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Fetal Echocardiography Dr. Durr-e-Sabih Multan, Pakistan [email protected] http://www.geocities.com/dsabih Why • Commoner than most realize • 1% in all live births • Approximately 5% in all pregnancies •The incidence increases if there is a positive family history •if sibling affected incidence is 2 – 4% •if mother affected incidence is 10-12% Indications • Family history • Exposure to known cardiac teratogens • Chromosomal abnormalities (trisomy 21, 50%; trisomy 13 and 18, almost 100%) • Maternal disease (diabetes, collagen disease, phenylketonuria, infections) • Non-cardiac abnormalities detected on US • Polyhydramnios Cardiac embryology Weeks Length Event` mm 1-2 1.5 No heart or great vessel 4 2 Single median cardiac tube, ineffective contraction 5 4 Bilobed atrium 5 4 Begining of circulation 5 7.5 AV orifices, 3 chamber heart 6 8.5-13 Septum secundum, complete inferior septum, divided truncus arteriosus, 7 20 4 chamber heart Cardiac Size 20 week fetus’ heart compared with an American quarter Usual HR 120-160/min Time • The best time to do a fetal cardiac exam is 18-22 weeks • Later exams may show anatomy better but might be difficult because of rib shadowing • Adequate exam depends on fetal position and maternal habitus • Some pathologies become obvious with fetal age Fetal Circulation Fetal circulation is complex and different from adult blood flows with three major shunts: Ductus venosus Forman ovale Ductus arterosus Rate and rhythm •The heart rate is usually 120-160/min, the rhythm is regular but transient bradycardia is normal in the 2nd trimester but not in the 3rd First assess fetal position Acquire a four chamber view • Transverse section through the fetal thorax • Corresponds to the 4 chamber apical view in the adult • The atrium nearest the spine is the left atrium • The atrium nearest the fetal anterior thoracic wall is the right Axis • 45+20 towards the left • Abnormal axis increases the risk of a cardiac malformation • The heart may also be displaced from its o normal position in dipaphragmatic hernia or cystic adenomatoid malformation •Fetus cephalic •Probe marker to mother’s left •Fetal spine posterior • Fetus breech • Probe marker normal • Fetal spine posterior Basic fetal cardiac examination General •Done on a 4 chamber view •Heart mostly in left chest •Occupies 1/3 of thoracic area •Normal cardiac situs, axis and position •No pericardial effusion rd Basic fetal cardiac examination Atria •Both of same size •Foramen ovale flap in left atrium •lower end of atrial septum (septum primum) present Atria •Lower end of septum •Foramen ovale •Flap of foramen ovale in LA Basic fetal cardiac examination Ventricles •Equal size •Intact septum •Moderator band identifies right ventricle Ventricles • Both of same size • Moderator band identifies right ventricle Basic fetal cardiac examination AV Valves •Both valves move freely •Tricuspid valve inserted more apically than mitral Extended basic cardiac examination • The outflow tracts are imaged by tilting the probe towards the fetal head • The great vessels should be of equal size and should cross at approximately 90o as they emerge from their respective ventricles Look for these: •The outflow tracts cross each other at about 90 •The anterior aortic root wall is continuous with the o Inter Ventricular Septum •The pulmonary artery bifurcates •The aortic and pulmonary valves move freely •Both great vessels are of similar size but the pulmonary artery tends to be slightly bigger The aortic arch • The aortic arch can be identified • The aortic cusps can be seen The pulmonary artery bifurcates The outflow tracts cross at around 90o Pulm trunk Aortic arch Cases Echogenic Intracardiac Focus (EIF) • Can be seen in up to 6% of normal pregnancies • Highly operator and machine dependant • Associated with cardiac and extracardiac anomalies • Bilateral EIF is more significant EIF Biventricular EIF are more significant this patient was 47XY Normal nuchal translucency