Hi Karen,

Great call to include the moderator band! It was interesting to learn that it will always be in the right ventricle, so that can help determine if the heart has developed left and right sides correctly. Apparently in the case of some congenital heart disease, the ventricles may be more ambiguous. Fun fact: It is also referred to as the septomarginal trabecula.

Hi Karen!

Great post! I love the images you added as well, it really helps me visualize all the structures I should be seeing. I feel like just since we talked about all of this yesterday, I've made more of a conscience effort to see all these structures while I'm scanning during clinicals!

Hey Karen! I like this picture because it shows the sup and inf pulm veins coming out of the LA. Do you know where we would seee the pulm arteries coming out of?

Great job Alexis, very thorough! What are some other things we can look at outside the heart at this view?

Hi Chrishawna! 

I really appreciate how you began your discussion post with the concepts from last week! Those concepts totally flew over my head and it's great that you went back to explain that the fetal heart should be laying more towards the left side of the thoracic cavity at a 45 degree angle. With all the classes and clinicals, it's easy to forgot how essential is its to know your basics to build a strong foundation for the rest of the quarter.... and the rest of our lives. 

After completely bombing the quiz and then writing it out as an explanation for this discussion post, I will never forget that Three S's of the heart. 

The images that you shared and your post was amazing! Thank you!! This really helped me out so much 

Hi Chrishawna! I think you are spot on. I like that you mentioned we should watch a few full cardiac cycles to make sure all the mechanics of the heart are functioning properly. I'm wasn't really sure what normal looked like so I found this short video clip of a normal fetal heart beating in the 4 chamber view. I also found a second video showing a couple fetal arrhythmias just to see what some abnormalities would look like. 

Normal fetal heart:

Common fetal arrhythmias:

Nice job bringing up the moderator band Chrishawna! That is definitely an easy way to orient yourself if you see it in the right ventricle! Good thinking with the hypoplastic ventricle if it is not symmetrical and similar in size as the opposite side. I did some searching on the survival rates of infants born with ventricular hypolasia; can you think of some things this type of defect may lead to in a newborn?

Hi Chrishawna!

I totally love how you incorporated the three S's. We definitely want to remember that when interrogating the heart and 4CH view. I also want to add that it's super important we see a solid interventricular septum and when we're scanning, get accurate pictures that aren't creating deviations or dropouts in the septum, because this could be a major problem if there truly is a deviation.

Hey Chrishawna!

I love that you acknowledge the importance of the moderator band, however, its not the best way to determine right from left. You haven't learned this yet, but there are pathologies that can cause thickening on the myocardium and it can almost mimic a moderator band. There are also pathologies that can make the walls hypoplastic. If there is anything I can instill in you guys it's that we shouldn't be using landmarks inside baby to determine right from left. It should be determined ONLY using fetal lie. Then once everything is definitely where it should be, then landmarks such as the stomach and the heart (left side) can be used. 

Thanks for sharing your thoughts!

Hi Brittany,

Great job listing out everything we see in such an organized way! Your post is very clear and to the point, love it! We may all put your post in our notes. 

That is a really good image you found, as well. I found it a little difficult to find one that has so many things labelled.

Thank you!

Karen

Thanks for adding these pictures to go along with the DB. I was thinking about the mitral and tricuspid valve and was wondering if you would be able to see the three and two valves. I believe DR. Wilson said that the membranous septum is more common to have the defect than the muscular septum is?  

Great job mentioning the foramen ovale! Michelle was showing me a case at cinicals once and they could tell there was something off about the heart. There was nothing huge, but it wasn't checking off all her boxes. She told me to look at it. One of the first things I noticed was that the foramen ovale was opening towards the right atrium rather than its usual left! It was something so small, but it definitely makes a difference! It makes you wonder how that blood is even circulating!

So many things to think about...

Hi Hailey,

Great job with the visuals, it really lists out everything that would be in the 4CH view! At this point, when we scan I'm sure we're just looking at a few key things, haha. But I love that as this class goes on and we see more diagrams like the one you shared, we are more and more likely to be able to list off the different anatomical structures that we see.

I'd love to see a fetal heart now and be able to list off some of the structures that we've learned just this past week.

Have you been able to scan any OB at your site? 

Thanks!

Karen

Hi Lania!

Love your list, very organized and easy to read. you mention that we see pulmonary veins. Do you know which ones we most often see? I was getting confused because Dr. Wilson said inferior but in the recorded lecture she said superior. 

