Department of Obstetrics and Gynecology Gatot Soebroto Army Central and Teaching Hospital School of Medicine, UPN - Jakarta 7 Desember 2011
MATERI AJAR INI HANYA UNTUK DIPERGUNAKAN PADA KEGIATAN PENDIDIKAN DAN KESEHATAN
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 2
Bandung, 7-1-1959
3
JJE-2011/12/07
Barang siapa mengamalkan apa-apa yang ia ketahui, maka Allah SWT akan mewariskan kepadanya ilmu yang belum diketahuinya, dan Allah SWT akan menolong dia dalam amalannya sehingga ia mendapatkan surga. Dan barang siapa yang tidak mengamalkan ilmunya, maka ia tersesat oleh ilmunya itu, dan Allah SWT tidak menolong dia dalam amalannya sehingga ia akan mendapatkan neraka (sabda Rasulullah Muhammad SAW) Ilmu lebih utama dari harta, ilmu adalah pusaka para Nabi, sedangkan harta adalah pusaka Karun atau Firaun. Ilmu lebih utama dari harta, karena ilmu akan menjagamu sementara harta malah engkau yang harus menjaganya. Ilmu lebih utama dari harta karena di akherat nanti pemilik harta akan dihisab, sedangkan orang berilmu akan memperoleh syafaat. Ilmu lebih utama dari harta karena pemilik harta bisa mengaku menjadi Tuhan akibat harta yang dimilikinya, sedangkan orang berilmu justru mengaku sebagai hamba Tuhan karena ilmunya. Harta itu jika engkau berikan menjadi berkurang, sebaliknya ilmu jika engkau berikan malahan semakin bertambah. Pemilik harta disebut dengan nama kikir dan buruk, tetapi pemilik ilmu disebut dengan nama keagungan dan kemuliaan. Pemilik harta itu musuhnya banyak, sedangkan pemilik ilmu temannya banyak. Harta akan hancur berantakan karena lama ditimbun zaman, tetapi ilmu tidak akan rusak dan musnah walau ditimbun zaman. Harta membuat hati seseorang menjadi keras, sedangkan ilmu malah membuat hati menjadi bercahaya. (hamba Allah) JJE-2011/12/07 5
Hanya untuk Pendidikan & Kesehatan
BAHAN RENUNGAN
IUFD Cerebral Palsy THE MOST DO IT ! !
JJE-2011/12/07
INTRODUCTION
n
> 90% of CHD is found in the normal low risk population Screening is essential Well-trained sonographers + multiple cardiac views (3V, 4CV, 5CV) : detection of CHD 60 80%
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 7
EMBRIOLOGY
JJE-2011/12/07
HEART ANATOMY
JJE-2011/12/07
FETAL CIRCULATION
n
Mixing of venous return High impedance and low flow in pulmonary circulation Presence of shunts : foramen
JJE-2011/12/07
JJE-2011/12/07
11
FAMILIAL HISTORY
n
2 affected siblings : 10% The father affected : the risk for the offspring is
2%
The mother affected : the risk 10% History of single gene disorder : Noonan,
Marfan, DiGeorge
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 13
FETAL
n
Suspicion of CHD on scan : 4-CV, 3-VV, 5-CV Fetal hydrops : 25% cardiac aetiology, mostly
arrhytmias
Arrhytmias
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 14
90% OF CoHD IS FOUND IN THE NORMAL LOW-RISK POPULATION THEREFORE THE SCREENING IS ESSENTIAL !!
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 15
SCREENING
AT 20 - 22 WEEKS
(optimum time, > 90% cases, 5 MHz)
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 16
TECHNICAL PREREQUISITE
n n
n n
Gestational age Ultrasound transducer Gray scale presetting Zoom and cine-loop Color Doppler presetting
JJE-2011/12/07 17
THE PROTOCOL
n
2D ultrasound with cine-loop, zoom facilities, and high resolution transducers, 5 7 MHz 11 14 weeks :
NT, Situs, FHR, 4-CV
18 22 weeks (optimum : 20 22 W)
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 18
Upper abdomen 4-CV 3-VV Great vessels : 5-CV and short axis
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 19
n n
ORIENTATION
JJE-2011/12/07
20
Getting Started
n
First, determine the situs. Define the right and left sides of the fetus Locate the fetal position Identify the fetal stomach (beware, it is not always on the left side) and other abdominal organs Verify the relationship of the fetal stomach to the fetal heart The apex of the heart should be on the left
JJE-2011/12/07
21
4. 5.
