Prenatal Diagnosis of Hypoplastic Left Heart Syndrome

EDITORIAL COMMENT: Terminate or operate? The editor was recentIy asked to address a meeting of paediatricians on this topic at the Royal Children's Hospital in Melbourne. It became obvious that the paediatric surgeon and the obstetrician can have diametrically opposed points of view on the management of a mother whose fetus is shown by ultmsonogmphy to have a major cardiac abnormality. The care that suggested the need for this meeting was that of an insulin‐dependent diabetic woman whose fetus was shown by ultrasonography at 25 weeks'gestation to have major heart defects there were various administrative and social reasons why the diagnosis was not made before 20 weeks' gestation. The prognosis of such infants who survive is unfavourable and it seems preposterous to suggest the possibility of neonatal cardiac tmnsplantation to a mother and her partner faced with the decision of ‘terminate or operate: The Australian rommunity tolerates an abortion rate of approximate& 20% of clinically confirmed apparently normal pregnancies (I). Therefore termination of a fetus with a major abnormality that is not completely correctable must be defendable and acceptable! mere are a host of problems apart from those of cost and conscience. There is the law, since the diagnosis may be made after 20 weeks’ gestation, when termination is no ronger by legal definition an abortion. However inductions of labour after 20 weeks'gestation and before fetal viability are being performed in increasing numbers when fetal mafformations are detected and when there is no other maternal indication for delivery (renal failure, severe pmclampsia with or without fetal hydrops). In this series reported here 2 of the 4 fetuses were candidates for termination and in I case the parmts elected to continue with the pregnancy. The authors do not tell us the results in the other 28 cases of cardiac abnormality detected in their series. Achiron and colleagues have presented the case for echocadiogmphic examination for detecting can‐liac marformatioons in low risk pregnancies (2). In their series 23 fetuses were born with cardiac anomalies prenatal echocadiogmphy identified N of the 23 cases and 5 pregnancies were terminated. Readers are referred to a provocative discussion on this subject in the Obstetrical and Gynecological Survey (31, since not all will agree that ‘there is compelling rationale for making available fetal echocardiographic screening for all prenatal patients’ (3) and further that ‘there probably is little cost benefit from the antenatal detection of fetaf cadiac anomalies for those patients who choose not to interrupt pregnancy’ (3).