Table 1

Suggested delivery options for infants with prenatally diagnosed critical CHD

Critical CHD	Comments	Expected neonatal cardiovascular status	Place of delivery and care plan
Duct-dependent pulmonary circulation All forms of CHD requiring PGE to maintain pulmonary blood flow	Includes all forms of CHD associated with: pulmonary atresia* or severe pulmonary stenosis	Without additional critical lesion Stable neonate on PGE infusion	Can be delivered in local hospital, with facilities to stabilise the neonate PGE infusion Transfer to cardiac centre
		With additional critical lesion, that is, neonate is expected to require urgent intervention Obstructed pulmonary venous return in complex cases associated with right isomerism Restrictive atrial septum in cases with associated mitral/tricuspid atresia or severe stenosis Potentially unstable neonate	Planned delivery at or near cardiac centre with surgical and catheter interventional facilities
Duct-dependent systemic circulation All forms of CHD requiring PGE to maintain systemic blood flow	Includes all forms of CHD associated with: aortic atresia or severe aortic stenosis or aortic coarctation† or aortic interruption	Without additional critical lesion Stable neonate on PGE infusion	Can be delivered in local hospital, with facilities to stabilise the neonate PGE infusion Transfer to cardiac centre
		With additional critical lesion, that is, neonate is expected to require urgent intervention HLHS with highly restrictive/intact atrial septum Restrictive atrial septum in cases with associated mitral or tricuspid atresia or severe stenosis Potentially unstable neonate	Planned delivery at or near cardiac centre with surgical and catheter interventional facilities
Complete transposition	No major associated abnormalities	Potentially unstable neonate Atrial septum can become restrictive shortly after birth (low sensitivity of prenatal scans) Fetus at risk of postnatal restriction of foramen ovale if septum primum bulges >50% towards the left atrium, forms an angle <30° with the rest of the septum or does not swing with the cardiac cycle Highly unstable neonate if the arterial duct is also constricted	Planned delivery at or near cardiac centre with facilities for balloon atrial septostomy
Other foramen ovale-dependent circulation	CHD that may require balloon atrial septostomy Includes CHD associated with mitral or tricuspid atresia or severe stenosis	Potentially unstable neonate if atrial septum is severely restrictive In HLHS and mitral atresia, a ‘to-and-fro’ pattern of pulmonary venous Doppler signal indicates severely restricted/intact atrial septum	Planned delivery at or near cardiac centre with facilities for balloon atrial septostomy
TAPVC, obstructed	Isolated TAPVC or associated with complex lesions (eg, isomerism)	Potentially unstable neonate due to obstruction at different sites	Planned delivery at or near cardiac centre with surgical and catheter interventional facilities
CHD associated with important valvar regurgitation and/or myocardial dysfunction	Ebstein malformation or dysplasia of the tricuspid valve Truncus arteriosus with severe truncal valve regurgitation Tetralogy of Fallot with absent pulmonary valve syndrome with severe pulmonary regurgitation CHD with severe atrioventricular valve regurgitation	Potentially unstable neonate	Planned delivery at tertiary neonatal unit or near cardiac centre

*Cases with pulmonary atresia with VSD and collaterals are usually non-critical lesions.
†For cases of suspected coarctation of the aorta, the elective use of PGE will depend on the degree of suspicion as antenatal diagnosis has a relatively high false-positive rate.
CHD, congenital heart disease; HLHS, hypoplastic left heart syndrome; PGE, prostaglandin E; TAPVC, total anomalous pulmonary venous connection; VSD, ventricular septal defect.