Inpatient Pathway for the Evaluation/Treatment of the Newborn with TGA

Prenatal Diagnosis / Management

Comprehensive Counseling Prenatal course
Delivery plans
Postnatal outcomes
Amniocentesis Should be offered as an option to all mothers carrying a fetus with TGA to evaluate and document associated defects
Assessment of Ductus Arteriosus Ductus arteriosus (DA) may be considered restrictive if:
  • 2D echo patency < 50% of diameter of MPA
  • Narrow jet of color flow across DA
  • DA pulsatility index ≤ 1.5
  • Bidirectional flow seen in the DA on Doppler assessment in the absence of any aortic or pulmonic obstruction
Assessment of Foramen Ovale Foramen ovale may be considered restrictive if:
  • No defect seen on 2D imaging
  • No color flow jet seen across atrial septum through a qualitatively small pfo
  • Minimal excursion of flap valve of septum primum (< 25% excursion towards left
    atrial free wall)
Serial Evaluation at 4 Week Intervals Includes:
  • Fetal echocardiography with specific notation made of status of DA and pfo, and
  • Counseling sessions with Fetal Heart Program Cardiology attending, nurse coordinator, and social worker
Delivery Site Recommendation All TGA to deliver at a site within CHOP system that:
  • Can offer immediate evaluation at delivery and
  • Provide for immediate access to cardiac interventional care such as urgent balloon septostomy, ventilator, and circulatory support
  • Goal – all prenatally diagnosed TGA to deliver at CHOP SDU, or at HUP
Delivery
  • Elective delivery no earlier than 39 weeks gestation
  • Earlier delivery to be considered based on fetal or maternal indications as determined by obstetrical/maternal-fetal medicine staff
  • Delivery may be vaginal or C-section based on maternal / fetal indications
  • Presence of TGA alone is not an indication for C-section delivery
  • Communication
  • Fetal Heart team notifies the Cath Lab team at least 24 hours prior to delivery (when feasible) of potential delivery of fetus with prenatally diagnosed TGA
Delivery Room Planning
  • Case is discussed at FHP weekly review conference (Neonatalogy/Cardiology, MFM) when fetus reaches 34 weeks gestation
  • CHOP classification system designation made at FHP Weekly Review based on input from fetal cardiologist, MFM, midwife, and neonatologist in attendance
    • Most TGA are designated Class III = neonatology manages newborn care and stabilization with CICU attending on stand-by
Delivery Room Management
  • Place umbilical arterial and venous catheter
  • Obtain first ABG in resuscitation room
  • Transport newborn to CICU