have to do all that workup afterwards and find out what kind of heart defect, what are the appropriate surgeries? What specialist needs to be there? 

So, generally, we think of the prognosis for that newborn to be much better if these heart defects are diagnosed beforehand, and that there is the right team of people that’s already been monitoring this baby and have a plan at the time of delivery in terms of whether the baby needs surgery immediately, what kind of surgery, and medication, and monitoring. 

Dr. Fox: Yeah, I mean, that can’t be overstated how important that is. I mean, the difference between a baby that’s born with a heart defect that’s anticipated and known about in advance versus the baby that’s born with a heart defect that is discovered after birth, particularly a major one that’s gonna require some sort of surgery or treatment, it’s night and day. First of all, you may have delivered in the wrong hospital, right? So there’s only so many good pediatric cardiothoracic surgeons on Earth, right? That’s a pretty specialized field, they’re not in every single hospital babies are born at. And so, if you deliver at a hospital and one of those people doesn’t work there, your baby’s gonna get transferred to have surgery elsewhere, by someone who’s never met you, never met the baby, is gonna have to do everything after birth. 

So, A, it could delay the surgery, B, you’re not gonna know what’s going on, and C, the mother and baby might be in different hospitals, potentially. Whereas, if you know in advance, you’re gonna say, “Okay, my baby’s probably,” and you don’t always know in advance, “but probably is gonna need a, b, and c, let’s deliver in this place, let’s make our plan to deliver there.” And also, right after birth, frequently, the way we find out the babies have a congenital heart defect if it wasn’t known in advance is they turn blue in the NICU, or in the nursery, or at home even, potentially, and then it’s a crazy emergency, and potentially the baby could be harmed during those events. And so, if you know in advance, you will have the measures in place to prevent the baby from turning blue from not getting enough oxygen because the heart isn’t pumping in the right directions. And so, it is thought that diagnosing these in advance absolutely improves the outcomes for the babies, they are better off having it diagnosed before they’re born. 

Dr. Lam-Rachlin: Correct. And I think also a lot of diagnosing it beforehand also just allows the parents to have informed information in a somewhat calm fashion, right? Like you get the diagnosis, there’s a moment of shock. Of course, you don’t hear anything that we’re saying. But then once they’re able to kind of settle down and read through all the materials, you generate a good list of appropriate questions to ask for all the specialists, it kind of makes them more informed in the decision making of what to do with this pregnancy and what they need to do for the baby. That’s obviously another important component of why it’s important to know beforehand. 

Dr. Fox: Yeah, I mean, this hits people like an anvil. I mean, when they get a diagnosis like this, I mean, their whole world has changed usually. People go through the same stages of grief that they go through, it’s the same types of things. That people need time for their denial, their anger, their bargaining, like, this happens, this is normal to process this. And if you find out two days after birth, and the baby is having surgery 2.1 days after birth, that’s not a lot of time to process what’s going on and to understand. Whereas, if you find out at let’s say 18, 20 weeks of pregnancy, you’re gonna have six months before the baby is gonna have surgery, you have plenty of time to talk about it, think about it, understand, figure out for your family, who’s the surgeon, let’s meet the surgeon, and to sort of wrap your heads around it. And it definitely makes the experience of it ultimately, I think, a little bit more reasoned, as opposed to just the fear and the panic that’s, again, expected, but there’s a lot of time to recover from that, so to speak. 

Dr. Lam-Rachlin: Some of these heart defects can be associated, as we said, with genetic syndromes or abnormality. So it offers the patients an option to do like their amniocentesis, to see if the baby has a genetic syndrome, because that might also change prognosis for the baby, right? Like if the baby, on top of having a heart defect, there is also a genetic problem, then this is what to expect, right? Like this is the prognosis for that. So it kind of gives, again, the parents more information and the ability to gather more information before the baby is delivered. 

