Ch. 27 The Fetal Heart and Chest

Question 1

The embryonic heart begins as _____ tubes. These two tubes ultimately fuse and fold to form into _____ chambers, two atria and two ventricles.

Answer 1

two; 4

Question 2

The heart begins to contract at __ to ___ days of gestation. It is initially recognized by its motion, which can be seen adjacent to the secondary ________, often before an embryo is distinguishable.

Answer 2

36 to 37; yolk sac

Question 3

A heart rate using _______ should be sonographically obtainable with endovaginal (EV) imaging when the crown rump length (CRL) measures __ to __ mm.

Answer 3

M-mode; 4 to 5

Question 4

a method of fetal monitoring with sonography to produce a numeric scoring system that predicts fetal well-being

Answer 4

biophysical profile

Question 5

During a biophysical profile assessment in the third trimester, an average fetal heart rate is _____ beats per minute (bpm), with a range of _____ to _____ bpm considered normal after the first trimester

Answer 5

150; 110 to 180 bpm

Question 6

An elevation in fetal heart rate is termed ________, whereas a decrease is referred to as _________

Answer 6

tachycardia; bradycardia

Question 7

The heart, which is fully formed by ___ weeks, is imaged most often in a cross-sectional or axial view of the fetal chest, just ______ the fetal stomach.The apex of the heart will be angled to the ______ of the midline, with the base closest to the spine.

Answer 7

10; above; left

Question 8

The normal fetal heart will fill approximately _______ of the fetal chest, with its apex forming a_______ angle with the fetal spine. The chamber closest to the fetal spine is the _____atrium. If it is suspected that the heart is enlarged, then a ____________ratio can be obtained.

Answer 8

one-third; 45-degree; left; cardio/thoracic diameter

Question 9

The four-chamber view can be used to evaluate the separation of the chambers, structures called _______. The two atria are separated by the _____ septum, and the two ventricles are separated by the ______ septum. The ventricular septum should be uninterrupted and of equal ________ to the left ventricular wall, whereas the atrial septum is open only at the __________

Answer 9

septums; atrial; ventricular; thickness; foramen ovale

Question 10

Within the _______can be seen the moderator band, a normal structure that appears as an echogenic focus. The _______ ventricle has much smoother walls compared to the right.

Answer 10

right ventricle; left

Question 11

Between the right ventricle and the right atrium, one should visualize the ______ valve, and between the left ventricle and the left atrium, the ______ valve should be noted. Normally, the ________valve is positioned closer to the cardiac apex than the mitral valve

Answer 11

tricuspid; mitral; tricuspid

Question 12

The right ventricular outflow tract leads to the ________ artery and branches, whereas the left ventricular outflow tract leads to the ______. One important anatomic finding is that the normal pulmonary artery should be positioned _______ to the aorta and should be visualized crossing over it. That means, the aorta and pulmonary artery normally ________each other.

Answer 12

pulmonary; aorta; anterior; crisscross

Question 13

The ________ places the main pulmonary artery, ascending aorta, and superior vena cava in the image. The ____ is used to detect abnormal vessel _____, abnormal vessel ______, abnormal ___________, and abnormal ________.

Answer 13

three-vessel view (3VV), 3VV, number, caliber, course or alignment of the vessels, flow

Question 14

The three-vessel trachea view (3VT) is used to evaluate the major vessels in the fetal mediastinum as well. In the 3VT, a “V” is formed by the merging of the transverse _____ arch and ______ and the ________trunk and _______ arteriosus. The 3VT is also used to assess the number, size, and alignment of the main pulmonary artery, aorta, and superior vena cava.

Answer 14

aortic, isthmus, pulmonary, ductus

Question 15

a fetal shunt that connects the umbilical vein to the inferior vena cava

Answer 15

ductus venosus

Question 16

an opening within the fetal heart within the atrial septum that allows blood to flow from the right atrium to the left atrium

Answer 16

foramen ovale (this closes to become the fossa ovalis

Question 17

a fetal shunt that connects the pulmonary artery to the aortic arch

Answer 17

ductus arteriosus

Question 18

The normal umbilical cord contains ____arteries and ____ vein.

