L’échocardiographie au 1er trimestre? E.Quarello Marseille 2011 lundi 25 avril 2011 Pour qui ? - Famille à risque élevée de Cardiopathie Congénitale (risque: 2-3%) - Hyperclarté de nuque - Malformation(s) - Fuite tricuspide - Onde A (-) au niveau du canal d’Arantius lundi 25 avril 2011 Downloaded from heart.bmj.com on 22 November 2007 hocardiographic correlates of normal cardiac morphology in the late first trimester fetus Heart 1997;77:68-72 fetus Figure image correlates Anatomical and echocardiographic of " j ......... fetus gestational (54 days post-conception). The plane from longitudinal imaged head first The in(UVT)the late normal cardiac morphology prominent, passing from front of spine passing trimester fetus connecting artery (UA) The (H) large ........... Lindsey D Allan, Rosalba Santos, Tomas Heart 1997;77:68-72 was obtained in a with a 1 This crown-rump length equivalent to 9 weeks 5 days is age to rump. in a umbilical vein is the cord through the liver to below the heart. The descending aorta is seen down the back in the and in the cord. A to the umbilical heart is seen in the head vessel is seen. thorax just above the diaphragm. The ultrasound beam is then positioned at right angles to this plane of section to cut through the heart in a transverse plane. The beam is Pexieder then swept up and down the thorax to produce the type of images seen in fig 2. liver and the equality of the right and left venAbstract nd Objectives-To describe the normal car- tricular dimensions when imaged in a four diac morphology as seen by transvaginal chamber projection. In addition, as was l ultrasound imaging in the first trimester expected from our knowledge of fetal physiolfetus and to compare it with the morphol- ogy, the patent foramen ovale and the patent arterial ductal connection were visible in every ogy of the heart as seen by microdissection rse thorax. at the same gestational age. normal fetus. with a Design-In 53 mothers undergoing early Since 1980 improvements in the resolution h the fetal heart was examined of sonography, vaginal transducers have led to the study of eks 2 ,ge (Si and the images recorded. The gestational the conceptus at increasingly early stages of geson). lat the age range was 5-12 weeks of gestation, tation. The evaluation of embryological feaat the which represents 21 to 70 days after contures such as the appearance of the yolk sac and is stage the physiological hemiation of the midgut can cm and ception. Images were analysed frame by ery less frame and compared with the anatomy of be studied and even used to date the pregnancy et etre. apposi.te embryos and fetuses at the same gesta- accurately.2 Many of the standard echocardioapex tional ages. graphic views can be obtained as early as 11 to and The Results-After the 9th week of 12 weeks of gestation' and the atrioventricular gestation, ed four cardiac the aortic and arterial Doppler flow velocity profiles can chambers, origin, t half of colour and the could be identibe pulmonary artery analysed.4 this ndt of fied onand crossleft sectional The heart is one of the first organs to develop sthe were right ven- echocardiography ndicates in conjunction with colour flow Doppler. in the embryo, with cardiac motion seen Yr septum en a four his is aimaged At 9 weeks,in the apex pointed anteriorly and between 26 and 32 days after conception' (5-6 the the right ventricle and pulmonary artery weeks post-menstrual age), when the crownnofethewalls as was fouraddition, to the right of the midline. By the 11th rump length is between 5 and 10 mm. The lay trunk ofoffetal ledge physiolthe apex pointed to the __ atrioventricular endocardial cushions and atrigestation, fined week left and the pulmonary artery lay to the left oventricular valves develop in post-menstrual ovale and the patent of the midline as in the older fetus. weeks 6-7, the outflow tract septum is comIt arose riclewere visible in ndline every Between 9 and 12 weeks' gestation the pleted between post-menstrual weeks 7-8, and to aorta was than the larger pulmonary the interventricular ending foramen closes between lour ed the artery. These findings were confirmed in post-menstrual weeks 8 and 9.6 The tricuspid inmicrodissected the resolution ents ary the