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FETAL CHESTDIAPHRAGM
◦ 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 hypoplasiaPLEURA - effusionsMEDIASTINUM - masses
CONGENITAL DIAPHRAGM HERNIABochdalek - 90% on left; most unilatAll should have amniocentesis and
dedicated echoSecondary pulmonary hypoplasia is
major cause of mortalityFindings
◦ Polyhydramnios◦ Stomach/bowel/liver adjacent to heart◦ Peristalsis in chest◦ Mediastinal shift◦ Absent gastric bubble◦ Reduced abdominal circumference
compared to rest of fetal biometry
Associated anomalies◦ Aneuploidy (T18, T21); NTD; CHD; malrotation, omphalocele
DDX◦ CCAM◦ Other cystic masses such as foregut duplication cysts are
rare
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
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
PULMONARY HYPOPLASIAAgenesis – 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 pouchHypoplasia – 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
PLEURAL EFFUSION = abnormalFetal hydropsChromosomal Underlying mass InfectionLymphangiectasiaChylothorax - assoc with T21 and Turner’s
MEDIASTINAL MASSESAnterior Medistinum
◦ Teratoma◦ Cystic hygroma◦ Normal Thymus
Posterior Mediastinum◦ Neurogenic tumours◦ Enteric cyst
FETAL HEARTTechnique 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
Best seen on Four-Chamber View◦ Septal defect◦ Endocardial cushion defect (AVSD)◦ Hypoplastic left heart◦ Ebstein’s anomaly◦ Critical AS◦ Coarctation
Best Seen on Outflow Tract Views◦ Tetralogy of Fallot◦ Transposition◦ Truncus Arteriosus◦ Pentalogy of Cantrell
Maternal Risk Factors for CHDDiabetesInfection - rubella, CMVSLEDrugs - EtOH, Phenytoin, lithiumFHX of heart disease, previous
child with CHDArrhythmia
VSDMost common CHD (1:1000)Membranous 80% vs Muscular 10% vs
Outlet (ECD) 5%Don’t mistake membranous to
muscular transition for VSD
Endocardial Cushion Defect40% have Trisomy 21EC forms lower atrial septum,
superior ventricular septum, anterior MV leaflet and septal TV leaflet
Transposition of Great VesselsAorta arises from RV and pulmonary trunk
from LVAorta and pulmonary artery are parallel
instead of perpendicular to each other
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
Ebstein’s AnomalySeptal and posterior leaflets of tricuspid valve
prolapse and are integrated into RV wallAtrialisation of RVLarge RA due to massive regurgMaternal lithium is a risk factor
Pericardial Effusion>2mmAssociated 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
Endocardial FibroelastosisIncreased echogenicity of
endocardiumVentricular dilatation and poor
contractility
Ectopia Cordis
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 ARRHYTHMIASPAC and PVC common and benignSVT is the most common
tachyarrhythmia - CMX hydropsFetal bradycardia (HR <100 for
>10sec)◦ If persistent - consider structural cardiac
defects or maternal CVDFetal heart block
◦ 40-50% have structural abnormality - usually lethal
◦ Associated with maternal SLE, RA, Scleroderma