Dr. Fox: Right. And you may choose how you manage the baby. So, for example, in like an extreme circumstance, you could have someone who, at 20 weeks of pregnancy, comes, they have, you know, they sort of haven’t had ultrasounds until then or sort of spotty. They come at 20 weeks, they see a major heart defect. And ultimately, they decide to do an amnio and find out the baby has, let’s say, trisomy 18, which is a pretty bad genetic condition. They may, after birth, because of the prognosis, say, “We’re not gonna do surgery on the baby for that reason.” Whereas, if you only found out about the defect two days after birth, you wouldn’t have that opportunity to think about that and make a more reasoned decision about what to do. And I think, again, having information is generally a good thing in these situations. And I think the elephant in the room when this comes up is always termination, right? Having an abortion because of it, and people are afraid, “Oh, you’re just looking, because if there’s a problem, you’re gonna tell me to have an abortion, to abort the baby.” 

And we hear that, and I think, unfortunately, that probably does occur, I’m sure there are people on Earth and in the U.S. that they see some sort of abnormality and the doctor says, “Oh, you need to have an abortion because of A, B, and C,” and sort of not an informed way. And again, in this country, it’s legal when people choose to do it. And there’s a lot of decisions that are made. But we don’t do the ultrasound because we’re looking for babies who need to be aborted, like, we’re doing the ultrasound for the vast majority of them so they can have information, because again, the majority of these findings are ones where the babies will survive, usually have very good quality of life, and again, based on the exact diagnosis. 

But at least it gives the parents an opportunity to understand and make an informed decision about what they do and don’t wanna do in these circumstances. And at least in our practice, I would say that, in my experience, the vast majority of people don’t terminate pregnancies when there’s congenital heart disease, again, it depends on the severity of it. In other parts of the country it’s probably never, in other parts it may be more frequently. But that’s not the reason we’re doing it. We’re doing it to improve outcomes for the babies, we’re not doing it to look for the ones to have an abortion. 

Dr. Lam-Rachlin: Correct. I think that’s exactly my mindset. We look for these things to hopefully help improve the outcome for the baby, assuming they carry to term and there’s a live born baby. Obviously, there’s always the option of termination. I don’t think there’s really…there has been any heart defects that I would say you absolutely must terminate for. But it’s part of that informed decision making for the parents, because we’re, you know, I’m not in their shoes. I don’t know what they’re able to handle and what they might not be able to handle, but at least they have all the information. And there are some heart defects that are very much associated with years of potential stages of surgery. And with each surgery, there’s always the thought like, “Will this child survive?” So when we look at the outcome, outcome data is great, but they always put that caveat of, “If the baby survives the surgery,” right? So that’s never good to hear as parent. 

Dr. Fox: Right, “Everything’s gonna be fine. Unless something horrible happens.” 

Dr. Lam-Rachlin: Yeah. 

Dr. Fox: It’s a valuable statistic, because parents are often thinking, “What is the chance I will have a very sick child who is suffering?” Sometimes even more so than “What is the chance my baby will survive?” For some people, they can wrap their heads around the idea that the baby may have a condition for which he or she may not survive. Again, it’s horrible, but they can sort of like grasp that. Whereas the idea of, “Your baby may have a condition where he or she may be very sick for a very long time.” That is, for many people, more difficult to deal with, potentially, in their minds and emotions, than the idea of a baby that might not make it. 

Dr. Lam-Rachlin: Correct. 

Dr. Fox: Who’s at risk for having a baby with congenital heart disease? Like who should like wake up and say, “Oh, my God, I’m at increased risk for this.” 

Dr. Lam-Rachlin: Generally, it can occur with really anybody, even if you don’t have any, “Risk factors,” right? Like we see the general population risk of having a child with congenital heart disease is about 1%. But there are certain patient populations that are at higher risk than that 1%. That list is ever expanding. But some of the common reasons our common patients that come for an echo is because that they are in this higher risk category. The easiest example would be if the patient themselves were born with a congenital heart disease, or their spouse was born with a congenital heart disease, that you’re gonna be at higher risk of having a child that has either the same heart disease or something different, and that’s probably one of the more common referral, some family history if it’s not just the patient or the spouse. 

Dr. Fox: Right, or a previous child had a heart defect. 

