Ekhokardiografi Janin

BASIC FETAL ECHOCARDIOGRAPHY

Judi Januadi Endjun

Presented at Intensive Obstetrics & Gynecology Ultrasound Course

Department of Obstetrics and Gynecology Gatot Soebroto Army Central and Teaching Hospital School of Medicine, UPN - Jakarta 7 Desember 2011

MATERI AJAR INI HANYA UNTUK DIPERGUNAKAN PADA KEGIATAN PENDIDIKAN DAN KESEHATANJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 2

Judi Januadi Endjun, dr. SpOG1985: FK UNPAD, S1 1991: Postgraduate ultrasound Course University of Zagreb (Diploma Ultrasound) 1993: FKUI, S2 SpOG 1993: RSPAD, Divisi Fetomaternal 1993: Dosen FKUI, PPDS OBGIN 1993: Pengajar di PUSKI 1995: Dosen FK UPN Veteran 2009: Ketua PERISTI RSPAD 2009: Ketua Komite Medik KMC 2010: Anggota Komite Medik RSPAD 2010: Manajer Medik YMU Pav RSPAD 2010: PIC Tahap 2 PPDS OBGIN FKUI 2011: POKJA Akreditasi Internasional & BLU RSPAD Gatot Soebroto Ditkesad 2011: Pengajar Akbid Gunadarma 2011: Pengajar S2 Keperawatan Maternitas UI Organisasi: IDI, POGI, ISUOGJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan

Bandung, 7-1-19593

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Barang siapa mengamalkan apa-apa yang ia ketahui, maka Allah SWT akan mewariskan kepadanya ilmu yang belum diketahuinya, dan Allah SWT akan menolong dia dalam amalannya sehingga ia mendapatkan surga. Dan barang siapa yang tidak mengamalkan ilmunya, maka ia tersesat oleh ilmunya itu, dan Allah SWT tidak menolong dia dalam amalannya sehingga ia akan mendapatkan neraka (sabda Rasulullah Muhammad SAW) Ilmu lebih utama dari harta, ilmu adalah pusaka para Nabi, sedangkan harta adalah pusaka Karun atau Firaun. Ilmu lebih utama dari harta, karena ilmu akan menjagamu sementara harta malah engkau yang harus menjaganya. Ilmu lebih utama dari harta karena di akherat nanti pemilik harta akan dihisab, sedangkan orang berilmu akan memperoleh syafaat. Ilmu lebih utama dari harta karena pemilik harta bisa mengaku menjadi Tuhan akibat harta yang dimilikinya, sedangkan orang berilmu justru mengaku sebagai hamba Tuhan karena ilmunya. Harta itu jika engkau berikan menjadi berkurang, sebaliknya ilmu jika engkau berikan malahan semakin bertambah. Pemilik harta disebut dengan nama kikir dan buruk, tetapi pemilik ilmu disebut dengan nama keagungan dan kemuliaan. Pemilik harta itu musuhnya banyak, sedangkan pemilik ilmu temannya banyak. Harta akan hancur berantakan karena lama ditimbun zaman, tetapi ilmu tidak akan rusak dan musnah walau ditimbun zaman. Harta membuat hati seseorang menjadi keras, sedangkan ilmu malah membuat hati menjadi bercahaya. (hamba Allah) JJE-2011/12/07 5Hanya untuk Pendidikan & Kesehatan

BAHAN RENUNGANIUFD Cerebral Palsy THE MOST DO IT ! !