Answer 18

2; 1

Question 19

The umbilical ______ brings oxygen-rich blood from the placenta to the fetus. It travels superiorly and connects to the _______portal vein. Half of the blood goes to the ____ through the left portal vein, whereas the other half is shunted directly into the inferior vena cava (IVC) via a small branch of the umbilical vein called the _______.

Answer 19

vein; left; liver; ductus venosus

Question 20

The blood that was taken to the liver is used to oxygenate the liver and is then returned back to the IVC by the ________

Answer 20

hepatic veins

Question 21

The existing oxygen-rich blood in the IVC travels up to the heart and enters the_______. Blood can then travel across the _______, an opening in the lower middle third of the atrial septum and into the left atrium, or it can enter the right ventricle through the _______ valve. The blood then leaves the right ventricle through the main ________. The main pulmonary artery bifurcates into right and left, thus allowing a small amount of blood to travel to the _________.

Answer 21

right atrium; foramen ovale; tricuspid; pulmonary artery; respective lung

Question 22

Blood from the right ventricle can flow through the _______and into the _______ aorta.

Answer 22

ductus arteriosus; descending

Question 23

The blood returning from the lungs through the pulmonary veins enters into the ____atrium. Blood then travels from the left atrium into the left ventricle via the ______ valve. From the left ventricle, it travels to the ________ aorta and into the aortic arch, where it exits into the _______ artery, ______ common carotid artery, and ______ subclavian artery on its way to the thorax, upper extremities, and head. The blood will return from the head and upper torso via the ________ to the ______ atrium.

Answer 23

left; mitral; ascending; brachiocephalic; left; left; superior vena cava; right

Question 24

The blood that flows through the ductus arteriosus and into the descending aorta travels inferiorly to either exit the abdomen via the ________ or travel to the abdomen and lower extremities to replenish those regions. Therefore, the ________ return the ________blood from the fetus back to the placenta.

Answer 24

umbilical arteries; umbilical arteries; deoxygenated

Question 25

Basic assessment of the fetal outflow tracts

1. The aortic outflow tract originates from the ______ ventricle.
   2.The pulmonary outflow tract originates from the ______ ventricle.
   3.The outflow tracts should be comparable in size.
   4.The ______ and the main pulmonary artery are perpendicular to each other because they exit their respective ventricles. They should be seen ______ and not lying in the same plane.

Answer 25

left; right; ascending aorta; crossing

Question 26

incomplete development of the left ventricle, resulting in a small or absent left ventricle

Answer 26

Hypoplastic left heart syndrome

Question 27

a chromosomal aberration where one sex chromosome is absent; may also be referred to as monosomy X

Answer 27

Turner syndrome

Question 28

abnormality in which there is a small or absent opening between the left ventricle and the aorta

Answer 28

Aortic atresia

Question 29

abnormal narrowing of the aortic valve

Answer 29

Aortic stenosis

Question 30

the narrowing of the aortic arch

Answer 30

Coarctation of the aorta

Question 31

_______ is the leading cause of cardiac death in the neonatal period, with 95% dying within the first month of life if surgery is not performed. This anomaly can be recognized on a ______-chamber heart view.

Answer 31

Hypoplastic left heart syndrome; four

Question 32

To distinguish this anomaly (Hypoplastic left heart syndrome) from complete absence of the left side of the heart, a small or normal ____ atrium must be visualized.

Answer 32

left

Question 33

When hypoplastic left heart syndrome(HLHS) found in girls, ______ syndrome should be suspected. There is also a connection with trisomy ______.

Answer 33

Turner; 18

Question 34

Sonographic Findings of _________

1.Absent or small left ventricle
2.No communication between the left atrium and the left ventricle
2.Aortic atresia (possibly)
3.Aortic stenosis (possibly)
4.Coarctation of the aorta (possibly)

Answer 34

Hypoplastic Left Heart Syndrome

Question 35

incomplete development of the right ventricle, resulting in a small or absent right ventricle

Answer 35

Hypoplastic right heart syndrome

Question 36

Hypoplastic right heart syndrome is also best visualized with the _____-chamber heart view. Hypoplastic heart syndrome most often results from pulmonary ______ or pulmonary ______, but it may result from stenosis or atresia of the _____ valve.