hearts. valve is the last cardiac structure to complete its e) Conclusions-The current of ultraat post-menstrual weeks 9-10. We quality e. (E) led ave to the ofusing transvaginal formation tion just sound imagesstudy obtained to evaluate the fetal heart during the attempted mber ngly stages in of transducers thegesfirst trimester fetus first trimester of pregnancy to see if any part of w the early onary allows the study of fetal cardiac anatomy. cardiac development was currently identifiable of Cand embryological feaorta Some of the later developmental changes by the most modem high resolution transducby of sac and As technology ers. nce canthe be yolk demonstrated. ng t improves further the details of earlier carion red) of the midgut can mards diac morphogenesis may also become visit this to date the pregnancy Patients and methods iderably ble. ECHOCARDIOGRAPHIC IMAGES ow standard echocardioIn 53 patients the fetal heart was imaged using seen in (Heart 1997;77:68-72) ained as early as 11 to The an Advanced Technical Laboratories HDI sysn front tem with a 5 or a 9 MHz vaginal tranducer. mnd the the atrioventricular Keywords: fetus; organogenesis; echocardiography; pre- These patients were referred for ultrasound a RV, natal diagnosis w examination to confirm the presence of an , left velocity profiles can a; PA, intrauterine pregnancy or to establish viability Aao, Advances in prenatal ultrasound imaging, espe- after an episode of vaginal bleeding. The firstcially to develop organs the advent of cross sectional scanning, crown-rump length was used to estimate the allowed the echocardiographic features of the gestational age, which ranged from 5 to 12 cardiac motion seen es lundinormal mid-trimester fetus to be correlated weeks. The gestational ages studied are shown 25 avril 2011 elates of irst Published online 10 February 2011 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.8934 69 Fetal echocardiography at 11–13 weeks by transabdominal high-frequency ultrasound N. PERSICO*†, J. MORATALLA*, C. M. LOMBARDI‡, V. ZIDERE*, L. ALLAN* and K. H. NICOLAIDES*§ *Department of Fetal Medicine, King’s College Hospital, London, UK; †Department of Obstetrics and Gynecology ‘L. Mangiagalli’, Ospedale Maggiore Policlinico, Milan, Italy; ‡Studio37: Diagnostico Eco, Vimercate, Italy; §Department of Fetal Medicine, University College Ultrasound Obstet Gynecol 2011; 296–301 Hospital, London, UK Published online 10 February 2011 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.10 K E Y W O R D S: cardiac defects; Doppler ultrasound; linear transducer; nuchal translucency Fetal echocardiography at 11–13 weeks b high-frequency ultrasound ABSTRACT in pregnancy fails to identify the majority of fetuses with major cardiac defects2,3 . By contrast, the majority of such defects are amenable to prenatal diagnosis Objectives To assess the accuracy of fetal echocarby specialist fetal echocardiography4,5 . Consequently, diography at 11–13 weeks performed by well-trained effective population-based prenatal diagnosis necessitates obstetricians using a high-frequency linear ultrasound improved methods of identifying the high-risk group transducer. for referral to specialists and/or improved standards of scanning in those undertaking routine screening. Methods Fetal echocardiography was performed by Traditionally, high-risk groups have been identified for obstetricians immediately before chorionic villus sampling for fetal karyotyping at 11–13 weeks. Digital videoclips referral for specialist fetal echocardiography, for example, *Department of Fetal Medicine, King’s College Hospital, London, UK; †Department of Obstetri of the examination stored by the obstetrician were those with a family history of cardiac defects, maternal Ospedale Maggiore Policlinico, Milan, Italy; ‡Studio Eco, Vimercate, §Depart reviewed offline by a specialist fetal cardiologist. historyDiagnostico of diabetes mellitus and maternalItaly; exposure to Hospital, London, UK teratogens. However, the performance of this method Results The obstetrician suspected 95 (95%) of the 100 of screening is poor, with a detection rate of only cardiac defects identified by the fetal cardiologist and approximately 10% of cases of fetal cardiac