Jakub Malinowski, Maciej Słodki, Krzysztof Szaflik and Wanda Mikołajczyk-Wieczorek
We present a case of a female fetus with large posterior fossa cyst. After detailed diagnosis in referral center revealing normal heart anatomy and no functional abnormalities in cardiovascular system, a trial decompression of the fluid reservoir was suggested to the parents and successfully performed at the 30th week of pregnancy. Neurosurgical treatment was continued in the neonatal period. At the age of 7 months, the child presented normal physical development, and the cranial image of the CNS showed good recovery of the brain.
Iwona Strzelecka, Joanna Płużańska, Jerzy Węgrzynowski, Tomasz Moszura, Maciej Słodki and Maria Respondek-Liberska
Most heart defects form between 4 and 6 weeks after fertilization. The detection rate is still growing. Despite significant progress in prenatal diagnosis some cases still go undetected. We present two cases of similar defects: prenatally detected and undetected, both presenting with a normal four chamber view in mid-pregnancy. We compared the follow-up of both neonates along with sustained health and economic consequences. The dynamics of the development of heart defects during prenatal life suggests the legitimacy to perform additional, late echocardiography exams (35-38 weeks of gestation)
Congenital heart defect (CHD) is one of the most common type of fetal malformations. Tissue-Doppler imaging, dynamic threedimensional (4D) echocardiography and fetal cardiac magnetic resonance imaging (MRI) are advanced modalities for the assessment of cardiac structure and function. MRI can study the cardiac morphology using T2-weighted half-Fourier single-shot turbo spin-echo sequence (HASTE) and steady-state free precession (True FISP) sequences. Also a dynamic study can be performed, through the acquisition of cine-MR sequences with real-time steady-state free precession (SSFP) oriented according to the standard projections used in fetal echocardiographic scanning. If the challenges relating to motion and cardiac gating can be overcome, MRI has the potential to provide high-resolution imaging of the fetal heart.
Background: Inflammatory markers in prenatal ultrasound are a heterogeneous group of images that can evolve during pregnancy, due to regression or exacerbation of infection in pregnant women.
Objective:The assessment if effective rebalancing of the bacterial flora of the vagina can lead to withdrawal of the symptoms of inflammation in ultrasound examination (US).
Methods: A retrospective pilot study, among pregnant woman admitted to the Department of Prenatal Cardiology ICZMP in 2013-2014 in whom ultrasonographic signs of intrauterine infection were present. Electronic database were searched for key words ”infection, placentitis, tricuspid regurgitation, poly/oligohydramnion, IUGR, CRP, antibiotics, vaginal treatment”. The analysis included 238 patients, 30 received antibacterial vaginal treatment, from 27 patients a complete follow-up (control ultrasound after 10-14 days and data on labor) were obtained.
Results: The average age of patients was 29 years. In 22% of patients tricuspid regurgitation was observed and it was the most commonly recognized marker of infection. Regression of infection signs were observed in 21 patients (77.8%) after 2 weeks of vaginal treatment.
2 patients presented with ultrasound image stabilization, in 3 patients worsening of tricuspid regurgitation or cardiac hypertrophy were detected. Polyhydramnios, the second most common parameter (18.51% of patients) resolved after treatment in all studied patients. The delivery took place an average at 39th week of gestation (SD +/- 1.93).
Conclusions: Effective anti-inflammatory vaginal treatment improved ultrasound images in 21 out of 27 fetuses. These preliminary observations suggesting a beneficial role of the vaginal treatment on inflammatory markers in pregnancy ultrasound require further investigation.
Rafał Zieliński, Sebastian Foryś and Maria Respondek-Liberska
The rare anomalies diagnosed in prenatal ultrasonographic examination include Pierre-Robin sequence. The aim of the report was to demonstrate a well-documented case of Pierre-Robin sequence detected by ultrasonography at the 24th week of gestation, present the differentiation of Pierre-Robin sequence in the prenatal ultrasonography and to emphasize the importance of early sonographic diagnosis of the anomaly.
The prenatal diagnosis of Pierre-Robin sequence in prenatal ultrasonographic assessment is of great importance as it permits planning further course of pregnancy as well as EXIT procedure and postnatal treatment.
Maria Respondek-Liberska, Mark Sklansky, Dennis Wood, Maciej Słodki, Stuart Weiner, Bettina Cuneo, James C. Huhta, Ulli Gembruch, Giuseppe Rizzo, Gurleen Sharland, Reuven Achiron and Jay D. Pruetz
The first recommendations and guidelines for physicians training in fetal echocardiography (FE) were created in 1990 and later on up-dated by multiple medical associations and journals in Europe and the United States. This time advanced fetal cardiac ultrasound recommendations focused more on the organizational and logistical aspects of FE, to better define the fetal echo guidelines for practitioners in tertiary centers. Underlined is FE in 3rd trimester, with special attention to the direction of flow across the foramen ovale and ductus arteriosus.