Answer 36

four; stenosis; atresia; tricuspid

Question 37

Sonographic Findings of _____

1.Absent or small right ventricle
2.Enlarged left ventricle
3.Fetal hydrops (secondary to cardiac failure)
3.Narrowing of the pulmonary valve

Answer 37

Hypoplastic Right Heart Syndrome

Question 38

the narrowing of the pulmonary valve

Answer 38

pulmonary stenosis

Question 39

the absence of the pulmonary valve, which, in turn, prohibits blood flow from the right ventricle into the pulmonary artery and essentially to the lungs

Answer 39

pulmonary atresia

Question 40

an abnormal accumulation of fluid in at least two fetal body cavities

Answer 40

fetal hydrops

Question 41

A ________ is an abnormal opening in the septum between the two ventricles of the heart. The _____ is the most common form of cardiac defect.

Answer 41

ventricular septal defect (VSD)

Question 42

This defect can be ____, seen in the presence of ______abnormalities, or associated with other ______anomalies, including tetralogy of Fallot, which is mentioned later in this chapter. _____can be used to identify the flow within and through the defect.

Answer 42

isolated; chromosomal; cardiac; Color Doppler

Question 43

a group of abnormalities consisting of an overriding aortic root, ventricular septal defect, pulmonary stenosis, and right ventricular hypertrophy

Answer 43

tetralogy of Fallot

Question 44

Sonographic Findings of _______

1.Absence of part of the ventricular septum
2.Color Doppler is helpful at detecting small defects

Answer 44

Ventricular Septal Defects

Question 45

Sonographic Findings of ______

1.Absence of part of the atrial septum
2.Color Doppler is helpful at detecting small defects

Answer 45

Atrial Septal Defects

Question 46

An ______ is an abnormal opening in the septum between the two atria of the heart . There are several different types (numbered 1-5) and an ASD can be isolated but may be found in the presence of various syndromes.

Answer 46

atrial septal defect (ASD)

Question 47

abnormal development of the central portion of the heart; also referred to as endocardial cushion defect

Answer 47

atrioventricular septal defect (AVSD)

Question 48

The combination of both ASD and VSD is termed _______or atrioventricular canal. An AVSD results from the abnormal development of the central portion of the heart.

Answer 48

atrioventricular septal defect (AVSD)

Question 49

The central portion of the heart is referred to as the “__________”; this is the reason why the AVSD may be referred to as an _________.

Answer 49

“endocardial cushion”; endocardial cushion defect

Question 50

AVSDs are commonly associated with aneuploidy, trisomy ___, and trisomy ___.

Answer 50

21; 18

Question 51

the malformation or malpositioning of the tricuspid valve that causes multiple heart defects

Answer 51

Ebstein anomaly

Question 52

the leakage of blood back through the tricuspid valve

Answer 52

tricuspid regurgitation

Question 53

abnormality in which the pulmonary artery arises from the left ventricle and the aorta arises from the right ventricle

Answer 53

transposition of the great vessels

Question 54

Malformation or malpositioning of the tricuspid valve results in _______.

Answer 54

Ebstein anomaly

Question 55

With this abnormality(Ebstein anomaly), the right ventricle is contiguous with the right atrium, a finding referred to as an “_______” right ventricle. This anomaly is associated with ______regurgitation, ASDs, tetralogy of Fallot, transposition of the great vessels, and coarctation of the aorta. The prognosis is poor, with 80% of infants dying in the perinatal period.

