Echogenic intracardiac focus: potential for misdiagnosis

Antenatal imaging: A pictorial review

Today, in parallel with the use of imaging modalities increases in all fields, the use of imaging methods in pregnant women is increasing. Imaging has become an integral component of routine pregnancy follow-up. Imaging provides parents with an early opportunity to learn about the current situation, including prenatal detection of anomalies or diseases, etiology, prognosis, and the availability of prenatal or postnatal treatments. Various imaging modalities, especially ultrasonography, are frequently used for imaging both maternal and fetal imaging. The goal of this review was to address imaging modalities in terms of usefulness and safety, as well as to provide demonstrative examples for disorders. And this review provides current information on selecting a safe imaging modality to evaluate the pregnant and the fetus, the safety of contrast medium use, and summarizes major pathological situations with demonstrative sonographic images to assist radiologists and obstetricians in everyday practice.

Society for Maternal-Fetal Medicine Consult Series #57: Evaluation and management of isolated soft ultrasound markers for aneuploidy in the second trimester: (Replaces Consults #10, Single umbilical artery, October 2010; #16, Isolated echogenic bowel diagnosed on second-trimester ultrasound, August 2011; #17, Evaluation and management of isolated renal pelviectasis on second-trimester ultrasound, December 2011; #25, Isolated fetal choroid plexus cysts, April 2013; #27, Isolated echogenic intracardiac focus, August 2013)

Soft markers were originally introduced to prenatal ultrasonography to improve the detection of trisomy 21 over that achievable with age-based and serum screening strategies. As prenatal genetic screening strategies have greatly evolved in the last 2 decades, the relative importance of soft markers has shifted. The purpose of this document is to discuss the recommended evaluation and management of isolated soft markers in the context of current maternal serum screening and cell-free DNA screening options. In this document, "isolated" is used to describe a soft marker that has been identified in the absence of any fetal structural anomaly, growth restriction, or additional soft marker following a detailed obstetrical ultrasound examination. In this document, "serum screening methods" refers to all maternal screening strategies, including first-trimester screen, integrated screen, sequential screen, contingent screen, or quad screen. The Society for Maternal-Fetal Medicine recommends the following approach to the evaluation and management of isolated soft markers: (1) we do not recommend diagnostic testing for aneuploidy solely for the evaluation of an isolated soft marker following a negative serum or cell-free DNA screening result (GRADE 1B); (2) for pregnant people with no previous aneuploidy screening and isolated echogenic intracardiac focus, echogenic bowel, urinary tract dilation, or shortened humerus, femur, or both, we recommend counseling to estimate the probability of trisomy 21 and a discussion of options for noninvasive aneuploidy screening with cell-free DNA or quad screen if cell-free DNA is unavailable or cost-prohibitive (GRADE 1B); (3) for pregnant people with no previous aneuploidy screening and isolated thickened nuchal fold or isolated absent or hypoplastic nasal bone, we recommend counseling to estimate the probability of trisomy 21 and a discussion of options for noninvasive aneuploidy screening through cell-free DNA or quad screen if cell-free DNA is unavailable or cost-prohibitive or diagnostic testing via amniocentesis, depending on clinical circumstances and patient preference (GRADE 1B); (4) for pregnant people with no previous aneuploidy screening and isolated choroid plexus cysts, we recommend counseling to estimate the probability of trisomy 18 and a discussion of options for noninvasive aneuploidy screening with cell-free DNA or quad screen if cell-free DNA is unavailable or cost-prohibitive (GRADE 1C); (5) for pregnant people with negative serum or cell-free DNA screening results and an isolated echogenic intracardiac focus, we recommend no further evaluation as this finding is a normal variant of no clinical importance with no indication for fetal echocardiography, follow-up ultrasound imaging, or postnatal evaluation (GRADE 1B); (6) for pregnant people with negative serum or cell-free DNA screening results and isolated fetal echogenic bowel, urinary tract dilation, or shortened humerus, femur, or both, we recommend no further aneuploidy evaluation (GRADE 1B); (7) for pregnant people with negative serum screening results and isolated thickened nuchal fold or absent or hypoplastic nasal bone, we recommend counseling to estimate the probability of trisomy 21 and discussion of options for no further aneuploidy evaluation, noninvasive aneuploidy screening through cell-free DNA, or diagnostic testing via amniocentesis, depending on clinical circumstances and patient preference (GRADE 1B); (8) for pregnant people with negative cell-free DNA screening results and isolated thickened nuchal fold or absent or hypoplastic nasal bone, we recommend no further aneuploidy evaluation (GRADE 1B); (9) for pregnant people with negative serum or cell-free DNA screening results and isolated choroid plexus cysts, we recommend no further aneuploidy evaluation, as this finding is a normal variant of no clinical importance with no indication for follow-up ultrasound imaging or postnatal evaluation (GRADE 1C); (10) for fetuses with isolated echogenic bowel, we recommend an evaluation for cystic fibrosis and fetal cytomegalovirus infection and a third-trimester ultrasound examination for reassessment and evaluation of growth (GRADE 1C); (11) for fetuses with an isolated single umbilical artery, we recommend no additional evaluation for aneuploidy, regardless of whether results of previous aneuploidy screening were low risk or testing was declined. We recommend a third-trimester ultrasound examination to evaluate growth and consideration of weekly antenatal fetal surveillance beginning at 36 0/7 weeks of gestation (GRADE 1C); (12) for fetuses with isolated urinary tract dilation A1, we recommend an ultrasound examination at ≥32 weeks of gestation to determine if postnatal pediatric urology or nephrology follow-up is needed. For fetuses with urinary tract dilation A2-3, we recommend an individualized follow-up ultrasound assessment with planned postnatal follow-up (GRADE 1C); (13) for fetuses with isolated shortened humerus, femur, or both, we recommend a third-trimester ultrasound examination for reassessment and evaluation of growth (GRADE 1C).