Dr. Lam-Rachlin: Exactly, or a prior child. Then other kind of high risk categories would include like someone who has diabetes coming into the pregnancy, which is becoming more and more prevalent now. And they’re at higher risk of having fetus with a congenital heart defect. And then IVF pregnancies, we’re seeing more and more patients who need assistance in terms of getting pregnant. And again, IVF is associated with a minor increase, but it’s still above that 1% for a congenital heart disease. So, that is one of the most common reasons why we see patients for fetal echoes. 

Dr. Fox: There’s a lot of reasons, and some of it is dictated also just by insurance companies, what’s on one list versus another list. But ultimately, the heart is a very complex structure. And so that’s part of the reason anyone is at risk, because it’s almost amazing that it ever goes right, not the fact that it sometimes it goes wrong. Because there’s so much that has to happen. And so there is a baseline risk in everybody and we’ll get to this, which is why we all pregnant women look at the baby’s heart very closely. But a fetal echocardiogram is sort of like an additional appointment devoted just to the baby’s heart. And so it’s currently limited, just for resources purposes, to women who have a somewhat of an increased risk over baseline. And how much of an increased risk do you need to have in order to warrant that is, who knows, like, it’s one of these things where how these decisions get made are extremely complex. And then you have to throw in the entire healthcare system into this, which makes it even more complex. But whatever. 

So things, like you said, certain types of twins, people on certain medications, certain medical problems, there’s definitely reasons, certain findings in pregnancy that we see would clue us into maybe what is going on. But ultimately, it’s an ultrasound, it’s an ultrasound of the baby’s heart like we do anyways. But instead of spending, let’s say, 45 minutes on the entire baby, head to toe, we spend 45 minutes on just the heart, head to toe. And how would you explain to people why it’s complicated? Like, why could you spend 45 minutes just on the heart? It’s a tiny little thing. I mean, it’s like the size of a quarter. So, yeah, how are you able to spend an hour on that? 

Dr. Lam-Rachlin: So, that’s the fascinating thing about the heart. And what I usually tell patients, it’s probably one of the smallest structure in the baby, but it’s the most complicated, right? This is what keeps the baby alive, keeps us functioning, keeps all the organs alive. So, to do an echo is really a very fine and systematic way of looking at all these big details. And also, mainly the finer details of the heart to make sure things are, you know, the valves are flapping the right way, the blood is moving in the right way, that there’s nothing that’s very subtle that’s not normal and might warrant some further evaluation. And I can argue that I could spend more than 45 minutes on the heart sometimes. 

Dr. Fox: It’s true. 

Dr. Lam-Rachlin: Especially if you find something. If you find something abnormal, that easily could be much longer, 

Dr. Fox: Right. And one of the nice things about the heart is, it’s actually something we can usually see. Because things that are moving, we can typically see blood flow, we can see, it’s in the… if the baby’s chest is up towards the mom’s belly, there’s not a lot of stuff in the way. For example, like looking at the brain, it’s harder to do to that intricate detail, because we can’t get the same views with ultrasound that we would with the heart. And so, frequently, if there’s issues of the brain, we’ll look very closely with ultrasound, but sometimes we have to move to something like MRI to really get the pictures we need. With heart, essentially, never. I mean, pretty much everything you’re gonna do is by ultrasound in the heart. And so, when you’re talking about this very detailed analysis of the heart in the echocardiogram, what is different between the looks we get in an anatomy ultrasound, which is, again, is thorough, compared to what we do in an echocardiogram? How would you explain that to somebody? 

Dr. Lam-Rachlin: That’s a good question. You know, it really depends on what is included in your anatomy, right? So, by the books in the anatomy scan previously, for the evaluation of the heart, what’s required really is solely just a four-chamber heartbeat, which is literally a shot up to say, there’s four chambers of the heart and they look normal. Recently, the guidelines have included to at least try to look for what’s called the outflow tracks. The two big vessels that come in from either side of the heart, the right and the left. But with an echo, we’re looking at, if you count them, it’s about like nine different structural views plus, we’re looking at blood flow, right? And we’re looking to see if there’s normal flow or is there some turbulence in the flow? Is there some restriction of flow? Is there blood flowing the wrong direction? Are certain structures that are missing that are generally not included in that anatomy scan. 