Answer 55

atrialized; tricuspid

Question 56

________ is the narrowing of the aortic arch. The most common location is between the ______ and the _______.

Answer 56

Coarctation of the aorta; left subclavian artery; ductus arteriosus

Question 57

Sonographic Findings of _______

1.Malpositioned tricuspid valve
2.Right and left atrial shunting
3.Tricuspid regurgitation
3.Enlarged right atrium
4.Deviation of the atrial septum to the left
5.Fetal hydrops (secondary to cardiac failure)

Answer 57

Ebstein Anomaly

Question 58

Sonographic Findings of _______

1.Narrowing of the aortic arch
2.Right ventricular enlargement
3.Pulmonary artery enlargement
4.disproportion in the size of the ventricles in the four-chamber view

Other common findings include patent ductus arteriosus and VSDs.

Answer 58

Coarctation of the Aorta

*Clue that differentiates coarctation of the aorta from hypoplastic left heart syndrome, is that the LV is apex forming in coarctation (look at image pg 671)

Question 59

________is defined as an overriding aortic root, subaortic VSD, pulmonary stenosis, and right ventricular hypertrophy. The right ventricular hypertrophy is not always noted in utero but rather manifests after birth.

Answer 59

Tetralogy of Fallot

Question 60

Sonographic Findings of ________

1.Overriding aortic root (defect where the aorta is positioned directly over a ventricular septal defect, instead of over the left ventricle.)
2.VSD
3.Pulmonary stenosis
4.Right ventricular hypertrophy

Answer 60

Tetralogy of Fallot

Question 61

With transposition of the great vessels, the outflow tracts are reversed. That means, the pulmonary artery abnormally arises from the ______, and the aorta abnormally arises from the ______.

Answer 61

left ventricle; right ventricle

Question 62

Often, the four-chamber view of the heart is ______ in the presence of transposition of the great vessels.

Answer 62

normal

Question 63

However, when the outflow tract images are obtained in a fetus with transposition, instead of the normal crisscross orientation of the outflow tracts, they will be positioned ____to each other, with the aorta noted ______ and to the right of the pulmonary artery

Answer 63

parallel; anterior

Question 64

Transposition of the great vessels, which may also be referred to as ________, has a good prognosis if it is discovered in utero, because corrective surgery can be performed shortly after birth.

Answer 64

transposition of the great arteries

Question 65

Sonographic Findings of _______

1.The pulmonary artery abnormally arises from the left ventricle, and the aorta abnormally arises from the right ventricle
2.The outflow tracts will be positioned parallel to each other rather than crisscrossing
3.VSD may be present

Answer 65

Transposition of the Great Vessels

Question 66

An echogenic intracardiac focus (EIF) is most often seen within the ______ ventricle of the heart. This is thought to represent the calcification of the _______ or chordae tendineae

Answer 66

left ventricle; papillary muscle

Question 67

paired muscles in both sides of the heart that hold in place either the mitral or tricuspid valves

Answer 67

papillary muscle

Question 68

tendons within the heart that attach the tricuspid valve in the right ventricle and the mitral valve in the left ventricle to their respective papillary muscle

Answer 68

chordae tendineae

Question 69

An EIF may be seen in the normal fetus. However, there have been studies that have linked the incidence of an EIF with trisomy ____, particularly if there is more than one EIF detected.

Answer 69

21

Question 70

Sonographic Findings of an _______

1.Echogenic structure most commonly located within the left ventricle (echogenicity comparable to that of fetal bone)

Answer 70

Echogenic Intracardiac Focus

Question 71

The most common fetal cardiac tumor is the _________.It is associated with ________.

Answer 71

rhabdomyoma; tuberous sclerosis

*they are also associated with eventual cardiac failure, and subsequent development of fetal hydrops

Question 72

a fetal heart tumor found within the myocardium

Answer 72

rhabdomyoma

Question 73

a systemic disorder that leads to the development of tumors within various organs

Answer 73

tuberous sclerosis

Question 74

Sonographic Findings of a _______

Echogenic tumor(s) within the myocardium of the heart (can be isolated or multiple)

Answer 74

Rhabdomyoma

Question 75

__________ is fluid located around the heart. This condition can be isolated or associated with fetal hydrops

Answer 75

Pericardial effusion

Question 76

when pericardial fluid is suspected the sonographer should evaluate the fetus closely for other signs of ________, such as ascites and pleural effusion

