Yagel - Two Dimensional Echocardiography Examination of the Normal Fetus

2D Echocardiographic Evaluation of the Normal Fetus Yegal12

1) Upper Abdomen Examination

[ ] fetal position- ddx R & L side

[ ] cross-section of upper abd- check for L side stomach, desc Ao, spleen (bn stmc adn diaph)

- check for R side liver, IVC, w IVC ant to Ao; tilt slightly to see confluence of 3 liver vns, & umbilical vn going to right side into portal sinus; then tilt cranially to see a 4Ch view & ensure IVC is connected to RA

2) 4 Chamber View

[ ] check position, size, rhythm, conttractility

[ ] slightly oblique plane- see both atria, ventricles, AV vlvs, IVS & atrial septum,

[ ] check for levocardia- 1/3 of hrt is on R, rest on L of midline

[ ] check cardiac axis- compared to sagittal, cardiac should be 45 +/-15 degrees; abNl esp w GA xx

[ ] check for hypokinesis of myocardium

[ ] check rhythm, but best w M-mode

[ ] check ea hrt structure- atria, ventricles, etc

-note lumen of RV is slightly smaller than L

-note FO flap bulges into LA

[ ] check desc Ao ant/lat to spine- see circular cross section, pulsatile

-see esoph just ant to Ao, echogenic circle- during a swallow it dilates transiently, looking like a vssl

[ ] check LA- ventral to Ao/esoph- most posterior structure of heart

-see PVns enter it

-see FO leaflet (flap) is the free part of the sept primum, bulges to L bc R-->L Q,varied shape & size

[ ] check RA is on R of LA w FO/ostium secundum in bn

-angle cranially/caudally or by tilting the transducer to longitudinal plane--> see IVC/SC connection

-atria should be - in size

[ ] check RAA (broad) & LAA (finger like)

[ ] check ventricles- RV- just behind sternum- most ant structure, LV adjacent/post to RV and is most L side structure

-RV more trabeculated, irregular cavity, LV is smooth and has longer lumen reaching apex

-RV has short lumen bc of the moderator band = septomarginal trabeculum going fr IVS to lower free wall of RV

-check ea AV vlv - MV vs TV, TV more apical...

[ ] check IVS, starts thicker at apex, thins as it reaches AV vlvs

-at 20wks GA, a thin membr part isn't seen fr apical approach, and a drop out --> false positive for VSD concern; must use a lateral view to see septum

-Nl thickness is bn 2-4mm dring gestation, must measure from lateral approach

[ ] check pericardium- slight double layer around cardiac wall

-at level of AV vlvs, a tiny amt of pericard fluid can be seen and isn't an abNl effusion

Visualization of Left & Right Ventricular Outflow Tracts

[ ] tilt transducer cranially fr 4C view & focus on LV, where MV connects w IVS

[ ] check Ao- arises in continuity with IVS, pointing slightly R ward, and other border of Ao is connected to the MV.

-Ao root- check Ao vlv- see an echocenic dot

-check continuity of IVS and AO, angulation of Ao and septum, Ao root size, Asc Ao, Ao vlv mvmt

-check for VSD as well

[ ] check PA- tilt transducer more cranially (some rec short axis view) to a 5 chamber plane

-tilt further and ensure PA is fr RV

-see PA w DA arising

-pulm trun crosses perpendicularly over Asc Ao and becomes the vessel on the L

-on the R side of PA, see 2 vessels in cross section- Asc Ao & SVC

[ ] check for correct connection of RV & PA and for the crossing of PA over Ao (TGA won't cross)

[ ] check PA trunk size slightly larger than Ao. PA vlv seen as a white trunk

[ ] DDx Ao fr PA by PA bifurcation & AO head/neck vssls- see Ao vssls fr short axis...

-for short axis, get to 5C view and rotate till you get a plane fr R hip to L shoulder => circle & sausage sign- w Ao in center and RA, RV, PA, bifurcation around it

-see RPA as it goes under Ao root twd R lung

Longitudinal Views of the Outflow Tracts

-to check the AO and DA arches

[ ] from a prasagittal plane, slightly to the L, including Ao vlv and desc Ao, and visualize arch

[ ] check Arch- emerges fr center of heart w candy cane look

-under Asc Ao, in cross section is RPA

-to the L, see longitudinal view of PA trunk w DA

-see RV & PA anteriorly, and DA arch going perpendicularly to connect to desc Ao

-DA has more hockey stick look w acute angulation

-hard planes to see except if fetus is in dosoanterior or dorsoposteior positions

-the planes are very close to each otehr so easy to be confused...

-three vessel view is easier to see them

Three-Vessel View

-from 4 chamber plane, move transducer parallel to upper thorax, to a sagital cross section of upper thorax

-see 3 vessels of PA trunk- the DA, Ao Arch w isthmus, and SVC

-Ao and DA arches are seen in tangential cross-section, make a V-form pointing to posterior thorax on L side of spine

-trachea prior to its bifurcation seen as a circle w echogenic walls on R side of Ao isthmus and ant to the spine

-see SVC in front of trachea on the R side of Ao arch

-on L & R side of the 3 vessels, see lungs

-in front of the 3 vessels, see less echogenic mass of thymus

-w color Doppler see antegrade Q at both outflow tracts if Nl..., DDx fr retrograde Q if xx

-can see outflow tract xx well, can see trachea vs Ao to see if L or R Ao arch

-can see thymus to c/s CATCH-22