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|Year : 2020
: 13 | Issue : 2 | Page
|Supraventricular tachycardia in one of the twins: The ethical dilemmas involved in treatment
Vinoth Doraiswamy1, Lalitha Natarajan2, Chitra TV Venkatesh3
1 Department of Cardiology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
2 Department of Fetal Medicine, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
3 Department of Obstetrics and Gynaecology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
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|Date of Submission||17-Dec-2019|
|Date of Decision||31-Jan-2020|
|Date of Acceptance||19-Feb-2020|
|Date of Web Publication||13-Apr-2020|
| Abstract|| |
The pediatric cardiologist now has an important role to play in fetal medicine. They are often called upon to manage fetal cardiac problems such as arrhythmias or perform fetal cardiac interventions such as balloon valvuloplasty or atrial septostomy. In these scenarios, it becomes very important for the pediatric cardiologist to understand the concepts of “fetus as a patient,” “viability,” etc., and their implications in management. We try to shed light on these principles through our case scenario of managing supraventricular tachycardia in one of the fetuses of a twin pregnancy.
Keywords: Beneficence, fetal arrhythmia, fetus as a patient
|How to cite this article:|
Doraiswamy V, Natarajan L, Venkatesh CT. Supraventricular tachycardia in one of the twins: The ethical dilemmas involved in treatment. Ann Pediatr Card 2020;13:150-2
|How to cite this URL:|
Doraiswamy V, Natarajan L, Venkatesh CT. Supraventricular tachycardia in one of the twins: The ethical dilemmas involved in treatment. Ann Pediatr Card [serial online] 2020 [cited 2020 Jun 1];13:150-2. Available from: http://www.annalspc.com/text.asp?2020/13/2/150/282375
| Introduction|| |
Fetal arrhythmias are detected in 2% of unsuspected pregnancies during routine obstetric ultrasound. Majority of them are benign. However, serious arrhythmias such as supraventricular tachycardia (SVT) and atrial flutter are common and can lead to fetal hydrops, premature delivery, and death if not aggressively treated. SVT in one of the fetuses of a multiple gestation is uncommon.,, In the treatment of fetal arrhythmia, there is no consensus on the regimen of drugs, and the protocol varies from institution to institution., We describe such an unusual case and the ethical dilemmas involved.
| Case Report|| |
A 23-year-old primigravida with 25 weeks' gestation presented to us with a dichorionic-diamniotic twin pregnancy. She conceived by in vitro fertilization resulting in a triplet pregnancy. Triplet reduction was done at 16 weeks' gestation. Her obstetric ultrasound showed twin 1 having intermittent atrial ectopics and persistent SVT [Figure 1]a and [Figure 1]b. Twin 2 was normal. After obtaining informed consent, the mother was loaded with oral digoxin (1 mg/24 h) followed by 500 μg/day in two divided doses. After 36 h, twin 1 developed pericardial effusion [Figure 1]c and cardiomegaly. In view of impending fetal hydrops, oral sotalol was started at 160 mg/day in two divided doses. It was increased to 240 mg/day in three divided doses due to persistent SVT. Twin 1 reverted to sinus rhythm on day 4 of admission [Figure 1]d and twin 2 was healthy. The patient was discharged on day 7 of admission.
|Figure 1: (a) Pulsed-wave Doppler of left atrial inflow and outflow tracts showing multiple nonconducted atrial ectopic beats. A: Atrial wave, V: Ventricular wave, (b) M mode tracing showing supraventricular tachycardia with 1:1 conduction and short ventriculoatrial interval. Heart rate is 263 beats/min. A: Atrial contraction, V: ventricular contraction, (c) two-dimensional fetal echocardiography showing pericardial effusion. White arrow – Pericardial effusion. (d) Pulsed-wave Doppler of left atrial inflow and outflow tracts showing sinus rhythm. Heart rate is 152 beats/min. A: Atrial wave, V: Ventricular wave|
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On follow-up after 2 weeks, both twins and mother were healthy, and pericardial effusion resolved in twin 1. Digoxin was stopped and the dosage of sotalol was tapered gradually to 80 mg/day and continued till delivery. She was delivered by elective cesarean section at 36 weeks' gestation, twin 1 and 2 weighing 2.16 kg and 2.1 kg, respectively. At present, they are 3 months of age with no recurrence of arrhythmia.