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INTRODUCTIONn

Prevalence : 1 / 8.000 5 / 1000births

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> 90% of CHD is found in the normal low risk population Screening is essential Well-trained sonographers + multiple cardiac views (3V, 4CV, 5CV) : detection of CHD 60 80%JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 7

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Ulrich G et al,Fetal Cardiology,2003

EMBRIOLOGY

Margaret LK et al, Fetal Cardiology, 2003

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Cornelia T, Fetal Cardiology, 2003

HEART ANATOMY

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FETAL CIRCULATIONn

Parallel arrangement of ventricular pumps : both left andright ventricle are perfusing systemic circulation

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Mixing of venous return High impedance and low flow in pulmonary circulation Presence of shunts : foramenJJE-2011/12/07

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ovale, ductus venosus, ductus arteriosusHanya untuk Pendidikan & Kesehatan 10

INDICATIONS : Targeted versus Routinen

Maternal risk factors Familial history Fetal

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MATERNAL RISK FACTORSn

Metabolic disorders : DM 3-5 x risk Exposure to teratogens : valproic acid, Rubella(especially in the first 6-8 W)

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Maternal heart disease : Tetralogy of Fallot(2%), left heart obstructive lesions (6-10%), AVSD (11-12%)

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Autoantibodies : anti Ro and or anti La which maycause A-V blockJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 12

FAMILIAL HISTORYn

Any previously affected child or fetus : recurrence 2%

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2 affected siblings : 10% The father affected : the risk for the offspring is2%

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The mother affected : the risk 10% History of single gene disorder : Noonan,Marfan, DiGeorgeJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 13

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FETALn

Suspicion of CHD on scan : 4-CV, 3-VV, 5-CV Fetal hydrops : 25% cardiac aetiology, mostlyarrhytmias

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Extracardiac malformations : NT and thepresence of exomphalos (30%)

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ArrhytmiasJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 14

90% OF CoHD IS FOUND IN THE NORMAL LOW-RISK POPULATION THEREFORE THE SCREENING IS ESSENTIAL !!JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 15

SCREENING

AT 20 - 22 WEEKS(optimum time, > 90% cases, 5 MHz)JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 16

TECHNICAL PREREQUISITEn n

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Gestational age Ultrasound transducer Gray scale presetting Zoom and cine-loop Color Doppler presettingJJE-2011/12/07 17


THE PROTOCOLn

2D ultrasound with cine-loop, zoom facilities, and high resolution transducers, 5 7 MHz 11 14 weeks :NT, Situs, FHR, 4-CV

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18 22 weeks (optimum : 20 22 W)JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 18

PLANES FOR THE FETAL CARDIAC EXAMINATIONn

Upper abdomen 4-CV 3-VV Great vessels : 5-CV and short axisJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 19

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ORIENTATION

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Getting Startedn

First, determine the situs. Define the right and left sides of the fetus Locate the fetal position Identify the fetal stomach (beware, it is not always on the left side) and other abdominal organs Verify the relationship of the fetal stomach to the fetal heart The apex of the heart should be on the leftJJE-2011/12/07

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Position of the Heart within the Chest1. 2. 3.

4. 5.

Identify the position of the fetus in utero Determine if the left side is up or down Identify the stomach and the heart to be on the left side Situs solitus : normal visceralsitus

Situs inversus : mirror image Situs ambiguous :

of the situs solitus, but stomach is on the left side anatomically undetermined type of visceral situs

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Cardiac apex point to the left (levocardia). In normal situs + dextrocardia : 95% CoHDJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 22

Normal Cardiac Axis

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Orientation of Sectionn n

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Locate the spine Opposite the spine is the anterior chest wall or sternum Below the sternum is the blunt ended RV The descending aorta is seen as a pulsatile circle in the mediastinum immediately anterior to the spine Related to the aorta anteriorly is the LA

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The RA and the LV may also identified MV is mobile and allows the LA to LV communications The tricuspid valve inserts onto the IVS, a little lower than MV and allows the RA to RV communication. The FO flap should be mobile and sees in LA The IVS is intact

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How to obtain the 4-CVn

Horizontal section of the fetal thorax just above diaphragm Obtained by scanning down, caudally from BPD. Easier to slide the transducer cranially from the AC view. A good trans-thoracic section with at least one whole rib present The stomach and the abdominal organs are not visible Left ventricular outflow tract (LVOT) not visibleJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 25

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Characteristic of the 4-CVn

Size : occupies one third of the fetal chest Position : cardiac axis is about 45o to the left Structure : Two atria of equal size (1:1) ,two ventricles of equal size (1:1), and intact crux