So it’s a lot more information that we get. And obviously, the pickup rate of congenital heart disease changes based on what views you’re looking at, right? So, historically, with just an anatomy four-chamber view, the best that we are gonna pick up is maybe 30% to 40% of heart defects. When we talk about some of these critical heart defects, a lot of it includes outflow tract issues. So we’re missing these major heart defects if we’re just doing the four-chamber view. When you do a systematic echo like we do for these normal echoes, you will pick up like increases up to the 90s. So that’s a tremendous difference in terms of diagnosis. 

Dr. Fox: Yeah. And there’s, I definitely wanna spent a little time on this, because there’s so many important points there. And, first of all, one of the really interesting things I remember from my fellowship when I was training is, we would have these conferences where we would, you know, the fellows and the attendings and we would meet together both the OB side, and the pediatric side, and the cardiology side. And they would present these either fetuses or babies based on whether they’re born or not, with these really complex heart diseases, I mean, crazy stuff. You need like a map, and a ruler, and a cup of coffee to figure out what’s going on there. 

And then they would say, “Here’s the picture of the four-chamber view of the heart.” And it’s perfect, like there was normal four-chamber. And you’re like, “And this is what the heart looks like.” And you’re, like, “Oh, my God.” And one lesson is, many abnormal hearts, you can get a normal four-chamber view. And like you said, that’s how it is, right? The four-chamber view only picks up certain heart defects, but not many others. And part of this is why it’s hard to like go on Google, or go on studies and figure out what we’re doing and what you’re gonna pick up and what you’re not. Because there’s, one variable is the views you’re gonna get, right? 

So if you’re only gonna get a four-chamber view, or let’s say a four-chamber view plus what they call the two outflow tracks, you’re gonna pick up a certain percent just from those three images. But the thing to keep in mind is, it also depends who’s doing it. So, for example, if I sent a patient to you, to Jen Lam, and I said, “Listen, I need you to do a quick scan of this heart, get me a four-chamber view.” You could do that, you could get me a four-chamber view and send it to me, but there’s no way that a baby with crazy heart disease is gonna get past your ultrasound without…because you’ll notice right away while you’re trying to get the four-chamber view, “Oh, this is off, this is off, this is off, I’m gonna sort of get other views.” And so, even though you are saying, “Okay, I’m gonna comply and just get the fourth-chamber view, or just get these three views.” Since you do fetal echocardiograms, and you understand the heart, and you spend days, and days, and days with the heart. It’s just, you’re not gonna miss as much even if you get the same views. Whereas if I sent to someone who literally just gets a four-chamber view and leaves and does that on all the babies every day, then they are not…they don’t know what to look for otherwise just while they’re quickly scanning through the heart. 

And so, part of it is what images are you trying to get, right? Are you trying to get two images, three images, four images, six images, eight images. And the other thing is, are the people who are doing it, the sonographer, the doctor, are these people who are accustomed to looking at the heart systematically? And if they are, even if they’re only gonna do a quick view, they’re not gonna miss it as much. Like we have people come in at the third trimester just for like a growth ultrasound, nothing to do with the heart, and our sonographers would be like, “This baby had heart disease.” And they weren’t even trying to look at the heart. And it’s glaring at them because they know what to look for. And that’s such an important variable that I can’t stress enough that, part of getting these things picked up is having ultrasounds in places, even if you’re not getting the echocardiogram in places that do echocardiograms, because they will know, they will very unlikely miss something. They’ll say, “Oh, we need to do an echo because there’s something wrong.” 

Dr. Lam-Rachlin: Right. Yeah, I agree. I forget sometimes that like how, that I do have that bias of, this is what I do on a daily basis, this is what I like, this is very easy for me to pick up. And I do forget that not everybody is trained that way, and not everybody who’s doing anatomy scans are able to really pick up these nuances that there’s something abnormal aside from, you know, the four-chamber might look totally normal, but when you’re scanning to get the four-chamber, there could be something else that’s let’s say occurring in the aortic arch or something like that, even though it’s not technically part of the four-chamber, I would, you know, we would pick it up in our centers, but probably not in a different center that doesn’t routinely do these. 