| Discussion|| |
The concept of “fetus as a patient” was mainly the work of McCullough and Chervenak who opposed the word “unborn child.” “Unborn child” was used by opponents of abortion to confer independent moral status to the fetus, meaning that parents and practitioners had a moral obligation to protect and promote the interests of the fetuses above everything. The authors, however, emphasized more on the dependent moral status where the fetus could not be seen as a separate entity. Hence, the physician had beneficence-based obligations to the mother and fetus which had to be balanced against autonomy-based obligations to the mother. The fetus, of course, being neurologically immature, there was no question of fetal autonomy.,
“Beneficence” simply means that clinical benefit should outweigh harm, based on sound evidence-based treatment. It would be common for the physician's recommendations to sometimes go against the mother's autonomy.,
In our situation, we had three patients and three possible treatment options. They included giving transplacental antiarrhythmics, no treatment, or urgent delivery. Our team opted for therapy. Here, we could justify our beneficence-based obligations to twin 1, but twin 2 and mother were exposed to side effects of the drugs with unknown consequences and harm.
The mother initially opted for no treatment. Her reasoning being, she could at least save twin 2. This resulted in conflict with our recommendations. Due to the scarcity of similar case reports, lack of treatment guidelines,,, and unpredictable side effects, sound evidence-based recommendations were difficult. Based on the limited literature available, our experience, and constant counseling, the mother eventually made an informed decision to treat. If conflict still persisted, would legal methods have to be sought? If the court ruled in our favor, wouldn't the decision be in conflict with the mother's autonomy?
The third option involved urgent delivery. Here lies the importance of the concept of “viability.” A fetus is said to be viable if it is of sufficient maturity to survive in the neonatal period and attain independent moral status given the available technological and professional support., In high-income countries, this is generally between 24 and 25 weeks. In India, it has been fixed administratively at 28 weeks, but there is a wide interregional variation of technological support available. Hence, the issue of viability becomes many times institution based. If urgent delivery was resorted to, both the twins of questionable viability would be exposed to the problems of extreme prematurity.
The role of pediatric cardiologists is expanding in the field of fetal cardiac interventions (FCIs). The FCI of early years was primarily for pharmacological therapy of arrhythmias, heart block, and heart failure. Then came the era of direct FCI with the advent of valvuloplasty and balloon atrial septostomy. All the above interventions were aimed toward improving fetal cardiac function, survival, and/or achieving a biventricular circulation to improve postnatal outcome. It is difficult to put forth guidelines in the above scenarios due to inability to conduct randomized control trials, uncertainty of the natural history of the disease, risk/benefit ratio of the intervention to both the mother and fetuses, etc. Especially in hypoplastic hearts, many fall in the gray zone between univentricular and biventricular circulations. Decision-making becomes even more difficult when you have a multiple gestation where the fetuses are discordant for the problem, as the nonaffected fetus in addition to the mother becomes an innocent bystander.
The management of such patients should always involve a multidisciplinary team. When it comes to counseling for/against an FCI, the team should understand the concepts of beneficence, autonomy, viability, and their ethical implications. In any event, should there arise a conflict between the mother and healthcare giver, it should be resolved through constant knowledge sharing and counseling, respecting the mother's autonomy and beliefs.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Vinoth Doraiswamy
Consultant Pediatric Cardiologist, Department of Cardiology, PSG Institute of Medical Sciences and Research, Peelamedu, Coimbatore - 641 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None