defects6 . K E Ythe Wcorrect O R Ddiagnosis S: cardiac defects; Doppler made in 84 (84%) of these cases. ultrasound; linear transducer; nuchal transluce A major improvement in screening for cardiac defects In 54 fetuses, the defect was classified as major and in came with the widespread introduction of four-chamber 46 it was minor. In 767 (86.6%) cases, the heart was view screening during the routine mid-trimester scan7 . normal and in 19 (2.1%) the views were inadequate First-trimester screening for aneuploidies by measurement for assessment of normality or abnormality. A subsequent of fetal nuchal translucency (NT) thickness identified second-trimester scan in the normal group identified major another important high-risk group8 . A meta-analysis cardiac defects in four cases. Therefore, the first-trimester performance offails NT scan A B by S TtheRobstetricians A C T and cardiologists identified 54 of studies examining the screening in pregnancy thickness for the detection of cardiac defects in euploid (93.1%) of the 58 major cardiac defects. with major cardiac fetuses reported that the detection rate was 23% for an NT Conclusions A well-trained obstetrician using highcut-off of the 99th centile9 . There is also evidence that of such defectsthe ar resolution ultrasound equipment can assess the fetal heart detection rate may be improved further by the additional Objectives Toa high assess the accuracy fetal echocarat 11–13 weeks with degree of accuracy. Copyright of early by specialist sonographic markers of aneuploidy, abnormalfetal flow 2011 ISUOG. at Published by John Wiley &performed Sons, Ltd. diography 11–13 weeks by well-trained through the ductus venosus10effective and across populationthe tricuspid valve11 .ultrasound In the presence of abnormal flow, the risk for obstetricians using a high-frequency linear improved cardiac defects in euploid fetuses is increased. methods INTRODUCTION transducer. In the last 10 years, as a consequence of inclusion of for referral to speci ‘aneuploidy sonographic markers’ in screening for cardiac Abnormalities of the heart and great arteries are in those Methods Fetalcongenital echocardiography was defects, performed bya shift scanning there has been in specialist fetal echocar-un the most common defects and account for diography from the second to the first trimester of pregapproximately 20% of all stillbirths and 30% of Traditionally, high obstetricians immediately before chorionic villus 12,13sampling 1 nancy . A technical limitation in such early echocarneonatal deaths due to congenital defects . Several for fetal karyotyping at ultrasound 11–13 weeks. videoclips referral for specialist diography is visualization of the desired structures. studies have established that routine screening Digital N. PERSICO*†, J. MORATALLA*, C. M. LOMBARDI‡, V. ZIDERE*, and K. H. NICOLAIDES*§ of the examination stored by the obstetrician were reviewed offline by a specialist fetal cardiologist. those with a family history of diabetes Correspondence to: Prof. K. H. Nicolaides, Harris Birthright Research Centre for Fetal Medicine, King’s College Hospital Medical School, teratogens. Howeve Denmark Hill, London SE5 8RX, UK (e-mail: [email protected]) Results The obstetrician suspected 95 (95%) of the 100 Accepted: 23 December 2010 of screening is poo cardiac defects identified by the fetal cardiologist and approximately 10% made the correct diagnosis in 84 (84%) of these cases. ORIGINAL PAPER Copyright 2011 ISUOG. Published by John Wiley & Sons, Ltd. A major improveme In 54 fetuses, the defect was classified as major and in came with the wides 46 it was minor. In 767 (86.6%) cases, the heart was How successful is fetal echocardiographic examination in the first trimester of pregnancy? Blackwell Science, Ltd Figure 3 Ultrasound image of the pulmonary trunk originating from the 2 W. R. TWISK† and the J. M. three-vessel G. VAN VUGT* view in a fetus at 13+4 weeks’ right J.ventricle, with A,M. C. HAAK*, *Department of Obstetrics and Gynecology, ‘Vrije Universiteit’ Medical Center, Amsterdam and †Department of Clinical Epidemiology and gestation; crown–rump length, 75 mm. Ao, aorta; SVC, superior vena Biostatistics, ‘Vrije Universiteit’ Medical Center, Amsterdam, the