The cardiac echogenic focus

Correlation of prenatal sonographic diagnosis and morphologic findings of fetal autopsy in fetuses with trisomy 21

OBJECTIVE

The purpose of this study was to compare the prenatal sonographic and postmortem pathologic findings of fetuses with trisomy 21.

METHODS

Among 22,150 fetal chromosome analyses, trisomy 21 was diagnosed in 207 fetuses between 1990 and 2004. Findings of second-trimester sonography and fetal autopsy were compared by organ system, and their correlation was assigned to 1 of 3 categories.

RESULTS

In total, 83.1% of the 184 fetuses that constituted the final study group had 1 or more abnormal structural findings at postabortion pathologic examination, whereas in 16.9% of the cases, fetal pathologic examination did not reveal any defects in fetal anatomy. Among major structural defects, the agreement between sonographic and autopsy findings was greater than 60% of all abnormalities of these systems: central nervous system (65.4%), heart (67.4%), fetal hydrops (100%), and cystic hygroma (93.3%), whereas the concordance rate was lower in these organ systems: abdominal abnormalities (46.2%), renal anomalies (50%), facial abnormalities (1.2%), and extremities (4.4%). The rate of additional major findings at autopsy was 34.2%. These mainly involved 3 organ systems: heart, head, and abdominal anomalies. Some sonographic findings (n = 16) were not verified at autopsy. The concordances between sonographic and autopsy findings regarding soft markers were considerably high in these markers: increased nuchal fold thickness (72%), short femur/humerus (75%), and pyelectasis (51.9%).

CONCLUSIONS

Examining the correlation between sonography and pathologic findings may indicate possible directions of further development in sonographic screening for trisomy 21. In addition to obstetricians, pediatricians, and geneticists, specialized perinatal pathologists have an important role in the multidisciplinary management of prenatally diagnosed fetal malformations.

Clinical implications of the prenatal sonographic finding of fetal myocardial echogenic foci

OBJECTIVE

The purpose of this study was to investigate the clinical implications of fetal echogenic foci limited to the myocardium of the ventricular wall (EMF) or intraventricular septum detected during prenatal sonography.

METHODS

A retrospective review of fetuses found to have EMF during prenatal sonography from April 1990 through December 2003 was undertaken. Videotapes and reports were reviewed to determine the indication for sonography, gestational age, location, sonographic characteristics of the masses, and additional fetal findings. Sources of outcome data included neonatal and pediatric records and echocardiographic reports.

RESULTS

Five fetuses were identified. Indications for sonographic evaluation included fetal growth (n = 4) and follow-up twin-twin transfusion syndrome (n = 1). Mean gestational age +/- SD at diagnosis was 23.7 +/- 8.0 weeks (range, 17.1-36.4 weeks). The EMF identified were within the right ventricular myocardium (n = 2), intraventricular septum (n = 1), left ventricular myocardium (n = 1), and myocardium of the cardiac apex (n = 1). All foci appeared sonographically "bright as bone." The foci ranged in size from 0.1 x 0.1 to 1.2 x 0.9 cm. Neonatal echocardiographic findings were reported as normal for each of the cases. Follow-up examinations available for up to 2.5 years of age showed normal cardiac function.

CONCLUSIONS

The prenatal identification of EMF is unlikely to lead to notable short-term pathologic conditions because the fetuses in this investigation had unremarkable neonatal and pediatric echocardiograms and normal cardiac function.

Prenatal diagnosis of aneuploidy and deletion 22q11.2 in fetuses with ultrasound detection of cardiac defects

OBJECTIVE

We report a prospective database evaluation of the occurrence of aneuploidy and deletion 22q11.2 after prenatal detection of cardiac abnormalities. To ensure the maximum inclusion, all cardiac defects were considered, with the exception of echogenic intracardiac foci.

STUDY DESIGN

Prenatal specimens with ultrasound findings of cardiac defects were identified. Physicians were provided supplementary information that described the risk of deletion 22q11.2 syndrome if the karyotype was normal. On approval, fluorescence in situ hybridization was performed to identify the 22q11.2 microdeletion.

RESULTS

Prenatal detection of cardiac abnormalities identified aneuploidy or unbalanced chromosome rearrangements in 41% of the cases that were studied. In those fetuses with normal karyotypes, 3% had the deletion 22q11.2.

CONCLUSION

These results indicate that prenatal ultrasound findings of congenital heart defects identify fetuses who are at increased risk for chromosome abnormalities. Fetuses with normal karyotypes should consider having fluorescence in situ hybridization studies for the microdeletion 22q11.2 syndrome. Chromosome and fluorescence in situ hybridization studies of family members should be recommended when a fetus is identified as having the deletion 22q11.2.

Pathologic correlation of sonographic echogenic foci in the fetal heart

The goal of the current paper is to present, on the basis of six investigated fetal hearts, the pathological substrate of prenatally, sonographically diagnosed echogenic intramyocardial foci. The right ventricle, left ventricle, interventricular septum and papillary muscles of both ventricles of six hearts of the fetuses of high-risk pregnant women showing sonographically diagnosed intramyocardial echogenic foci were investigated. At termination of pregnancy all the women were between the 20th and the 24th week of gestation. Of the six cases, four were induced abortions and two were spontaneous abortions. For the control group we investigated the hearts of two fetuses without heart defects at the 22nd and 23rd week of gestation which had proven extracardial anomalies and a normal karyotype. Both cases were induced abortions which prenatally showed no echogenic cardiac foci. In all eight cases a prenatal karyotyping was performed. In the six cases with echogenic foci the location and number of the foci were determined both prenatally and by means of histologic sections; the size of the foci was measured as well. Histological staining was with routine haematoxylin-eosin; Masson-Goldner was used for connective tissue; Kossa for calcification; and Berlin blue for haemosiderin. Histologically, in all six cases, intramyocardial calcifications surrounded by fibrotic tissue were in: papillary muscle of the left ventricle in six cases; papillary muscle of the right ventricle in one case; and the subendocardial myocardium of the right ventricle in one case. Four cases had one, one case had two and one case had three calcified foci. Three cases had cardiac and two cases had extracardiac anomalies. Four cases had chromosome anomalies: two were trisomy 21, one trisomy 13 and one triploidy. The remaining two cases had a normal karyotype. No case showed pathological changes of the chordae tendinae, myocardial cell necrosis or inflammation. There were no patho-morphological differences between the intramyocardial calcifications of the papillary muscles in cases with chromosome anomalies and with normal karyotype. As the patho-morphological correlate of the sonographically diagnosed echogenic foci, histological investigation on all six fetal hearts showed coarse intramyocardial calcifications surrounded by myocardial fibrosis. Conventional histological methods gave no indication of the cause of the intramyocardial calcifications.