1. Fetal Echocardiography Dr. Durr-e-Sabih Una contribucion para Dr Lattus de Dr. Hector Fernandez

2. 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%

3. 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

4. WeeksLength mm Event` 1-21.5No heart or great vessel 42Single median cardiac tube, ineffective contraction 54Bilobed atrium 54Begining of circulation 57.5AV orifices, 3 chamber heart 68.5-13Septum secundum, complete inferior septum, divided truncus arteriosus, 7204 chamber heart Cardiac embryology

5. Cardiac Size 20 week fetus’ heart compared with an American quarter Usual HR 120-160/min

6. 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

7. Fetal Circulation Fetal circulation is complex and different from adult blood flows with three major shunts: Ductus venosus Forman ovale Ductus arterosus

8. Rate and rhythm The heart rate is usually 120-160/min, the rhythm is regular but transient bradycardia is normal in the 2 nd trimester but not in the 3rd

9. First assess fetal position

10. 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

11. Axis 45+20 o towards the left Abnormal axis increases the risk of a cardiac malformation The heart may also be displaced from its normal position in dipaphragmatic hernia or cystic adenomatoid malformation

12. Fetus cephalic Probe marker to mother’s left Fetal spine posterior

13. Fetus breech Probe marker normal Fetal spine posterior

14. Basic fetal cardiac examination Done on a 4 chamber view Heart mostly in left chest Occupies 1/3 rd of thoracic area Normal cardiac situs, axis and position No pericardial effusion General

15. Basic fetal cardiac examination Both of same size Foramen ovale flap in left atrium lower end of atrial septum (septum primum) present Atria

16. Lower end of septum Foramen ovale Flap of foramen ovale in LA

17. Basic fetal cardiac examination Equal size Intact septum Moderator band identifies right ventricle Ventricles

18. Both of same size Moderator band identifies right ventricle

19. Basic fetal cardiac examination Both valves move freely Tricuspid valve inserted more apically than mitral AV Valves

20. 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 90 o as they emerge from their respective ventricles

21. Look for these: The outflow tracts cross each other at about 90 o The anterior aortic root wall is continuous with the 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

22. The aortic arch The aortic arch can be identified The aortic cusps can be seen

23. The pulmonary artery bifurcates

24. The outflow tracts cross at around 90 o Pulm trunk Aortic arch

25. Cases

26. 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

27. EIF Biventricular EIF are more significant this patient was 47XY Normal nuchal translucency