Answer 76

fetal hydrops

Question 77

a condition in which the heart is located either partially or completely outside the fetal chest

Answer 77

ectopic cordis

Question 78

a group of anomalies that include an omphalocele, along with ectopic cordis, cleft sternum, anterior diaphragmatic defect, and pericardial defects

Answer 78

Pentalogy of Cantrell

Question 79

an anterior abdominal wall defect where there is herniation of the fetal bowel and other abdominal organs into the base of the umbilical cord

Answer 79

omphalocele

Question 80

a test of the amniotic fluid that predicts fetal lung maturity

Answer 80

lecithin-to-sphingomyelin ratio (L/S ratio)

Question 81

With ________, the heart is located either partially or completely outside the chest. _________is a group of anomalies that combine ectopic cordis and an existing omphalocele. The prognosis is poor.

Answer 81

ectopic cordis; Pentalogy of Cantrell

Question 82

The lungs develop in early embryogenesis. However, functional fetal lung tissue does not typically exist until after _____weeks.

Answer 82

25

Question 83

Fetal lung maturity can be assessed using the _______. An amniocentesis is performed for this test, and the laboratory findings indicate the levels of lecithin and sphingomyelin within the amniotic fluid. Normally, as the lungs mature, the level of lecithin ______, whereas the level of sphingomyelin _______

Answer 83

lecithin-to-sphingomyelin ratio (L/S ratio); increases; decreases

Question 84

_________, or underdevelopment of the lungs, is caused by a decreased number of lung cells, airways, and alveoli. ___________ is often associated with major structural and chromosomal abnormalities.

Answer 84

Pulmonary hypoplasia

Question 85

The most common lesion that occupies the chest, resulting in pulmonary hypoplasia, is the ___________.

Answer 85

diaphragmatic hernia

Question 86

Amniotic fluid plays an important role in the development of the fetal lungs; therefore, the fetus, surrounded by ____or ___ amniotic fluid, is at increased risk of pulmonary hypoplasia. Consequently, pulmonary hypoplasia is a common finding with ________

Answer 86

little or no,oligohydramnios

Question 87

the herniation of the abdominal contents into the chest cavity through a defect in the diaphragm

Answer 87

diaphragmatic hernia

Question 88

the sonographic appearance of a fetal unilateral pleural effusion

Answer 88

“bat-wing” sign

Question 89

a procedure that uses a needle to drain fluid from the pleural cavity for either diagnostic or therapeutic reasons

Answer 89

thoracentesis

Question 90

Sonographic Findings of a ________

1.Anechoic fluid surrounding the fetal lung(s)—“bat-wing” sign
2.Other signs of hydrops may be present

Answer 90

Pleural Effusion

Question 91

Fluid surrounding the lungs is referred to as a ______ or _______. __________that occur in utero may spontaneously resolve or may be found in the presence of fetal hydrops, other chest abnormalities, and Turner syndrome. They can be unilateral or bilateral

Answer 91

pleural effusion or hydrothorax; pleural effusions

Question 92

Fetal pleural effusions can be treated with an ultrasound-guided __________

Answer 92

thoracentesis

Question 93

a mass consisting of abnormal bronchial and lung tissue that develops within the fetal chest

Answer 93

Cystic adenomatoid malformation (CAM)

Question 94

a separate mass of nonfunctioning lung tissue with its own blood supply

Answer 94

pulmonary sequestration

Question 95

_____________, also referred to as congenital cystic adenomatoid malformation (CCAM), is actually a mass consisting of abnormal bronchial and lung tissue. Although there are three types (types 1 to 3), a common sonographic appearance of CAM is that of a mass that has both ______ and ______ components. However, it can also appear completely echogenic (type 3) and, therefore, sonographically similar to __________

Answer 95

Cystic adenomatoid malformation (CAM); cystic and solid; pulmonary sequestration

Question 96

Most CAMs are _______ and may resolve spontaneously, although large masses can lead to fetal hydrops and carry a poor prognosis.