Dr. Fox: Right. And I think that also is part of the decision, “Do I need a fetal echocardiogram?” And need is a strong word, again, because it’s just about improving the odds of picking something up. But I would say, if the standard anatomy ultrasound that someone is getting is very basic and done in places that don’t do them all the time, and don’t look at hearts all the time. Then if you have risk factors, yeah, you should probably go somewhere that does this all the time, whether it’s a maternal fetal medicine place, or whether it’s a pediatric cardiologist, or whether it’s radiologist who does a lot of these and have them look at the heart. But if you’re already going to one of those places for routine care, and they’re looking at the heart in a pretty thorough way, maybe there is, maybe there isn’t an advantage of getting an echocardiogram, it sort of depends on the circumstances, and you can listen to the recommendations. But if they didn’t recommend an echocardiogram, and these are people who do them, it’s unlikely you need one. Let’s put it that way. 

Dr. Lam-Rachlin: I agree. I agree. 

Dr. Fox: And is there anything different that is done on an echocardiogram based on who does it? Because a pediatric cardiologist versus your maternal fetal medicine specialist, as am I, versus maybe a radiologist? 

Dr. Lam-Rachlin: I would say what we do and potentially radiologists who do echos are very similar in terms of what we’re looking for. Our goal is really to see like structure, is this normal, not normal? And then overall like rhythm and function. But the pediatric cardiologists will look at it from a different view where they’re mostly seeing these children after delivery. So they kind of know what to look for to give prognosis for the parents, right? In terms of, “If this shows this, then these are the better prognosis.” 

So the pediatric cardiologists kind of look a little bit more in-depth in terms of like overall function, sizes and calibers of certain vessels to decide whether this baby can have like certain types of surgery, and correction, and then give them a prognosis that way. So, for us, we’re primarily looking to see that there is a heart defect that warrants an evaluation by the pediatric cardiologist. And generally, we’re able to give like a diagnosis of what the heart defect is, but then the cardiologist goes that extra step of looking to see how severe, how’s the function, and then also what kind of options are available in terms of procedure after delivery. 

Dr. Fox: Yeah. I mean, the way I look at it and explain to patients is, certainly, there are pediatric cardiologists who do fetal echocards, not all of them do. There are many pediatric cardiologists who are not comfortable doing fetal echocardios, because, again, as we said, the hearts of children are different from the hearts of fetuses. And if they’re not trained in that and they’re not comfortable doing it, they probably won’t offer it. They’ll say, “No, no, no, you have to go to my colleague.” But the ones who do them, they do them a lot. And certainly, that’s a good place to go. If you’re seeing someone who does them like a maternal fetal medicine specialist, frequently, that’s all you’ll need to do. But if there is a heart defect that’s picked up and there’s a question about, does the baby need surgery or not? What is the prognosis? What is the management could be like after birth? Usually, the pediatric cardiologists will have a lot more insight on that. Even if they totally agree on the images, it’s just because that’s what they do, right? That’s their job. So they’ll say, “Well, yeah, I take care of these kids, here’s what you should expect.” Whereas, for us, it would just be from reading about it, we don’t take care of the children, so we may have some insight, but not the same that they would. And so, usually, it ends up being that anyone who does this, like maternal fetal medicine, always works hand-in-hand with pediatric cardiologists, and based on that relationship, it’ll determine how many patients start with the MFM and then go to pediatric cardiology, or just one versus the other. 