Netherlands Ultrasound Obstet Gynecol 2002; 20: 9 – 13 cava; PA, pulmonary artery; Sp, spine. K E Y W O R D S: Cardiac examination, Echocardiography, First trimester, Normal pregnancies, Transvaginal ultrasound How successful is fetal echocardiographic examination Table 4 Success rate for full cardiac examination the first trimester of pregnancy? Blackwell Science, Ltd ABSTRACT INTRODUCTION Gestational age (weeks) Success rate (%)* M. C. HAAK*, J. W. R. TWISK† and J. M. G. VAN VUGT* 11+0 to 11+6 20 12+0 to 12+6 60 13+0 to 13+6 92 Objective Transvaginal echocardiography is still rarely First-trimester transvaginal ultrasound examination has been incorporated into the first-trimester ultrasound examination, an established method to detect many structural abnordespite the fact that heart defects are the most frequently malities for several years1,2. Despite a few reports on the possibilities of visualizing and examining the fetal heart at this encountered congenital malformation. This study was Universiteit’ *Department of Obstetrics and Gynecology, ‘Vrije Medical 3–5 Center, Amsterdam and †Department of Clinical Epid early gestational age , transvaginal echocardiography in undertaken to explore the possibilities of fetal echocardioBiostatistics, ‘Vrije Universiteit’ Medical Center, Amsterdam, the Netherlands the late first trimester remains a rarely applied method. This graphy in the late first trimester. despite the fact that heart defects are the most frequently Methods In 85 women with uncomplicated singleton encountered congenital malformation, affecting 4 –8 infants pregnancies, three transvaginal ultrasound examinations per 1000 births6. between 13+6 weeks’ gestation were performed. K E Y W11+0 O Rand D S: Cardiac examination, Echocardiography, First trimester, Normal pregnancies, This study was undertaken to explore the relevance of fetal Transvaginal ultr The examinations were carried out at weekly intervals echocardiography in the late first trimester of pregnancy and and visualization of several echocardiographic planes was to construct growth curves of the aortic root and pulmonary attempted (four-chamber view, aortic root, long axis of trunk for this gestational age. The study also aimed to deterthe aorta, pulmonary trunk with three-vessel view, crossmine the optimal gestational age at which to perform transover of the great arteries). The diameter of the aorta and vaginal echocardiography. pulmonary trunk were measured to establish reference ranges. *Rounded. earlier in gestation than the aortic root (75.3% vs. 32.9% at 11+0 ABSTR A C T to 11+6 weeks of gestation). I N T R O D U disappears CTION M E T H O D SThis difference Results The success rate of visualization of the different women singleton pregnancies participated vs. gradually with the increasing ofwiththe fetus (97.6% parameters increased with gestational age. The ability to isEighty-nine Objective Transvaginal echocardiography stillsize rarely First-trimester transvaginal ultrasound exam perform a full lundi 25 avril 2011 cardiac examination increased from 20% in the study. They received written information and gave incorporated into the first-trimester ultrasound examination, an established method to detect many st Not on ultrasound n = 1 (Case 183) n = 29 (Cases 67, Cardiac malformations in first-trimester fetuses with increased n = 30 Total n=8 Blackwell Science, Ltd nuchal translucency: ultrasound diagnosis and postmortem *Ignoring minor defects and unsuccessful examinations. A&H, alive and healthy. morphology M. C. HAAK*, M. M. BARTELINGS†, A. C. GITTENBERGER-DE GROOT† and J. M. G. VAN VUGT* *Department of Obstetrics and Gynecology, ‘Vrije Universiteit’ Medical Center, Amsterdam and †Department of Anatomy and Embryology, Leiden improved in 40 singleton first-trimester pregnancies with nuchal translucency porated m thickness > Echocardiography, 95th centile First at two levels oftranslucency, agreement KEYWORDS: Cardiac examination, trimester, Nuchal Postmortem, Transvaginal of the he ultrasound Cardiac malformations in first-trimester fetuses with inc cificity (8 Detailed agreement General agreement nuchal translucency: ultrasound diagnosis and postmor is of an (n (%)) (n (%)) echocard Conclusion Transvaginal echocardiography can be permorphology ABSTRACT formed Sensitivity 7/13reliably (54) in first-trimester fetuses 7/8 with (88)an increased discrepan Objective The aim of this study was to explore the diagnosNT. In this study, the proportion of chromosomally Specificity 26/27 29/30 (97) tic accuracy of first-trimester transvaginal echocardiography abnormal(96) fetuses with a heart defect was not different from nosis on p in fetuses with increased nuchal translucency (NT) thickness, that found in newborns, except for cases of Turner synM. C. HAAK*, M. M. BARTELINGS†, A. GITTENBERGER-DE False-positive rate 1/8C.