Hey Lania and Hailey! We discussed this in our DB but I believe you see inferior and superior coming out of left atrium. Can someone tell me where the pulmonary arteries come out of. 

Great job mentioning pulmonary veins! We take those guys for granted because they are not always readily seen! But all you have to do is wiggle the probe around and they should come into view.

Awesome!

So sweet and concise! Thank you for sharing the break down and your resources, Lania! 

Definitely adding this information to my notes. You think you understand something and more information comes at you! We should get together and break out a list for every other view lol. I'm finding this discussion post so helpful!

Howdy Monica,

That's a great way to remember the apex of the heart! 

I think it's easy to overlook but the aorta is a helpful marker when looking for that 4 chamber view. As simple as it sounds, seeing the aorta can help orient left/right and anterior/posterior.

Sarah

Great response, Monica! Can you think of what we look for in the 4 chamber heart view if we come across a dextrocardia or mesocardia fetal heart to identify the correct atria/ventricles?

One thing I always do when I am taking my split screen situs picture (heart in one image and stomach on the other), I always annotate "apex" on the heart image. This lets the radiologist (and myself) know that I'm certain that the heart is pointing where it should be and even at the appropriate angle. 

Hey Molly,

Great job our your response! One thing you mentioned that I found to be super important is the anatomical landmarks we should see when capturing this image! I noticed all of fetal biometry has specific areas where measurements should be taken so I assume this is also the level we could take the thorax circumference or cardiac-thoracic ratio as well!

Hey Molly! Your DB included everything I thought you should be able to see in the heart. Do you remember the degree variation the heart should be within when it is at 45 degrees? 

SHAPE SIZE SYMMETRY!! I will always remember it now that I got it wrong on the quiz haha

Hey Molly girl, 

 I love how you divided your response by left and right side. I am so confused though about the differences between the interventricular septum and septum primum and septum secundum. Do you have an understanding on this?

Love how this is organized and includes the picture. awesome!

Hi Candee! 

I noticed how you mentioned assessing the foramen ovale and I think this is definitely an important part of a fetal exam. We want to assess that firstly there is an opening between the ventricles, and that blood is able to flow freely between the two ventricles. If flow is impaired this can alter the fetal circulation system. The best way to do this would presumably be with color doppler and maybe M-mode too?

I also saw a few studies that were looking into measuring the foramen ovale opening and relating this to IUGR! Definitely seems like we may eventually do more in terms of assessing this structure. 

Here's an image of what the foramen ovale looks like with color Doppler on! You can see the flow entering the left atrium.

Hey Candee girllll,

Hope your day at clinic was good, really good response. I just wanted to add that we also see the pulmonary veins. I'm not sure which ones we see most often because Dr. Wilson mentioned both. Do you know? Inferior or Superior. We also see the interventricular septum! so many small parts that are too easy to forget about. 

Hi Candee,

Great insight! I'm still trying to wrap my brain around levocardia vs levoposition when establishing situs. 

The septa and valves should absolutely be analyzed in the 4-chamber view. I was looking for more information about potential septal defects and came across what is referred to as a Swiss Cheese septum. This describes "uncountable" ventricular septal defects. Thankfully it sounds like it is quite rare. I'm sure we'll dive into all the different anomalies and pathologies next quarter, but it is interesting to start investigating now as we learn the normal anatomy.

Hi Candee, great job! Everyone has put such thoughtful responses to your post already, but do you remember why the right side of the heart grows larger than the left in later in the pregnancy? In addition, do you think if we don't see that shift in symmetry or if we see it too early, that could point to some issue in the fetal heart?

Great job noting the direction of the foramen ovale! I've had a situation where it was backward. I explained in an earlier post ^^

You don't need to put color on the heart unless you are further investigating something pathological or trying to prove a fetal demise.

We typically don't even mention an EIF unless there are other soft markers as well. They are super common and are actually typically just the chordae tendineae reflecting the sound beam! 

We will definitely talk about all those pathologies next quarter. What are some normal things we can be evaluating in a 4ch view (in the entire thorax)?

aahhh and the pulmonary veins I totally forgot!! There was some confusion though if the veins in this view were the superior or inferior ones.

Love that labeled ULS image! beauty

I LOVE your response Nailah! Straight to the point and nicely labeled/detailed. Nice work!

Yesssss the muscle thickness! This is one of those things that you get so used to seeing normal that when the muscle thickness is off, you can tell! Awesome thinking!

Great job on your post Sarah!