Dr. Lam-Rachlin: And I would say that we also have a lot of patients that we co-manage together, where, for let’s say a baby with a rhythm abnormality, and they have to be seen frequently, and between pediatric cardiology and us, like, sometimes we share some of the visits so that the patients can come back and forth between the cardiologist and us. Or like there’s a fair amount of patients where, yeah, they agree with the diagnosis, and they would kind of come to us and say, “We’re gonna see these patients routinely. But if something else comes up, then refer back the patient to the cardiologist, but for now, we’ll just manage until delivery.” And the benefit from our standpoint is that, we kind of take a look in terms of like the entire pregnancy too, right? Like, it’s not just the diagnosis of a heart defect, but also just the counseling of what does this mean when it’s diagnosed prenatally? In terms of, as we said before, like genetics, how do we manage the pregnancy differently? Maybe there’s some delivery considerations that we have to think about that the pediatric cardiologist might not necessarily be talking to the patient about. 

Dr. Fox: Exactly. Yeah. And I think that each situation is unique in terms of how much time will they need to spend before delivery with pediatric cardiology versus us. In some situations they have to see pediatric cardiology like every week, and in other situations, they see them once and then they say, “Well, we’ll see the baby after birth.” And it’s everything in between. And again, the same thing with us. Some of these situations involve, “Okay, well, how often do we have to monitor how the baby’s growing? Is the baby at risk for certain things that we have to follow? Do we have to deliver early?” And all these other obstetrical nuances that the pediatric cardiologist wouldn’t have the insight in, just like we wouldn’t on how the baby is treated after birth. And we have a concept of what’s done, and they have a concept of what we do, but certainly you want everyone doing what they’re most expert at in this environment. Which is, again, why in pretty much all well-functioning systems, the pediatric cardiologists and the maternal fetal medicine doctors are really friendly. And they work together on these cases and get along and always consider it like a joint effort, and doing what’s best for the fetus and for the parents in these circumstances. And those relationships tend to be pretty tight, because there’s a lot of people going back and forth between them. 

Dr. Lam-Rachlin: Yes, I agree. 

Dr. Fox: There are some centers where you have an opportunity to sort of see both at the same time, like at the same stenographer. That’s generally the exception in the U.S., but it happens. Bigger academic centers, they have the capability maybe of doing that. But it doesn’t have to be that way. But that’s obviously a very neat circumstance to get everyone in the room at the same time every time. 

Dr. Lam-Rachlin: That would be very unique. I mean, even where I trained for fellowship, it’s still like two separate units. And we did our rotations at pediatric cardiology. And it’s just interesting to see their perspective, because, again, they’re so used to seeing just the child that patient in front of them, and now they kind of think, “Oh, this baby is in a floating space in the mom,” right? That’s a little unique for them. And I remember going there the first day and they were scanning the mom like upright, like she was sitting upright, and they’re like, well, I’m like, “Why would you do that? It’s like such an awkward position to do the ultrasound.” They’re like, “Well, she’s pregnant, we can’t have them laying down.” I’m like, “You could go ahead and leave them down, it’s fine.” And it was like mind boggling for them to do that. 

Dr. Fox: Right. If she’s upright then I think the sonographer will have to lie down. 

Dr. Lam-Rachlin: I know. But yeah, it’s a very symbiotic relationship. And I mean, I think that a certain view that we get as MFMs is this three-vessel trachea view, which, when I was in training and fellowship the cardiology team in Michigan, which was a fantastic team, they never did that, that’s not a standard view that they do on a child or adults. And it was, again, like this mind boggling experience for them, like, this is an amazing view. You can pick up so many more like subtle heart defects based off of that view. And so, it’s been very symbiotic. And I think that, even now as an attending here, it’s been very symbiotic. And they are probably the consultants that I contact the most out of all the pediatric sub-specialties. 

Dr. Fox: Yeah, I think that makes sense. And they contact us a lot too, it’s really interesting. It goes both ways with that, it’s so much fun. And when you’re training MFM, it’s almost always you’re gonna have those conferences with the cardiologists, like the cardiologists and the NICU people are the teams that you meet with the most, because you just have the most overlap with patient care. And it’s cool because when you think about it, this baby is a fetus then a baby. It’s the same being, right? And so, it’s just…and we’re totally on it when they’re the fetus, and they’re totally on it when they’re the baby, but there has to be some overlap there. And it does work out pretty well. 

