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Mosaed P. Fetal Echocardiography; Introduction and Approaches. SJMR 2017; 2 (4) :31-34
URL: http://saremjrm.com/article-1-98-en.html
Sarem Fertility & Infertility Research Center (SAFIR), Sarem Women’s Hospital, Tehran, Iran , pasha_viuna@yahoo.com
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Introduction
Congenital heart defects are currently the most common congenital anomalies at birth, with an incidence of between 8 and 10 deaths per 1,000 live births [1]. According to the World Health Organization (WHO), between 1950 and 1994, 42% of infant deaths were due to heart disease [2]. One of the most difficult birth defects is screening for fetal heart failure. For example, low-risk embryos appear uncomplicated during pregnancy [3]. With the use of screening tests and administration of folic acid, the abnormalities of the neural tube and common trisomy have gradually been eliminated and heart anomalies have climbed to the top of the third category of congenital anomalies. Of course, the presence of known and unknown teratogens and increasing gestational age should also be considered. On the other hand, despite the introduction of new diagnostic methods during pregnancy, the diagnosis, treatment and assignment of those affected by these abnormalities remains a serious problem in embryonic and maternal medicine [4], and solving and eliminating these complication needs the collaboration of related groups.
Detection of cardiac abnormalities is valuable and important before birth. In this regard, fetal echocardiography is considered as a standard part of prenatal care and service [5]:
1- Decision should be made whether to end pregnancy or continue pregnancy (termination of pregnancy in abnormalities without treatment and disabling ones).
2- syndromes such as DiGeorge syndrom, Down syndrome, tuberculosis, and so on. Should be dignosed and detected.
3- Embryonic treatments such as treatment for fetal arrhythmias, pericardial fluid drainage, etc.should be started.
4. Early treatment of the disease in the first days of life (before a complication), such as arterial switch in the displacement of large vessels should be carried out.
5. Mother's disease, such as diabetes and lupus, should be diagnosed and managed.
6. Mental support of mother and parents should be carried out.
Today, one of the most important parts of embryonic screening is embryo echocardiography during pregnancy, used for the study of congenital heart disease and fetal heart irregularities. Considering the necessity of pregnancy screening and the high importance of identifying cardiac abnormalities in this period, this study attempted to collect a collection of the most important subjects and experiences of specialists in this field. This article was compiled by using authoritative sources and scientific articles on fetal echocardiography and researcher experiences. The aim of this study was to evaluate fetal echocardiography.
 
Knowledge and skills
The heart is a small and moving in a fetus. The placement of the embryo in the womb does not always allow the taking of standard images. So, there is a huge variety of images that make it difficult to interpret a natural from abnormal interpretation, especially on Off Axis images.
On the other hand, due to the large variety of these abnormalities, we face a variety of anatomical and physiological disorders that make work more difficult. Consequently, performing and interpreting echocardiography requires knowledge and skill [3]. This knowledge and skill includes familiarity with the principles of ultrasound (minimum abilities and skills in 2D, M mode, and Pulsdapler and Caldeaplera modalities), knowledge of embryology and embryological circulation physiology, practice and focus on space imagination, physiology, clinical course and treatment of congenital heart abnormalities, knowing the mechanism of diagnosis and treatment of arrhythmias, knowing the mechanism of the effect and side effects of an antiarrhythmic drugs, full and three-dimensional recognition of cardiac anatomy, knowledge about hemodynamic events and the appropriate time for cardiac and circulatory physiology during 16-18 weeks of pregnancy. Of course, according to previous sources, the time was about 18 to 22 weeks of gestation, and if the echocardiography machine has high sensitivity and accuracy, with enough experience it can do it from the 14th week.
The length of time that an echocardiographic study can last will depend on the condition of the fetus, and the time is at least 1-2 hours. Patience is very important in doing this. Having an embryo's ecchymosis for mother and fetus has no pain or risk, and there is no need to fill the bladder. If the study is normal, it does not need to be repeated during pregnancy; however, postpartum echocardiography is also recommended for changing the physiology of postnatal embryo circulation.
In the following cases, it is recommended that ecocardiography be done during the pregnancy, depending on the case, between 1to 4 weeks later  (on average two weeks):
1- Suspecion for a complication that its decision is difficult at present.
2. patient's weakness, usually caused by the mother's structure and body (especially the mother's obesity), scar from previous cesarean section or any previous scar in the lower abdomen, uterine anomalies, and placenta and embryo position.
3- existence of an associated diseases such as diabetes and lupus in the mother that in this case repition of study is needed.
4. Tracking or treating some fetal diseases such as arrhythmia, pericardial effusion, VSD (ventricular wall defects), duct stenosis, etc.
 