I hadn't thought about the heart muscle thickness, thanks for mentioning it! I found a few images that might be good examples of how this can appear on this webpage.

https://obgynkey.com/fetal-cardiomyopathies-and-fetal-heart-tumors/

Hey Allison, 

 Nice response. I really appreciate the organization. I like how mentioned the crux of the heart too! So important! I got confused on the foramen ovale. The lecture said the flap should be seen within the left atrium, but other sources are mentioning it is between the both atria and this eustachian valve plays a role? The book super confused me on fetal circulation. I thought I had a mild understanding, but maybe not.

nailah 

Love how this is organized Allison, great job!

I just want to clarify two things:

1- you can't clear situs from a 4ch view. This as a radiologist. If they are just given an image of the 4ch heart, that doesn't tell them how the fetus is lying and if it's situs solitus (normal situs). We can only clear situs based on fetal lie. I think I know what you were getting at, but I just wanted to make sure we are on the same page.

2- When it comes to the crux of the heart, you're right, that's SUPER important! Like Michelle said in class, sometimes based on how the baby is lying, you can get drop out and that's typically where it occurs. We as sonographers have to make sure we aren't creating pathologies with artifact. When taking 4ch images, be sure there is no drop out right in the center! 

Great job!

Hey Allison,

I love the way you organized your response. You mentioned something that is so important, but that I feel would be easy for a student to overlook, and that's the opening of the foramen ovale. It's hard to imagine an organ the size of a pocket change could have that many key structures within it. It got me wondering what would happen if the FO didn't form properly or never formed at all? I guess blood would have no choice to go through the right ventricle and through the pulmonary artery!

Allison Wine always on the beat!!

Wow your discussion post is gold. I won't be surprised if I pick up the next edition of a Penny book, your name is going to be on it. 

I appreciate how you created this into sections. Taking little bits of information from this huuuuuuuuge concepts is helpful. 

Looking at your's makes me realize how much information I missed on my post. Especially the the area of most frequent septal defects, the crux of the heart. But also M-Mode! Thats super important to take note of during a fetal scan. 

It's interesting to know that almost 90% of the time, if the baby has a higher heart rate...its a girl & if the baby has a low heart rate... its a boy!

Hi Allison!

Great response and I love the image you posted!

All super organized and well explained! I also wanted to add that the apical view of the heart is what most radiologist want to see for our 4ch view of the heart when doing the exam!

Great response Allison! Like Paris and Michelle said, at the crux and interventricular septums of the heart there can be drop out due to the baby's positioning and ossification points of the spine. What are some ways you can overcome this artifact and how do you tell the difference of an artifact versus an actual abnormality?

Hi Zuly!

Great post and image! I just wanted to say I appreciate how you brought it's important to see one solid rib. I can't emphasize how many times my CI has told me that while scanning lol. It's very important for an accurate image, shape, and size of the heart.

Hi Zuly!

Like Lania said, great job mentioning the addition of seeing a complete rib to make sure we are getting the correct view/ angle!

I also liked your diagram and how it shows the transducers' view "slicing" through the heart to get that optimum picture. Sometimes we talk about things but don't or can't really visualize it, so your post really helps.

Thanks!

Karen

Hi Zuly,

I love this image! I was wondering if you have been able to visualize the pulmonary veins at your clinical site. It seems like it's hit or miss seeing those important structures. I included a color Doppler picture that i think highlights them nicely, I hope to get good enough at OB to get images like this one day!

Hi Zuly, 

I really liked the picture that you shared and that you mentioned the whole rib should be in the view s well. That has not really been mentioned at my site. Have you been scanning a lot of fetal hearts at your site, and if so then do you have any tips? 

Hi Raman!

Great job bringing up M-mode and the fetal heart rate! I feel like I need to look into M-mode a bit more as I haven't learned as much about it as we have Doppler.

Have you seen your CI use M-mode on the fetal heart much yet? If so, what view do they typically take the heart rate in? Do they only use it for heart rate or do they also use it for other purposes like chamber size?

I also found this cool graphic that breaks down what's being seen on an M-mode strip in this view.

Hey Raman,

No need to use color doppler! We really only need to use it if we think something pathological is happening or if we are trying to confirm a fetal demise. 

Raman,

The right side should have a little thicker myocardium for sure. Remember that we can learn all sorts of things from the 4 chamber heart view. Remember each outflow tract, the valves, AO, and the moderator band too. Also the septum from this view can give us some helpful information.

Sarah

Hi Lauren!

In my story I explained the different valves as being bridges! I also explained the aortic arch as being on top of a hill.

Great image! I love that it shows the exact sonographic view side by side with the labels so we can compare and identify.