See a Need; Fill a Need

The Increasing Demand for the Detailed Fetal Echocardiogram & Specialization of the Fetal Cardiac Sonographer

With congenital heart defects (CHDs) continuing to lead the pack of anomalies resulting in infant mortality (1) the need for detailed cardiac screening of the developing fetal heart remains a pertinent and valuable tool for obstetrical providers and their patients.

Fetal echocardiography was derived for the purpose of improving antenatal detection rates of fetal cardiac defects. Identification of these in utero can initiate referrals to perinatology, genetic counseling, and pediatric cardiologists where parents can gain further insight about the suspected anomaly, as well as consult about any recommendations and/or expected outcomes. Timely diagnosis can provide the opportunity for a planned delivery at a tertiary center that is properly equipped to provide any necessary support and/or intervention the afflicted newborn may require.

While the basic evaluation of the heart remains part of the fetal anatomical survey (2), obtaining even the standard cardiac views continues to be a challenge in many cases, as adequate views are dependent on many factors including fetal position, maternal body habitus, and sonographer experience.

In order to provide you a visual of why imaging a fetal heart can pose such a challenge for sonographers, keep in mind that the fetal heart is roughly the size of a quarter (3) at 20 weeks of gestational age, which happens to be the timeframe of when most detailed anatomical surveys are attempted. Even more impressive is the fact that the pulmonary veins, whose anomalous drainage can be fatal if undetected prior to delivery, are comparable in size to Jefferson’s nose on the nickel. It has been my experience, if you ask any sonographer performing obstetrical exams which organ is the most difficult to assess on the anatomical survey, the fetal heart likely sits somewhere near the top of their list.

However, the demand for fetal echocardiography is expanding as the understanding of congenital heart disease continues to identify specific populations that have an increased risk of having a fetus with a CHD. (4) This lengthy list of indications for the fetal echocardiogram has historically been divided up into 2 main categories: maternal risk factors and fetal risk factors. As the number of indications for the exam continues to grow larger, so does the need to have highly trained and competent OB sonographers who go on to become certified in fetal echocardiography.

I must also point out that it is a necessity for all sonographers performing anatomical surveys to sharpen their skills at obtaining fetal cardiac images as even with the established indications, congenital heart defects continue to be the most missed anomaly on the prenatal screening sonogram. (5) This is a great example of why continuing education in the sub-specialty of fetal echo, as well as standardized protocols and training, is so important for all of us. Increasing prenatal detection rates of CHDs is a community effort that we can all contribute towards.

The challenge of deepening one’s understanding of fetal cardiac anatomy/physiology, and becoming more proficient at obtaining the detailed fetal echo views, remains an intimidating next-step for many OB sonographers. However, I personally invite those sonographers to face this challenge head-on, understanding that with experience and time, you’ll feel more confident and capable of completing a detailed fetal heart study with every fetal echo you perform.

Fetal echocardiography is a prime example of how something can be both extremely challenging and yet incredibly fulfilling at the same time. Detection of even the smallest cardiac defect in utero can later prove to have made a significant impact on the neonatal management of the newborn and positively impact infant mortality rates in the cases of more severe cardiac lesions. You may ultimately become a key factor in ensuring that your patients get the postnatal care that they require and deserve.


(1) Maulik D, Nanda N, Vilchez G. A brief history of fetal echocardiography and its impact on the management of congenital heart disease. Echocardiography 2017; 34:1760–1767.

(2) Pellerito J, Bromley BS, et al. AIUM-ACR-ACOG-SMFM-SRU Practice parameters for the performance of standard diagnostic obstetric ultrasound examinations. J Ultrasound Med 2018; 9999:1–12.

(3) Drose JA. Scanning: indications and technique. Fetal Echocardiography. Philadelphia, PA: Saunders; 1998:15–16.

(4) Wesley L, Anton T, et al. AIUM Practice parameter for the performance of fetal echocardiography. J Ultrasound Med 2020; 39:E5–E16.

(5) Abuhamad A, Chaoui R. Guidelines for the sonographic screening and Echocardiogram of the fetal heart. A Practical Guide to Echocardiography: Normal and Abnormal Hearts. 3rd ed. Wolters Kluwer; 2015:13.

Jaime Taylor-Fujikawa, BS, RDMS, RDCS, is a perinatal sonographer/fetal echocardiographer at The Center for Genetics and Maternal Fetal Medicine in Springfield, Oregon. She is a graduate of The Seattle University Diagnostic Ultrasound Program, class of 2005. She is a wife and mother to two boys.