Indications
As noted, echocardiography is a prerequisite for standard care during pregnancy. However, so far, there has not enough human resources to do it. So its indications are as follows [6]:
1- Family history such as congenital heart abnormalities in first-degree relatives (parents and children), cardiac syndromes in first-degree relatives such as Marfan, Tuberous Sclerosis, William's, Digeorge, Long QT, Noonan, as well as chromosomal disorders and anomalies, and hereditary diseases should be checked.
2. Maternal diseases, metabolic diseases:
A: Diabetes: It is important to note that in diabetes mothers who have diabetes before pregnancy (teratogenic diabetes), echocardiography should be done at weeks 16 to 18. However, in women with pregancy diabetes, an echocardiographic study should be performed as soon as possible after diagnosis.
B) Phenylketonuria (in each type of diabetes, in the absence of precise blood glucose control, it is recommended that the study be repeated in the third quarter due to hypertonic cardiomyopathy) and autoimmune diseases such as lupus, infectious diseases such as rubella, influenza, mumps, cytomegalovirus, and coccasia be studied.
C) Hypothyroidism which has not yet been proven.
D) Obesity not yet proven.
3. Teratogens that include teratogenic substances, ionizing radiation, drugs, alcohol and cigarettes.
4. Use of medications such as anticonvulsants (valproate, carbamazopine, phenytoin and phenobarbital), warfarin, nonsteroidal anti-inflammatory drugs (NSAIDs), especially brofen and aspirin, tricyclic anti-depressant drugs (TCAs), lithium, isotretinoin and antiarrhythmics.
5. IVF
6. The presence of chromosomal abnormalities or extracorporeal abnormalities in the fetus be studied.
7. embryo's arrhythmias should be checked.
8. Sonographic findings including NT elevation, the presence of ecchymal points in the embryonic heart or abnormal ecchynenicity in the endocardium, hydrops (pericheal effusion, pleuritis, ascites), vein regurgitation such as TR, polyhydramine, intrauterine growth retardation (IUGR), extracorporeal malformations, Embryonic umbilical cord, fetal arrhythmia, failure to see standard heartbeat views, such as 4 abnormal cavities and abnormal cysts.
9. Multi-embryo pregnancy, especially if there is probability of transfusion from one embryo to other.
The most common non-heart abnormalities in the fetus that heart should be considered are as follows:
1. Central nervous system abnormalities including neural tube defect, hydrocephalus, corpus callosum absence, arnoldaciral malformation and Dandy Walker malformation.
2. Gastrointestinal abnormalities including amphlocell, duodenal atresia, closed anus and gastroschemia.
3. Abnormalities of the genitourinary system include all dysplasia or kidney failure, hormonal dysplasia and obstruction of the ducts.
4. Chest anomalies including fistulae, cystic lymphadenomatous malformation and diaphragmatic hernia.
5. Abnormalities of the skeletal system including Holt-Orem syndrome, Apert syndrome, Fanconi syndrome, and Van Creveld.Ellis syndrome.
 
Methods of study and ultrasound
An ultrasound device (echocardiography) should have at least 2D modalities with high resolution, M mode, Color-Doppler and Pulse-Doppler. Due to the fetal heart rate (FHR), the device should have the high PRF. The speed of the frame rate is approximately 80 to 100. The appropriate detection is the Phase Arrey Convex (4-12 MHz). However, at present, probes with the same characteristics, but with more advanced technology are being marketed.
In the study technique, the goal must be to obtain all the standard views. For example, in Off Axis views, Over Diagnosis falsely detects abnormalities and makes mistakes. Due to the position of the embryo and the placenta, the rapid movement of the fetus (in the hands of an experienced instructor or inappropriate echocardiography machine) and the mother's size, all the views may not be available in all embryos. In these cases, one should either wait or have to repeat the study; the decision in these cases is different in each case.
 