Effectiveness of Chromosomal Microarray Analysis for Prenatal Diagnosis of Fetal Echogenic Intracardiac Focus: A Single-Center Experience

BACKGROUND

Echogenic intracardiac focus (EIF) is a common ultrasound finding during pregnancy. However, the correlation between fetal EIF and cardiac abnormality remains in dispute until now. The study aimed to examine the association of fetal EIF with chromosomal abnormality by means of chromosomal microarray analysis (CMA).

MATERIALS AND METHODS

A total of 192 pregnant women with fetal EIF undergoing amniocentesis or umbilical cord blood puncture were recruited and assigned into groups A (8 cases with isolated EIF alone), B (75 cases with EIF and other cardiac malformations) and C (109 cases with EIF and extracardiac malformations). All fetuses underwent karyotyping analysis and CMA simultaneously. The detection of chromosomal abnormality and copy number variations (CNVs) were compared.

RESULTS

Chromosomal karyotyping identified 5 fetuses with chromosomal abnormality, including 3 cases with trisomy 21, one fetus with Turner's syndrome, and one fetus with chromosome 8 mosaicism, while CMA detected 6 additional fetuses with CNVs, including 2 fetuses with pathogenic CNVs and 4 fetuses with variants of uncertain significance (VOUS). There was no significant difference among groups A (0), B (5.33%) and C (6.42%) in terms of the prevalence of chromosomal abnormality (P> 0.05). Among the 4 fetuses with VOUS, pregnancy continued in 2 fetuses, and pregnancy was terminated in other 2 fetuses.

CONCLUSION

An isolated EIF may not correlate with chromosomal abnormality. However, CMA is recommended in fetuses with CMA complicated by other abnormal cardiac ultrasound findings, which facilitates the prediction of fetal outcomes during the genetic counseling and precision assessment of prognosis.

Follow-up of sonographically detected soft markers for fetal aneuploidy

Sonographic soft markers of fetal Down syndrome were first reported in the 1980s. With improvements in aneuploidy screening, detection rates of 90% and higher are possible, and such screening is offered to women of all ages. The utility of sonographic detection and reporting of soft markers, particularly to women at low risk of fetal aneuploidy, is controversial. Some soft markers have no additional significance beyond an association with aneuploidy, while some potentially indicate other pathology, and therefore require sonographic follow-up or other evaluation. The definitions of soft markers vary among reported series, and any practice using such markers to adjust the risk of aneuploidy should carefully determine the most appropriate definitions as well as likelihood ratios and how to apply these in practice.