(13) 1/8 (13)GROOT† and J. M. G. V by comparing the ultrasound diagnosis with the findings on drome. Fetal demise occurred in all three euploid fetuses with on postm *Department of Obstetrics and Gynecology, ‘Vrije Universiteit’ Medical Center, Amsterdam and †Department of Anatomy and Emb False-negative rate (19) 1/30 (3)defect had a postmortem examination or mid-gestational ultrasound and a 6/32 heart malformation. The fetuses with a heart University Medical Center, Leiden, The Netherlands primum A neonatal outcome. larger than did those without. 7/8 (88) Positive predictive value 7/8 NT (88) Methods Transvaginal echocardiography was performed defects ar Negative predictive valuein 26/32 (81) 29/30 (97) 45 fetuses with a NT > 95th centile. Karyotyping was performed in 43. In 20 of the 23 pregnancies in which INTRODUCTION third-trim K E Y W O R D S: Cardiac examination, Echocardiography, First trimester, Nuchal translucency, Postmortem, Trans termination of pregnancy was carried out, postmortem Measurement of the fetal nuchal translucency (NT) thickness tem is fur examination was performed to determine the presence and ultrasound in the late first trimester of pregnancy has become an estabtype of heart defect. Mid-gestational echocardiography was lished method for identifying fetuses at risk for aneuploidy . The en performed in ongoing pregnancies and neonatal follow-up The frequent occurrence of heart malformations in fetuses information was obtained. Findings on first-trimester transultrasound, the sensitivity to 88% with a false-negative study did or in combination withrose an enlarged NT, either isolated vaginal echocardiography were compared to those of second45 embryons CN ≥95e p with a chromosomal abnormality , has gained much trimester echocardiography or the results of postmortem value of 3% (Table 7). the cases 10 malformations cardiaques attention. It was suggested that NT thickness measureexamination. The mean NT in the fetuses with and without ment could also be used as a screening tool for fetal heart Conclusion To compare the mean NT in fetuses with orTransvaginal without aechocardiography common heart defects was calculated. lundi 25 avril 2011 malformations in an unselected population . FurtherUltrasound Obstet Gynecol 20: 14 – 21 characteristics of transvaginal echocardiography Table 7 2002; Performance University Medical Center, Leiden, The Netherlands Blackwell Science, Ltd 1–3 4–6 7,8 9 A systematic review of the accuracy of first-trimester ultrasound examination for detecting major congenital heart disease S. V. RASIAH*, M. PUBLICOVER†, A. K. EWER*, K. S. KHAN‡, M. D. KILBY‡ and J. ZAMORA§ *Department 112of Neonatology, †Library Services and ‡Department of Maternal and Fetal Medicine, Birmingham Women’s Hospital, Ultrasound Obstet 2006; 28:of 110–116 Division of Reproduction andGynecol Child Health, University Birmingham, Edgbaston, Birmingham, UK and §Clinical Biostatistics Unit, Hospital Romony Cajal, Madrid, SpainInterScience (www.interscience.wiley.com). DOI: 10.1002/uog.2803 Published online in Wiley Rasiah et al. Table 1 Study characteristics of the articles included in the systematic review of the accuracy of first-trimester fetal echocardiography K E Y W O R D S: congenital heart disease; Year offirst trimester; systematic review; ultrasound scan publication Authors (study period) Country Study population Gestational range scans done (weeks) Number of fetuses < 14 weeks A systematic review of the accuracy of first-trimest ultrasound examination for detecting major conge heart disease Carvalho et al.27 Huggon et al.29 A B S T RGalindo A