Identify the position of the fetus in utero Determine if the left side is up or down Identify the stomach and the heart to be on the left side Situs solitus : normal visceral
situs
of the situs solitus, but stomach is on the left side anatomically undetermined type of visceral situs
6.
7.
Cardiac apex point to the left (levocardia). In normal situs + dextrocardia : 95% CoHD
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 22
JJE-2011/12/07
23
Orientation of Section
n n
Locate the spine Opposite the spine is the anterior chest wall or sternum Below the sternum is the blunt ended RV The descending aorta is seen as a pulsatile circle in the mediastinum immediately anterior to the spine Related to the aorta anteriorly is the LA
The RA and the LV may also identified MV is mobile and allows the LA to LV communications The tricuspid valve inserts onto the IVS, a little lower than MV and allows the RA to RV communication. The FO flap should be mobile and sees in LA The IVS is intact
JJE-2011/12/07
24
Horizontal section of the fetal thorax just above diaphragm Obtained by scanning down, caudally from BPD. Easier to slide the transducer cranially from the AC view. A good trans-thoracic section with at least one whole rib present The stomach and the abdominal organs are not visible Left ventricular outflow tract (LVOT) not visible
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 25
JJE-2011/12/07
26
Size : occupies one third of the fetal chest Position : cardiac axis is about 45o to the left Structure : Two atria of equal size (1:1) ,
two ventricles of equal size (1:1), and intact crux
Normal 4-CV
n
The internal surface of the left ventricle is smooth-looking compared with the trabeculated right ventricle containing the moderator band
(MB in RV thicker than LV)
MB
RV
Normal 4-CV
n
The two AV-valve meet at the junction of the inter-atrial and interventricular septa to form the crux of the heart. The mitral and tricuspid valves should move freely, with the tricuspid valve attached slightly more apical
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan
APEX
29
Normal 4-CV
n
The appearance of the 4-CV will vary greatly according to the orientation of the fetus. FO protrudes into the left atrium The 3rd trimester features : - RV may be slightly larger than LV - Pulmonary artery > aorta
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 30
Normal 4-CV
n
Scanning up and down horizontally at the back of LA may reveal the pulmonary veins entering LA Views of fetal liver adjacent to RA common reveal IVC and hepatic vein entering RA with slight medial tilting SVC parallel with ascending aorta may also be located draining RA
JJE-2011/12/07
31
ISUOG Guideline
Cardiac screening examination of the fetus: guidelines for performing the basic and extended basic cardiac scan
JJE-2011/12/07
32
ISUOG Guideline
Cardiac screening examination of the fetus: guidelines for performing the basic and extended basic cardiac scan
http://www3.interscience.wiley.com/cgi-bin/fulltext/112221709/HTMLSTART
33 Hanya untuk Pendidikan & Kesehatan JJE-2011/12/07
AIUM 2010
JJE-2011/12/07
34
AIUM 2010
JJE-2011/12/07
35
AIUM 2010
JJE-2011/12/07
36
ISUOG
JJE-2011/12/07
38
Cranial to the 4-CV Pulmonary artery, ductus arteriosus, aorta, right pulmonary artery, superior vena cava (SVC) Pointers to abnormalities : dilatation of the
aorta, pulmonary trunk or SVC; one of the two great arteries being small & the other being large; abnormal vessel alignment; abnormal vessel arrangement; only two vessels; additional vessels; right descending aorta; and abnormal origin of one pulmonary artery from the aorta JJE-2011/12/07 39 Hanya untuk Pendidikan & Kesehatan
JJE-2011/12/07
40
ISUOG Guideline
Cardiac screening examination of the fetus: guidelines for performing the basic and extended basic cardiac scan
http://www3.interscience.wiley.com/cgi-bin/fulltext/112221709/HTMLSTART
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 41
JJE-2011/12/07
42
3 VV
JJE-2011/12/07
43
Both the aorta and pulmonary outflow tracts are about the same size except at the pulmonary valve where the pulmonary artery is larger The pulmonary artery arises from the right ventricle and branches into 2 LPA and RPA, and the ductus arteriosus The aorta arises from the LV and gives rise to the arch with 3 vessels The aorta and pulmonary artery cross each other from where they originate Both the pulmonary and aortic valves should be seen
JJE-2011/12/07
44
ISUOG Guideline
Cardiac screening examination of the fetus: guidelines for performing the basic and extended basic cardiac scan