Interested in learning more about Obstetric Ultrasound? Check out the following posts from the Scan:

From Sonographer to Ultrasound Practitioner: My Career Journey

I have been a sonographer for 18 years, and this year I was awarded Distinguished Sonographer at the 2018 AIUM Annual Convention. I can say without reservation that it is the biggest career honor that I have ever received and a moment that I will never forget. My path to becoming an Ultrasound Practitioner with a faculty appointment in the Department of Reproductive Medicine at UC San Diego has been rewarding, but it has not been easy. To be honest, I wasn’t always sure that I wanted to be a sonographer for more than a few years. I remember asking myself: Is this career as a sonographer enough or should I push myself further and go back to medical school? I have an incredible husband (who is also a sonographer) and he would have supported any choice I made, but ultimately – I decided not to pursue medical school. Even though I made that choice, I also told myself that there was nothing stopping me from learning as much as I could—my degree would not limit my potential and would not be what defines me.tantonheadshotblog

Since then, I have been studying the fetal heart A LOT. I enjoy all aspects of Maternal-Fetal Medicine (MFM) ultrasound, but the heart has always been an area of fascination for me. I love that it is both dynamic and complex, and, in my opinion, the most challenging aspect of fetal ultrasound. I have taken every opportunity to learn as much as I can from the incredible mentors that I have had the privilege of working with over the years. To this day, I am still learning, and I am amazed at all of the details we can see in these tiny little hearts! I eventually got the opportunity to cross train in pediatric echo and I jumped at that chance as well. I really enjoy being a part of a team of providers that can help the families affected by congenital heart disease.

I am, or I guess I should say I used to be, terrified of public speaking. I am proud of myself for overcoming this fear. Being in an academic center, I was used to teaching one on one, but it was about 8 years ago when I really pushed myself out of my comfort zone by lecturing to larger groups in the San Diego community. Putting together lectures can be time-consuming, difficult, and even stressful. I have spent many hours on weekends and evenings working on them, but I have also learned so much in the process. I started by speaking at local societies and hospitals, but over the years I have progressed and now I am proud to be invited to lecture at AIUM, SMFM, and other CME events around the country. Overcoming my fear of public speaking has been a huge stepping stone in my career and I love representing the sonographer voice on a larger platform.

So, how did I become a Practitioner with a faculty appointment?

I had a vision of how an Ultrasound Practitioner could function in our department. After all, by that point in my career, I was a seasoned MFM sonographer with 10 years of experience and I was still incredibly driven to learn and grow. I was keen to expand my skill set to function as a mid-level provider. Ultrasound Practitioner is not a new concept; SDMS had proposed a working model for an Ultrasound Practitioner in 2001. Dr. Beryl Benacerraf, among others, had already been successfully using an Ultrasound Practitioner for years. But working in a large academic center – my vision took years to bring to reality. I knew it would never happen if I didn’t continue to push for it. Along the way, I struggled, I questioned myself, I got overwhelmed, but I never gave up. I also had the support of some key physicians who believed in me. Their support was crucial to my eventual success.

I have now been an Ultrasound Practitioner for 6 years and as our department has grown to 8 ultrasound rooms, my role has expanded. Some of my responsibilities include: checking sonographers’ cases for quality and completeness, directing sonographers to get more images, obtaining images on difficult or complex cases, deeming the exam complete, writing preliminary reports, and discussing routine sonographic findings with patients. This working model frees up the physicians to spend more time with patients with abnormal findings and also allows the sonographers to keep moving with their schedules while ensuring quality patient care. Of course, this is only a snapshot of my day to day work, I still perform many of the fetal echocardiograms. I love to scan and I wouldn’t have it any other way.

My path to becoming a faculty member in the Department of Reproductive Medicine at UC San Diego was similar to my journey to becoming an Ultrasound Practitioner: it took time, lecturing nationally as well as teaching locally, coauthoring research papers and once again, having mentors who supported my appointment.

So, when people ask me about my success, I tell them it is because of hard work, persistence, believing in myself, and having mentors who believe in me too. My advice to sonographers is to know how important your role is; you are not “just a sonographer.” You should always keep learning, take pride in your work, and don’t be intimidated by the hierarchy of medicine. Our voice is crucial to the care of our patients, and that is really what matters.

Benacerraf BR, Bromley BS, Shipp TD, et al. The making of an advanced practice sonographer. J. Ultrasound Med 2003; 22:865–867.

Lockhart ME, Robbin ML, Berland LL, Smith JK, Canon CL, Stanley RJ. The sonographic practitioner: piece to the radiologist shortage puzzle. J Ultrasound in Med 2003; 22:861–864.

Bude RO, Fatchett AS, Lechtanski RT. The Use of Additionally Trained Sonographers as Ultrasound Practitioners. J Ultrasound Med 2006; 25:321–327

Society of Diagnostic Medical Sonography. Ultrasound Practitioner master’s degree curriculum and questionnaire: response by the SDMS membership. J Diagn Med Sonography 2001; 17:154–161.

How has ultrasound shaped your career? If you are an Ultrasound Practitioner, how did you get there? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 


Tracy Anton, BS, RDMS, RDCS, FAIUM, is an Ultrasound Practitioner with a faculty appointment in the Department of Reproductive Medicine at University of California, San Diego.