Echogenic focus in the fetal left ventricular cavity: is it a false tendon?

OBJECTIVE

To draw attention to the left ventricular false tendon which can be misinterpreted as echogenic focus in the fetus.

METHODS

The study group consisted of 9 fetuses out of the 161 who had been misdiagnosed for left ventricular false tendon as echogenic focus by obstetricians. Fetal echocardiography and 2-D color Doppler echocardiography were performed in the pre-postnatal period. The standard fetal echocardiographic views (4,5 chamber views, long axis view of the left ventricle, short axis view of the ventricles and great arteries, three vessels and trachea view, long axis views of the duct and aortic arch) were obtained for each case.

RESULTS

Of the 161 fetuses with echogenic focus in the left ventricle which underwent fetal echocardiography, 9 (5.6%) were diagnosed with false tendons present in the left ventricular cavity with no other cardiovascular anomaly. Six out of 9 patients underwent amniocentesis as follows: for age of over 35 years (two patients), abnormal double-triple screening tests plus echogenic focus (two patients) and soft ultrasonographic markers including echogenic focus (two patients). These fetuses revealed no cardiovascular and other systemic pathology or dysmorphism except for false tendons in the left ventricular cavity.

CONCLUSION

False tendon should be taken into account as differential diagnosis of left ventricular echogenic focus in the fetus. Misinterpretation of false tendon as echogenic focus may cause unnecessary fetal invasive approach and maternal anxiety, especially when it arises with a background of borderline fetal findings and knowledge.

The history of the second-trimester sonographic markers for detecting fetal Down syndrome, and their current role in obstetric practice

This review summarizes the development, history and use of second-trimester sonographic markers for the detection of fetal Down syndrome over three decades. Starting with the nuchal fold thickening in 1985 and culminating in the genetic sonogram in the 1990 s. The combination of second-trimester serum screening with the ultrasound markers improved the detection rate of affected fetuses but also allowed patients to decrease their risk of carrying a fetus with Down syndrome if the genetic sonogram was normal. More recently the role of the genetic sonogram and its markers have changed with the wide spread use of first-trimester screening. This prior screening ultimately decreases the prevalence of fetal Down syndrome in the second trimester to less than 85% of what it was in the first-trimester as most fetuses with Down syndrome are now identified early. Current interpretation of the second-trimester Down syndrome markers must be based on the result of the first trimester and combined screening to achieve the most accurate risk estimate of an affected fetus.

Morphogenetic aspects of the septomarginal trabecula in the human heart

INTRODUCTION

The septomarginal trabecula is a constant element of the anatomy of the human heart, which connects the interventricular septum and the anterior wall of the right ventricle. Considering the diversity of opinions about the structure and numerous studies suggesting its important role in haemodynamics and conduction of electrical impulses in the heart, we decided to study this element in detail.

MATERIAL AND METHODS

The research was conducted on 220 human hearts. Attention was mainly paid to the structure and topography of the trabecula. Its relation to the anterior papillary muscle was also a part of the study.

RESULTS

The presence of this morphologically diverse element was confirmed in each of the studied hearts. In most cases the trabecula originated from the upper part of the interventricular septum, separating at an angle increasing proportionally to the number of branches of the crista supraventricularis as well as the number of secondary trabeculae. The criteria established for the study, which included the course of the trabecula in the lumen of the right ventricle and its relation to the anterior papillary muscle, let us distinguish 4 types of septomarginal trabecula (I, II, III, IV). The most common was type III, the undivided trabecula, tightly connecting with the anterior papillary muscle.

CONCLUSIONS

Based on the results of the following study we propose a hypothesis on the genesis of respective parts of the septomarginal trabecula and a plausible sequence of changes they undergo during human ontogenesis and phylogenesis of the primates.

Isolated choroid plexus cyst or echogenic cardiac focus on prenatal ultrasound: is genetic amniocentesis indicated?

OBJECTIVE

The purpose of this study was to determine whether or not genetic amniocentesis is warranted when isolated choroid plexus cysts (CPC) or echogenic cardiac foci (EF) are noted on prenatal ultrasound.