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Function : two opening atrioventricularJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan

valves and two equally contracting ventricles27

Normal 4-CVn

The internal surface of the left ventricle is smooth-looking compared with the trabeculated right ventricle containing the moderator band(MB in RV thicker than LV)

MB

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The RV lies under anterior chest wallJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 28

Normal 4-CVn

The two AV-valve meet at the junction of the inter-atrial and interventricular septa to form the crux of the heart. The mitral and tricuspid valves should move freely, with the tricuspid valve attached slightly more apicalJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan

APEX

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Normal 4-CVn

The appearance of the 4-CV will vary greatly according to the orientation of the fetus. FO protrudes into the left atrium The 3rd trimester features : - RV may be slightly larger than LV - Pulmonary artery > aortaJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 30

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Normal 4-CVn

Scanning up and down horizontally at the back of LA may reveal the pulmonary veins entering LA Views of fetal liver adjacent to RA common reveal IVC and hepatic vein entering RA with slight medial tilting SVC parallel with ascending aorta may also be located draining RA

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ISUOG GuidelineCardiac screening examination of the fetus: guidelines for performing the basic and extended basic cardiac scan

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http://www3.interscience.wiley.com/cgi-bin/fulltext/112221709/HTMLSTART33 Hanya untuk Pendidikan & Kesehatan JJE-2011/12/07

AIUM 2010

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AIUM 2010

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AIUM 2010

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ISUOG

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3-V (Triple Vessels)n n

Cranial to the 4-CV Pulmonary artery, ductus arteriosus, aorta, right pulmonary artery, superior vena cava (SVC) Pointers to abnormalities : dilatation of theaorta, pulmonary trunk or SVC; one of the two great arteries being small & the other being large; abnormal vessel alignment; abnormal vessel arrangement; only two vessels; additional vessels; right descending aorta; and abnormal origin of one pulmonary artery from the aorta JJE-2011/12/07 39 Hanya untuk Pendidikan & Kesehatan

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http://www3.interscience.wiley.com/cgi-bin/fulltext/112221709/HTMLSTARTJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 41

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3 VV

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The features of the outflow tractsn

Both the aorta and pulmonary outflow tracts are about the same size except at the pulmonary valve where the pulmonary artery is larger The pulmonary artery arises from the right ventricle and branches into 2 LPA and RPA, and the ductus arteriosus The aorta arises from the LV and gives rise to the arch with 3 vessels The aorta and pulmonary artery cross each other from where they originate Both the pulmonary and aortic valves should be seen

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http://www3.interscience.wiley.com/cgi-bin/fulltext/112221709/HTMLSTARTJJE-2011/12/07 45 Hanya untuk Pendidikan & Kesehatan

LVOT

http://www.aiu.edu.au/Images/aog1.jpg; 14-3-2011JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 46

LVOT

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http://www3.interscience.wiley.com/cgi-bin/fulltext/112221709/HTMLSTARTJJE-2011/12/07 48 Hanya untuk Pendidikan & Kesehatan

RVOT

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ISUOG

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ISUOG

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OUT FLOW TRACTS

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LVOT AND RVOT

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Sumber: ISUOG

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M-mode

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M- Mode abnormality

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Arhytmia


SVT

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THE 4-CV & ANOMALIESn

Standard assessment The most easily obtained Sensitivity and specificity :16% (Crane at al 1994) 99.7% (Coppel at al 1994)

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sensitivity of 40 50%

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Clues to abnormalities on the 4-CVn n

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Abnormal position of the heart Abnormal A-V connections, discordant connection, univentricular connections Cardiomegaly Asymmetrical chamber & valve size Atrial, ventricular, or atrioventricular defect Apical displacement of the septal leaflet of the tricuspid valve Abnormal pulmonary venous connections58 JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan

Clues to any abnormalities of outflow tractsn

Abnormal dilatation or narrowing of the aorta and pulmonary artery (seen on 3-V or outflow views) The ascending aorta is discordant in size with the descending aorta (arch view). This can occur with narrowing. 2 or 4 vessels seen in 3-V view VSD at the outlet septum (basal short axis view). Overriding aorta with VSD (outflow tract views) Discordant valves (basal short axis view)JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 59

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Abnormalities which may be detected in the 4-CV viewn

Hypoplastic LV (mitral &aortic stenosis)

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Hypoplastic RV(tricuspid & pulmonary atresia)

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Single ventricle (mitralatresia, tricuspid atresia, double outlet)

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AVSD Ebstein anomaly (TVdisplacement)JJE-2011/12/07

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Cardiomegaly

Large VSD Cardiac tumours Dextrocardia Situs inversus Ectopia cordis Cardiomyopathies Pericardial effusion Valvular atresia, stenosis, and insufficiency60


RVOT and LVOTPointers to abnormalities :n

Abnormal ventriculo-arterial connections, transposition, double outflow outlet right or left ventricle, and single arterial trunk VSD Overriding aorta or pulmonary trunk Abnormal dimension of the outflow tracts and / arterial valvesJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 61

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VSD (Ventricular Septal Defect)n

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Incomplete septation between LV and RV 0.4 2.7 per 1000 livebirths Most common CHD diagnosed in the 1st year of life 50% isolated & 50% part of a complex heart defect Classified based on locationJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 62

VSDn

Multiple cardiac views essential for correct diagnosis Diagnosis needs visualisation of dropout echoes in ventricular septum. Features of drop-out echoes : Largelyrestricted to the very thin part of ventricular septum; most marked when ultrasound beam strikes the septum obliques; and no associated with mal-alignmentJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 63

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Location of VSDn

Perimembraneous :

80% VSD, involve the membraneous septum below aortic valve, best seen on 4CV

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Inlet : on inflow tract of RV Trabecular : muscular partof septum, best seen on short axis view

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Outlet : infundibular portionof RVJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 64

VSD

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ASD (Atrial Septal Defect)n

2 types : primum (below FO) and secundum (above FO) Secundum ASD : more common & usually isolated 7% of CHD, 1 in 3000 births Prenatal diagnosis difficult due to physiological FOJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 66

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AVSDn

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Spectrum of lesions from complete AVSD to incomplete AVSD 0.1 0.5 per 1000 live births 60% association with chromosomal aberration In complete AVSD : absent

central core structures of the heart; and single valve opening into both ventricular chambersJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 67

HLHS (HYPOPLASTIC LEFT-HEART SYNDROME)n

Spectrum anomalieshypoplasia

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Characterised by : very small LV and mitral and / or aortic atresia /

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Associated with aortic coarctation, diaphragmatic hernia, and omphalocele Most ultrasound images are self explanatory Definitive diagnosis needs visualization of hypoplasia of ascending aorta and atresia of aortic valve Colour flow extremely helpful : no flow into LV

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CARDIOMEGALYn

The heart occupies > 1/3 of the fetal chest (CTR > 0,33%) CTR can be due to : - chest size (skeletal dysplasia oroligohydramnios)

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- heart size caused by abnormal inlet/ outlet valves ; abnormal great vessels ; functional disturbance (hydrops fetalis, arrhytmias, TTTS

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KARDIOMEGALI

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PERICARDIAL EFFUSIONn

Visible in multiple planes Minimum thicknes 2 mm Associated with chromosomal aberrations Extend across the A-V junction of the heartJJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 72

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DIAPHRAGMATIC HERNIAn

Congenital defect of the diaphragm with herniation of abdominal contents into the chest cavity Usually on the left side (75%) 8% of all major congenital abnormalities Earliest sign is the displacement of the heart to the right Antenatal diagnosis only 50%JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 73

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Tetralogy of Fallot

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BAHAN RENUNGANIUFD C Palsy THE MOST DO IT ! !

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THE FUTURE

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THANK YOU

Madinah..dokter haji 2006 UMROH 2010JJE-2011/12/07 78


Ekhokardiografi Janin

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