And so, in terms of just a review, I think that it’s important for people to realize that, again, in all pregnancies, there is a risk of a heart defect, but it’s in the range of 1%-ish. And the majority of them, like you said, are not critical, but some are. Everybody gets the baby’s heart looked at during pregnancy to some degree, based on exactly where you are and where you go. But people have additional risk factors. And if you’re not sure if you have additional risk factors, you can ask your doctor, “Do I have any risk factors for congenital heart defects or other birth defects?” And if the answer is yes, you will say, “Well, am I getting my ultrasounds in the best places?” Right places that either can do this or will pick it up. Or if not, if that’s not available, potentially, right? Not everything’s available anywhere, “Do I need to get a fetal echocardiogram with either a pediatric cardiologist? Or maybe I will travel the two hours on that one time to get that one ultrasound versus the other eight that I’m getting in pregnancy.” And it’s a conversation. And your doctor or midwife should be able to talk about these things with you and say, “Oh, no, you don’t need this because of A, B, and C, or you do need this and we’re gonna do it here and there.” And these are very typical conversations that happen over the course of pregnancy. 

And when an echocardiogram is done, it’s an ultrasound, just like the ultrasounds you get for every other reason in pregnancy. The difference is, again, we just hone in on that fetal heart for 30 to 60 minutes as opposed to the entire baby, head to toe, and we look at all the details of the heart. If it’s normal, it does not mean 100% your baby won’t have a heart defect, but the likelihood is very, very low, and how low it is, it’s based on exactly who does it and also what you define as a defect, right? You can always miss a tiny little hole in the heart or something like that. But it’s very unlikely to miss something major, again, based on how much you look and what we’re talking about. And if there is some sort of defect, based on exactly what it is, you may or may not need to meet with a pediatric cardiologist to discuss a plan after birth and what exactly that means. Is the plan to watch and wait? Is the plan to operate? We don’t know, and there’s all these options based on what they find. 

Well, Jen, always good to talk to you, always good to talk about fetal echoes. I know it’s one of your great passions in life and in work. But it’s been so much fun doing this. I’ve learned so much since coming into practice and working with you about the fetal heart. And it’s just one of the things that I continue to learn, there’s so much to get and to learn and to get better at. But it is cool. And I’m definitely getting to your point of the great enthusiasm that you have. I’m working my way there. This is hard, it’s hard. You gotta really pay attention. 

Dr. Lam-Rachlin: Yes. But it is amazing. And I think it’s just so much fun. Obviously I’m biased, and I do think that everybody, all the sonographers and all the docs that I’ve worked with, they’ve had a lot of fun kind of learning. And I’m still constantly learning obviously. There’s so many new technology that is coming out to look at varying degrees of the heart. But it’s a constant evolving field. 

Dr. Fox: It’s constantly evolving, but also, even to get in the game. There’s so much you have to learn. I mean, the stenographers who do fetal echocardiograms have to do like this crazy difficult course, and submit images, it’s like a real certificat…you can’t just like start dabbling in it. You really have to do it, and for the doctors, there’s all this, we do CME for it, and we have to learn. People who do it have already invested a ton of time, and that’s just the tip of the iceberg and you continue to do it throughout years, and years, and years of training and practice and trying to continue to learn these nuances. And then technology changes, and you have to continue to learn. 

So it’s an ever-expanding discipline, and it’s great and it’s fun. And I think that it’s important because, as we said, it really can improve outcomes for these babies after birth. I’ve seen that over the course of my career for sure that babies are doing better and better with these conditions. A, because we pick them up earlier, and B, because the surgeries have gotten better. But it’s just, it’s been remarkable what the prognosis is nowadays compared to just 10, 20 years ago. 

Dr. Lam-Rachlin: Yeah, I mean, nowadays we’re seeing these babies become pregnant, right? They’re older, they survive, they do so well, that now we have to kind of complete the cycle by working with them through a pregnancy and making sure that everything goes smoothly with that. So, that’s kind of remarkable. I don’t think that 50 years ago that was even a possibility. 

Dr. Fox: Thank you so much for coming on the podcast. We will absolutely have you again. And we’ll see you in the echo lab.

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