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.

References

(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:

• Saving Lives With Ultrasound: How to Improve Placenta Accreta Spectrum Antenatal Detection and Management
• Pre-eclampsia, Growth Restriction, and a Placenta Bank
• Determining Umbilical Cord Blood Flow
• Dating Pearls