AHA classification of heart defects in prenatal cardiology into seven major groups (from 2014) is presented as well as the Polish classification into four groups (from 2012) related to the urgency of required time to postnatal treatment/intervention based on FE findings in the 3rd trimester of pregnancy.
Current definition of fetal cardiologist in 2015 is also presented.
Diane E. Spicer, Maria Respondek-Liberska and Robert H. Anderson
The situation in which the bodily organs are “jumbled up”, frequently described in terms of visceral heterotaxy, was first brought to prominence by Ivemark, who emphasised the situation in terms of anatomy and development of the spleen. Putschar and Mannion then indicated that “between the normal situs, which is asymmetrical, and the situs inversus, which is the asymmetrical mirror-image of normality, a symmetrical situs sometimes exists, and this is the essence of bodily isomerism”.
In the setting of the congenitally malformed heart, however, the isomeric features are found uniformly only in the atrial appendages. To date, these such subtle features have largely been recognised at autopsy, but if specifically sought for, they should be identified by the echocardiographer, even when working in the prenatal setting.
The positive diagnosis of cardiac isomerism, therefore, depends on the recognition of isomeric atrial appendages. There is no evidence of isomerism at ventricular or arterial level. The relationship of the great vessels as they traverse the diaphragm, nonetheless, has been shown to be helpful in pointing to the need for more specific examination of the atrial appendages. When analysed on this basis, there can only be left or right isomerism, although the isomeric features are not always found uniformly throughout the bodily organs. Should there be disharmony between the systems, the specific findings should be described for each system, thus removing any suggestion of ambiguity.
The distinction between left and right isomerism is crucial for counselling, not only for immediate decisions regarding the progress of the pregnancy in question, but for future potential pregnancies. Distinguishing between pregnancies developing with right and left isomerism could also provide the key for determining the genes responsible for the production of laterality.
Iwona Gawron, Magdalena Borówka, Jacek Kołcz and Janusz H. Skalski
Thanks to recent progress in foetal imaging, it is now possible to detect many anatomical defects at earlier gestational age. To illustrate the importance of prenatal diagnosis and the impact of extracardiac congenital anomalies we presented the cases of sibling with prenatal diagnosis of hypoplastic left heart syndrome (HLHS) and post-mortem diagnosis of adrenal hypoplasia.
Prenatal diagnosis was made in one mother twice, in two subsequent pregnancies, respectively at 22 and 18 weeks gestational age. The mother-to-be was referred to specialist foetal echocardiography because of suspected image of the heart. After the diagnosis was made, future parents were thoroughly informed about prognosis and possible management and decided to continue pregnancy, and treat a newborn, despite the fact that the foetal defect was diagnosed subsequently. The two newborns underwent surgical treatment and no complications occurred during the surgery. The children died after Norwood operation among the symptoms of acute adrenal failure. In post-mortem examination of the younger, the severe adrenal hypoplasia was identified.
Prenatal diagnosis enables to make informed, conscious decisions at appropriate gestational age. Detection of congenital heart defect should incline an ultrasonographer towards searching for extracardiac lesions, which might significantly influence prognosis and surgical outcomes.
An example of missed Down syndrome with congenital heart defect by prenatal ultrasound evaluation was presented. A jury of 12 physicians, experts in prenatal ultrasonography and echocardiography were asked in questionare was this malpractice or not.
The answers were very different. The results of the questionaires were discussed with the background to the selected data from Eurocat, from Polish National Prenatal Cardiac Registry, from Polish Registry of Congenital Malformations by 2nd year of life, and financial data of the Polish Prenatal Program in Lodz Region.
Should we increase the cost of screening or the cost of ultrasound and echo training ? Or just provide patients with better knowledge regarding the differences between expertise of primary care obstetricians and experts in referral centers
Paulina Kordjalik, Beata Radzymińska-Chruściel, Maciej Słodki, Agata Włoch, Joanna Szymkiewicz-Dangel, Maria Respondek-Liberska and Zdzisław Tobota
As in every year since 2004, we analyzed data from the Polish National Registry for Fetal Cardiac Pathology to follow actual trends in types of congenital heart disease (CHD) and to assess the development of prenatal cardiology in Poland. Overall, the most frequent cardiac malformation detected prenatally in 2013 -2014, similar to the previous years, was hypoplastic left heart syndrome (HLHS). The average age of the examined fetuses was unchanged and remained above 20 weeks of gestation. An increased trend of detecting other cardiac malformations, such as transposition of the great arteries (d-TGA) and aortic stenosis (AS), and the predominance of vaginal deliveries over cesarean deliveries suggested significant improvements in prenatal and perinatal care in Poland.