http://www3.interscience.wiley.com/cgi-bin/fulltext/112221709/HTMLSTART
JJE-2011/12/07 45 Hanya untuk Pendidikan & Kesehatan
LVOT
http://www.aiu.edu.au/Images/aog1.jpg; 14-3-2011
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 46
LVOT
JJE-2011/12/07
47
ISUOG Guideline
Cardiac screening examination of the fetus: guidelines for performing the basic and extended basic cardiac scan
http://www3.interscience.wiley.com/cgi-bin/fulltext/112221709/HTMLSTART
JJE-2011/12/07 48 Hanya untuk Pendidikan & Kesehatan
RVOT
JJE-2011/12/07
49
ISUOG
JJE-2011/12/07
50
ISUOG
JJE-2011/12/07
51
JJE-2011/12/07
52
JJE-2011/12/07
53
Sumber: ISUOG
M-mode
JJE-2011/12/07
55
M- Mode abnormality
JJE-2011/12/07
Arhytmia
SVT
56
sensitivity of 40 50%
JJE-2011/12/07
57
n n n
Abnormal position of the heart Abnormal A-V connections, discordant connection, univentricular connections Cardiomegaly Asymmetrical chamber & valve size Atrial, ventricular, or atrioventricular defect Apical displacement of the septal leaflet of the tricuspid valve Abnormal pulmonary venous connections
58 JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan
Abnormal dilatation or narrowing of the aorta and pulmonary artery (seen on 3-V or outflow views) The ascending aorta is discordant in size with the descending aorta (arch view). This can occur with narrowing. 2 or 4 vessels seen in 3-V view VSD at the outlet septum (basal short axis view). Overriding aorta with VSD (outflow tract views) Discordant valves (basal short axis view)
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 59
n n n n n n n n
Hypoplastic RV
(tricuspid & pulmonary atresia)
n n
Cardiomegaly
Large VSD Cardiac tumours Dextrocardia Situs inversus Ectopia cordis Cardiomyopathies Pericardial effusion Valvular atresia, stenosis, and insufficiency
60
Abnormal ventriculo-arterial connections, transposition, double outflow outlet right or left ventricle, and single arterial trunk VSD Overriding aorta or pulmonary trunk Abnormal dimension of the outflow tracts and / arterial valves
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 61
n n n
n n
Incomplete septation between LV and RV 0.4 2.7 per 1000 livebirths Most common CHD diagnosed in the 1st year of life 50% isolated & 50% part of a complex heart defect Classified based on location
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 62
VSD
n
Multiple cardiac views essential for correct diagnosis Diagnosis needs visualisation of dropout echoes in ventricular septum. Features of drop-out echoes : Largely
restricted to the very thin part of ventricular septum; most marked when ultrasound beam strikes the septum obliques; and no associated with mal-alignment
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 63
Location of VSD
n
Perimembraneous :
80% VSD, involve the membraneous septum below aortic valve, best seen on 4CV
VSD
JJE-2011/12/07
65
2 types : primum (below FO) and secundum (above FO) Secundum ASD : more common & usually isolated 7% of CHD, 1 in 3000 births Prenatal diagnosis difficult due to physiological FO
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 66
AVSD
n
n n
Spectrum of lesions from complete AVSD to incomplete AVSD 0.1 0.5 per 1000 live births 60% association with chromosomal aberration In complete AVSD : absent
central core structures of the heart; and single valve opening into both ventricular chambers
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 67
Spectrum anomalies
hypoplasia
Associated with aortic coarctation, diaphragmatic hernia, and omphalocele Most ultrasound images are self explanatory Definitive diagnosis needs visualization of hypoplasia of ascending aorta and atresia of aortic valve Colour flow extremely helpful : no flow into LV
JJE-2011/12/07
68
JJE-2011/12/07
69
CARDIOMEGALY
n
The heart occupies > 1/3 of the fetal chest (CTR > 0,33%) CTR can be due to : - chest size (skeletal dysplasia or
oligohydramnios)
JJE-2011/12/07
70
KARDIOMEGALI
JJE-2011/12/07
71
PERICARDIAL EFFUSION
n
Visible in multiple planes Minimum thicknes 2 mm Associated with chromosomal aberrations Extend across the A-V junction of the heart
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 72
DIAPHRAGMATIC HERNIA
n
Congenital defect of the diaphragm with herniation of abdominal contents into the chest cavity Usually on the left side (75%) 8% of all major congenital abnormalities Earliest sign is the displacement of the heart to the right Antenatal diagnosis only 50%
JJE-2011/12/07 Hanya untuk Pendidikan & Kesehatan 73
Tetralogy of Fallot
JJE-2011/12/07
74
JJE-2011/12/07
75
BAHAN RENUNGAN
IUFD C Palsy THE MOST DO IT ! !
JJE-2011/12/07
76
THE FUTURE
JJE-2011/12/07
77
THANK YOU