Transposition of the Great Arteries (TGA), Newborn — Prenatal Diagnosis/Management — Clinical Pathway: ICU and Inpatient

Transposition of the Great Arteries (TGA) Clinical Pathway — CICU

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 echocardiogram 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 4-6 Week Intervals
  • Includes:
    • At least 1 fetal echocardiogram after 34 6/7 weeks to specifically assess DA and PFO
    • 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 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 is 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 Program sends an updated list of active fetal patients every Friday as well as a separate list of fetuses with d-TGA > 34 weeks gestational age
  • Both lists provide information regarding induction of labor or C-section scheduling as well as relevant extracardiac clinical information
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