Studied images
views that are used to diagnose or reject heart abnormalities are as follows:
1- Upper abdomen sagittal view (V)
2- 4 Chamber view (V)
3- 5 Chamber view (V)
4- LVOT Long Axis (LX)V
5- RVOT LX V
6- Great Arteries Short Axis (SX)V
7- 3 Vessels V
8- 3 Vessels Tracheal V
9- Bi caval V
10- Ventricular Sx V
11- Aortic Arch (Race Tract) V
12- Ductal Arch V
13- Ventricular Septum Subcoital V
14- Doppler Exam of AV Valves
15- Doppler Exam of Semi lunar Valves (Out flow pattern)
16- M mode of Ventricular Wall
17- Doppler Exam of Foramen Ovale
With the above images and views, the following should be obtained.
1- Fetal Number
2- Fetal Position
3- Visceral situs
4- Cardiothorasic ratio
5- Atrioventricular and Ventricularterial Connection
6- Pulmonary Veins (Number and Return)
7- IVC and SVC
8- Foramen Ovale (FO)
9- Ductus Venosis (DV)
10- Umblicle Arteries and Vein
11- Chambers Position and situs and size
12- AV Valves (Size and Flew)
13 Semi Lunar Valves (Size and Flew)
14- Pulmonary Artery (Size and Branching)
15- Aorta and Aortic Arch
16- Ductal Arch
17- Ductus Flow Pattern
18- Interventricular Septum (Size and Integrity)
19- Fetal Heart Rate (FHR)
20- Atrial and Ventricular Contraction and Conduction
21- Fractional Shortening (FS)
The point to be made is that in transphoracic echocardiography, we can detect with 7 or 8 classic sequential views, but in embryo echocardiography we face a lot of images that are not sequenced, and this justifies the difference, sensitivity, complexity, the accuracy and timing of embryonic echocardiography. Moreover, this complexity is more about the diagnosis and interpretation of fetal arrhythmias.
 
Reporting format
In echocardiographic study methods, there is no uniform, standard, and learning format, but different from center to center. Given the bulk of images and information, the checklist format will have a long appearance, although this can be done, but in some cases it may not be possible to fill out all the components of the checklist. Therefore, the attachment form, which has been completed in more than one thousand items, was also reviewed and is being proposed at the Center for Echocardiography in Sarem Hospital.
 
Conclusion
The identification and diagnosis of accompanying syndromes, the initiation of embryonic therapy, the decision to terminate or continue pregnancy, and maternal mental support are among the issues that recognize the value and importance of identifying fetal abnormalities. Given the fact that most congenital heart disease can be cured, in case of congenital heart disease, schedules for prenatal care and treatments can be performed with specialized screenings such as timely echocardiography and early diagnosis.

Acknowledgements
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Ethical permissions
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Conflict of Interest
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Financial support
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Contribution of authors
Pasha Mosaed (author), all sections related to the article has been carried out by him (100%).
 
 
 
 
Article Type: Systematical Review | Subject: Reproduction
Received: 2016/08/20 | Accepted: 2016/12/23 | Published: 2018/02/20

References
1. Drose JA. Fetal echocardiography. Amsterdam: Elsevier Health Sciences; 2013. 4- Creasy RK, Resnik R, Iams JD. Maternal-fetal medicine: Principles and practice. Houston: Gulf Professional Publishing; 2004. [Link] [PMCID]
2. Carvalho J, Allan L, Chaoui R, Copel J, DeVore G, Hecher K, et al. ISUOG Practice guidelines (updated): sonographic screening examination of the fetal heart. Ultrasound Obstet Gynecol. 2013;41(3):348-59. [Link] [DOI:10.1002/uog.12403] [PMID]
3. Satomi G. Guidelines for fetal echocardiography. Pediatr Int. 2015;57(1):1-21. [Link] [DOI:10.1111/ped.12467] [PMID]
5. Rychik J, Ayres N, Cuneo B, Gotteiner N, Hornberger L, Spevak PJ, et al. American society of echocardiography guidelines and standards for performance of the fetal echocardiogram. J Am Soc Echocardiogr. 2004;17(7):803-10. [Link] [DOI:10.1016/j.echo.2004.04.011] [PMID]
6. Fetal Echocardiography Task Force; American Institute of Ultrasound in Medicine Clinical Standards Committee; American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Practice guideline for the performance of fetal echocardiography. J Ultrasound Med. 2011;30(1):127-36. [Link] [DOI:10.7863/jum.2011.30.1.127]

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