STUDY DESIGN

We performed a retrospective analysis on patients from our perinatal database. All obstetric patients with CPC or EF noted on second-trimester perinatology ultrasound from April, 1998 to November, 2004 were included. Information regarding ultrasound findings and neonatal outcome were analyzed.

RESULTS

During the study period, 515 patients with CPC or EF were evaluated. Of these, 429 (83.3%) had isolated CPC or EF and 86 (16.7%) had additional risk factors. The incidence of abnormal karyotype was 0 versus 2.3%, respectively (P = .03). The additional risk factors considered were: advanced maternal age, abnormal serum triple marker screening, and/or other abnormal ultrasound findings. Furthermore, during the study period there were 20,122 live births and 27 (0.1%) cases of aneuploidy diagnosed postnatally. Of these, none had isolated CPC or EF on prenatal ultrasound.

CONCLUSION

CPC or EF noted on prenatal ultrasound warrants referral for careful consultative ultrasound evaluation. In the absence of other risk factors, however, genetic amniocentesis for isolated CPC or EF does not appear to be necessary.

Isolated fetal intracardiac hyperechogenic focus associated with neonatal outcome and triple test results

OBJECTIVE

To investigate the relationship between isolated intracardiac hyperechogenic focus (IHF) in the mid trimester of pregnancy with neonatal outcomes and triple test results.

MATERIALS AND METHODS

The study included low-risk pregnant women who came for routine follow-up to our antenatal clinic between years 2000 and 2005. A detailed structural survey by ultrasound (USG) of the fetal heart was performed on each fetus in the mid-trimester of pregnancy. All patients had mid-trimester triple tests performed between the 16th and 18th weeks' of pregnancy. We recruited a total of 40 pregnancies that had fetal IHF in the level II USG examination and a control group of 100 healthy pregnant women those which were followed-up during the same period. Twenty-nine fetuses (72.5%) had left, 8 (20%) had right whereas 3 (7.5%) had bilateral ventricular IHF. We compared the perinatal and neonatal outcomes and triple test results of the fetuses that had right and left IHF, and the controls.

RESULTS

Cytogenetic amniocentesis was performed to 6 (15%) women in the study and 5 (5%) in the control group and all were normal. During follow-up IHF spontaneously disappeared in 30 fetuses [right (n: 5), left (n: 23) or bilateral (n: 2)]. We did not observe any cardiac problem in the postnatal period in all newborns. Only one infant (2.5%) in the study group was admitted to neonatal intensive care unit because of prematurity. Median delivery weeks (P = 0.023), head circumference (P = 0.013), 5-min Apgar score (P = 0.021] and apnea (P = 0.042) were significantly higher in fetuses with right IHF. Compared to the controls, median delivery weeks (P = 0.038) was significantly higher in fetuses with right IHF, but head circumference (P = 0.004), 1-min (P = 0.003) and 5-min (P < 0.001) Apgar scores were lower in fetuses with left IHF. However no difference was observed in second-trimester serum human chorionic gonadotropin (HCG), alpha-fetoprotein (AFP) and estriol (E(3)) levels, in the three groups. There was no correlation between serum HCG, AFP and E(3) levels and the presence of IHF.

CONCLUSIONS

Isolated IHF in the fetal heart in the mid-trimester of pregnancy seems not associated with adverse neonatal outcome and does not correlate with triple test results.

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.

Influence of Fetal Heart Orientation on the Sonographic Identification of an Echogenic Intracardiac Focus in the Left Ventricle

The objective of this study was to compare the ability to visualize an echogenic intracardiac focus (EIF) of the left ventricle in four different cardiac projections. One hundred seventeen fetuses at 15 to 24 weeks’ gestation with a known EIF were rescanned in at least one longitudinal cardiac plane (apical or basilar) and one lateral plane (left or right lateral). An EIF was recorded as present if an intensely bright focus was visualized within the left ventricle. An EIF was identified in 100% (111/111) of apical views, 49.2% (29/59) of left lateral views, 46.8% (29/62) of right lateral views, and 100% (12/12) of basilar views. An EIF was seen in 100% of longitudinal views compared with 48.7% of lateral views ( P < .001). It was concluded that an EIF is more consistently seen from the apical and basilar views than from the right or left lateral views of the fetal heart. A longitudinal view of the heart is required to truly rule out an EIF.