Fetal chest fetal heart
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FETAL CHEST FETAL HEART. FETAL CHEST. DIAPHRAGM Assess diaphragm (thin echogenic line) Diaphragm hernias Lung and bowel similar echogenicity- Look for peristalsis Left easier to see than right due to gastric bubble LUNGS Look for pulmonary masses CCAM Sequestration Pulmonary hypoplasia

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FETAL CHEST FETAL HEART

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Fetal chest fetal heart

FETAL CHESTFETAL HEART


Fetal chest

FETAL CHEST

DIAPHRAGM

Assess diaphragm (thin echogenic line)

Diaphragm hernias

Lung and bowel similar echogenicity- Look for peristalsis

Left easier to see than right due to gastric bubble

LUNGS

Look for pulmonary masses

CCAM

Sequestration

Pulmonary hypoplasia

PLEURA - effusions

MEDIASTINUM - masses


Fetal chest fetal heart

CONGENITAL DIAPHRAGM HERNIA

Bochdalek - 90% on left; most unilat

All should have amniocentesis and dedicated echo

Secondary pulmonary hypoplasia is major cause of mortality

Findings

Polyhydramnios

Stomach/bowel/liver adjacent to heart

Peristalsis in chest

Mediastinal shift

Absent gastric bubble

Reduced abdominal circumference compared to rest of fetal biometry


Fetal chest fetal heart

Associated anomalies

Aneuploidy (T18, T21); NTD; CHD; malrotation, omphalocele

DDX

CCAM

Other cystic masses such as foregut duplication cysts are rare


Fetal chest fetal heart

CCAM

Most common fetal lung mass

Types I-III

Types I and II macroscopic cysts >5mm with good prognosis and hydrops is rare

Small risk of malignant degeneration (rhabdomyosarcoma)

Imaging

Macroscopic types appear cystic

Microscopic types appear solid (echogenic)

Pulmonary hypoplasia of normal lung - degree determines prognosis

Mediastinal shift - cardiac compromise; polyhydramnios (impaired swallowing)

Associations (type II)

Cardiac anomalies

Pulmonary sequestration

Pectus excavatum

Jejunal atresia

Renal agenesis, prune-belly syndrome

Pathology

Hamartomatous proliferation of terminal bronchioles

Cysts lined by respiratory epithelium and communicate with airways at birth


Fetal chest fetal heart

CCAM


Fetal chest fetal heart

EXTRALOBAR SEQUESTRATION

More common in males (4:1)

90% LLL or below diaphragm

Always airless as it has its own pleural envelope and no communication with bronchial tree

Systemic arterial supply - Aorta 80%

Systemic venous drainage - IVC, azygos, portal v

Imaging Findings

Solid hyperechogenic mass

Look for systemic arterial supply on Doppler

Polyhydramnios

Hydrops

Associations 65%

CDH

Cardiac

GI, Renal, Vertebral anomalies

Often regress in utero

DDX

CCAM

Congential lobar emphysema (initially filled with fetal fluid)

Neuroblastoma


Sequestration

SEQUESTRATION


Fetal chest fetal heart

PULMONARY HYPOPLASIA

Agenesis – complete absence of one or both lungs (airways, alveoli, and vessels)

Aplasia – absence of lung except for a rudimentary bronchus that ends in a blind pouch

Hypoplasia – decrease in number and size of airways and alveoli

Primary

Secondary

Bilateral - Oligohydramnios (Potter’s sequence); Skeletal dysplasia

Unilateral - CCAM; Sequestration; CDH; Hydrothorax

Imaging

Reduced thoracic circumference (<2SD) is suggestive

Fetal lung maturity best sssessed with lecithin:sphingomyelin ratio in amniotic fluid