Answer 96

unilateral

Question 97

Sonographic Appearance of ______________

1.Lung mass with varying degrees of cystic and solid components
2.Completely echogenic mass within the lungs
2,Pleural effusion may be present

Answer 97

Cystic Adenomatoid Malformations

Question 98

______________ ,or bronchopulmonary sequestration, is a separate mass of nonfunctioning lung tissue with its own blood supply. The fetal form of this disease is specifically referred to as extrapulmonary sequestration, which denotes its location.

Answer 98

Pulmonary sequestration

Question 99

The most common sonographic appearance of pulmonary sequestration is an _____, triangular-shaped mass, typically located within the _______ side of the fetal chest. Pulmonary sequestration may resolve spontaneously or lead to the development of fetal hydrops.

Answer 99

echogenic; left

Question 100

Sonographic Findings of ________

1.Echogenic, triangular-shaped mass within the fetal chest
2.Pleural effusion may be present

Answer 100

Pulmonary Sequestration

Question 101

The most common reason for fetal cardiac malposition is the existence of a _________.

Answer 101

diaphragmatic hernia.

Question 102

A diaphragmatic hernia results in an abnormal opening in the fetal ________ that allows the herniation of abdominal contents into the chest cavity. The most common location of a diaphragmatic hernia is on the _______side. This type may also be referred to as a Bochdalek hernia.

Answer 102

diaphragm; left

Question 103

the herniation of abdominal contents into the chest cavity because of an opening in the left posterolateral portion of the diaphragm

Answer 103

Bochdalek hernia

Question 104

an opening located in the left posterolateral portion of the diaphragm

Answer 104

foramen of Bochdalek

Question 105

The _________ is located in the left posterolateral portion of the diaphragm.

Answer 105

foramen of Bochdalek

Question 106

The __________, which is located right anteromedially within the diaphragm, may lead to a ______-sided diaphragmatic hernia, thus allowing the entire liver to herniate into the chest

Answer 106

foramen of Morgagni; right

Question 107

an opening located right anteromedially within the diaphragm

Answer 107

foramen of Morgagni

Question 108

Diaphragmatic hernias that are located on the _______ side may be more difficult to diagnose, given the similar echogenicity of the fetal lungs and fetal liver.

Answer 108

right

Question 109

One differential diagnosis of a diaphragmatic hernia is ________, which is a lack of muscle in the dome of the diaphragm. This will have a similar sonographic appearance to a diaphragmatic hernia and can, therefore, be difficult to distinguish sonographically.

Answer 109

eventration of the diaphragm

Question 110

lack of muscle in the dome of the diaphragm

Answer 110

eventration of the diaphragm (*Diaphragm located to high)

Question 111

Sonographic Findings of a ________

1.Malposition of the heart
2.Anechoic stomach bubble noted adjacent to the fetal heart in the four-chamber heart view
3.Other abdominal organs, including the liver, pancreas, and spleen, may be located within the chest

*Often, sagittal and coronal imaging at the level of the diaphragm can be helpful to confirm this abnormality.

Answer 111

Diaphragmatic Hernia

Question 112

The ________ gland is located anterior to the mediastinum. It is part of the ________ system because it provides a place for the maturation of ___ cells, which are specialized white blood cells.

Answer 112

thymus; immune; T

Question 113

The thymus sonographically, it appears as a _______structure located in the _______ chest at the level of the sternum between the lungs.

Answer 113

hypoechoic; anterior

Question 114

a genetic disorder characterized by an absent or hypoplastic thymus, which ultimately leads to impairment of the immune system and susceptibility to infection, as well as cognitive disorders, congenital heart defects, palate defects, and hormonal abnormalities

Answer 114

DiGeorge syndrome

Question 115

The fetal heart is fully formed by _____

Answer 115

10wks

Question 116

The blood returning from the lungs through the pulmonary veins enters into the:
a. right atrium
b. left atrium
c. right ventricle
d. left ventricle

Answer 116

left atrium