C T et al.34 2004 (1997–2002) 2003 (2000–2001) 2003 (1997–2003) Ultrasound approach England England Spain High-risk; increased NT 10–16 79 Transabdominal High-risk; increased NT 11–14 262 Transabdominal increased NT postnatally 12–161,2 . In addition, 41 Transvaginal & orHigh-risk; palliative surgery the presence of CHD increases perinatal mortality. Prenataltransabdominal 30 Objective To evaluate the accuracy of first-trimester Weiner et al. 2002 (1995–1999) Israel High-risk 11–14 392 Transvaginal ultrasonography with fetal echocardiography performed 28 ultrasound examination in2002 detecting major congenital Netherlands High-risk; increased NT 11–14 38 Transvaginal Haak et al. at 18–20 weeks’ gestation is used routinely to screen 33 Comas(CHD) et al. (1999–2001) Spain High-risk 12–17 117 Transvaginal & heart disease using2002 a systematic review of the for CHD. The ultrasound examination is based ontransabdominal literature. examination of a ‘four-chamber view’ of the 17 heart, with 1999 (1997–1998) England High-risk; increased NT 13–16 Transabdominal Zosmer et al.31 17 MethodsCarvalho Generaletbibliographic and specialist computeradditional examination great and aortic al. 1998 (1995–1997) England High-risk; increased NT of12the to 13 + 6 vessels 11 Transabdominal 32 ized databases searching of reference 1994 (1991–1993) Israel Unselected 201such scans Transvaginal Achironalong et al. with manual arch. The screening specificity13–15 and sensitivity of 14 *Department of Neonatology, †Library Services and ‡Department of Maternal and Fetal Medicine, Gembruch et al. (1988–1992) Germany Unselected 11–16 85 TransvaginalBirmingham lists of primary and review1993 articles were used to search are variable, with some studies indicating a detection rate S. V. RASIAH*, M. PUBLICOVER†, A. K. EWER*, K. S. KHAN‡, M. D. KILBY‡ an W Division Reproduction andincluded Child Health, Birmingham, Edgbaston, UK and §Clinica for relevantofcitations. Studies were if a first-University as low asof 26% in an unselected population3Birmingham, . However, All studies were carried in tertiary referral nuchalechocardiography translucency. trimester ultrasound scan wasout carried out to detectcenters. CHD NT, fetal in experienced hands performed Hospital Romony Cajal, Madrid, Spain that was subsequently verified by a reference standard. in the second and third trimesters has a sensitivity of Data were extracted on study characteristics and quality, 60–100% for diagnosing major CHD even in a low-risk (95% CI, 98–100%), respectively. The findings among Potentially relevant citations 4–9 17,27,28,30,34 and 2 × 2identified tables were constructed to calculate sensitivity screening population by initial screening had a pooled sensitivity high-quality. studies globale and specificity. (from all sources searched) With improved has become to of 99% (95% of 70%technology (95% CI, it55–83%) and feasible specificity n = 622 K E Y W O R D S: congenital heart disease; first trimester; systematic review; ultrasound scan obtain images the fetal heart in predominantly the first trimester, CI, of 98–100%). Studies undertaken before Results Ten studies (involving 1243 patients) were globale with visualization both the –four heart chambers 14,17,30 32 had a lower sensitivity of 56% the yearof2000 suitable for inclusion. Of these, fourexcluded used transabdominal Citations as and the outflow tracts of the great vessels being ultrasonography, four used transvaginal (95% CI, 35–75%) compared with those carried out after not relevant and two used 10,11 performed from as early as 11 weeks’ gestation . The 27 – 29,33,34 n = 539 a combination. Pooled sensitivity and specificity were 2000 , which had a sensitivity of 92% (95% CI, majority of the initial studies were carried out using lundi 25 avril 2011 Sensibilité Spécificité : 85% (IC 95%, 78-90%) : 99% (IC 95%, 98-100%) Que peut-on doit on voir ? Situs Connections atrio-ventriculaires Connections ventriculo-artérielles Identification des cavités cardiaques et leur symétrie Croisement des gros vaisseaux Evaluation du flux: valves, cavités et gros vaisseaux lundi 25 avril 2011 Echocardiographie au 1er trimestre lundi 25 avril 2011
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