Echogenic pattern unreliable marker for maturity


Fetal chest fetal heart

PLEURAL EFFUSION = abnormal

Fetal hydrops

Chromosomal

Underlying mass

Infection

Lymphangiectasia

Chylothorax - assoc with T21 and Turner’s

MEDIASTINAL MASSES

Anterior Medistinum

Teratoma

Cystic hygroma

Normal Thymus

Posterior Mediastinum

Neurogenic tumours

Enteric cyst


Fetal heart

FETAL HEART

Technique

Abdominal situs view

4-chamber view

LVOT

Posterior/central to RVOT

Runs left to right

RVOT

Anterior to LVOT

Runs right to left

Bifurcates early: DA and RPA

Check for antegrade flow in DA

Anatomical trifurcation: DA, RPA, LPA

3-vessel view

amniocentesis indicated in all abnormal: 15-40% will have chromosomal anomalies

ventricles/atria are of roughly same size as other ventricle/atria

3 in 1 rule: heart fills 1/3 of axial chest

Cardiac circumference 1/2 chest circumference

Length atrial septum: ventricular septum 1:2

Normal HR: 120-160bpm, SR


Fetal chest fetal heart

Best seen on Four-Chamber View

Septal defect

Endocardial cushion defect (AVSD)

Hypoplastic left heart

Ebstein’s anomaly

Critical AS

Coarctation


Fetal chest fetal heart

Best Seen on Outflow Tract Views

Tetralogy of Fallot

Transposition

Truncus Arteriosus

Pentalogy of Cantrell


3 vessel view

3-VESSEL VIEW


Fetal chest fetal heart

Maternal Risk Factors for CHD

Diabetes

Infection - rubella, CMV

SLE

Drugs - EtOH, Phenytoin, lithium

FHX of heart disease, previous child with CHD

Arrhythmia


Fetal chest fetal heart

VSD

Most common CHD (1:1000)

Membranous 80% vs Muscular 10% vs Outlet (ECD) 5%

Don’t mistake membranous to muscular transition for VSD


Fetal chest fetal heart

Endocardial Cushion Defect

40% have Trisomy 21

EC forms lower atrial septum, superior ventricular septum, anterior MV leaflet and septal TV leaflet


Fetal chest fetal heart

Transposition of Great Vessels

Aorta arises from RV and pulmonary trunk from LV

Aorta and pulmonary artery are parallel instead of perpendicular to each other


Fetal chest fetal heart

Tetralogy of Fallot

Tetralogy

Infundibular RV outflow tract stenosis

Overriding aorta

VSD

Hypoplastic RV

LV and RV are symmetric due to equal pressures

Often missed on 4-chamber view


Fetal chest fetal heart

Ebstein’s Anomaly

Septal and posterior leaflets of tricuspid valve prolapse and are integrated into RV wall

Atrialisation of RV

Large RA due to massive regurg

Maternal lithium is a risk factor


Fetal chest fetal heart

Pulmonary Atresia

Hypoplastic RA and RV

Pulmonary artery calibre may be normal

Reversed flow in DA


Fetal chest fetal heart

Pericardial Effusion

>2mm

Associated with hydrops fetalis, congenital infection and cardiac anomalies

Look for fluid in other compartments (hydrops)

Look for signs of congential infections

Cerebral calcification

Hepatic calcifciation

Echogenic bowel


Fetal chest fetal heart

Endocardial Fibroelastosis

Increased echogenicity of endocardium

Ventricular dilatation and poor contractility

Ectopia Cordis


Fetal chest fetal heart

Rhabdomyoma

Hamartoma of myocytes

Strong association with Tuberous Sclerosis

50-85% of fetuses with it have TS

50% of TS have it

Echogenic mass, usually intraventricular, can arise from IV septum


Fetal chest fetal heart

FETAL ARRHYTHMIAS

PAC and PVC common and benign

SVT is the most common tachyarrhythmia - CMX hydrops

Fetal bradycardia (HR <100 for >10sec)

If persistent - consider structural cardiac defects or maternal CVD

Fetal heart block

40-50% have structural abnormality - usually lethal

Associated with maternal SLE, RA, Scleroderma


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