British Journal of Obstetrics and Gynaecology July 1983, Vol. 90, pp. 683-684.
Echo cardiographic diagnosis of fetal pericardial effusion.
Case report
MOHAMED 0. HASSAN Associate Professor, Department of Physiology, King Fahd
Medical Research Centre, Jeddah
FAIG W . MORGOS* Assistant Professor & ABDULLAH H. BASALAMAH Professor,
Department of Obstetrics and Gynaecology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
Case report
A 28-year old woman was first seen in the 18th week of her fourth pregnancy. She was threatening to abort and the bleeding was so pro- fuse that she was transfused with five units of blood. The uterine size was appropriated for the gestation and fetal heart sounds were detected by the Doppler technique. She was seen regularly until the 30th week of gestation when she com- plained of severe nausea. She was found to be slightly jaundiced and had a tender liver. The serum bilirubin was 22 pmol/l, SGOT 291 iu/l, SGPT iu/l and alkaline phosphatase 205 iu/L She was admitted to the hospital with a diagnosis of hepatitis. Tests for hepatitis B surface antigen were negative. In hospital a glucose tolerance test revealed mild gestational diabetes mellitus. This was controlled by diet alone. She left hospital after 2 weeks when her jaundice had cleared but SGOT, SGPT and alkaline phosphatase concen- trations were still raised. As the patient was included in a study of fetal heart dynamics, at 36 weeks she had a real-time ultrasound scan as well as a fetal M-mode echocardiogram. Fetal heart location using the technique described by Wladimiroff & McGhie (1981a) was followed by fetal echocardiography. This showed an echo-free space extending throughout the cardiac cycle between the right ventricular wall and the chest wall of the fetus (Fig. 1). The pericardium, which was clearly identified, remained flat during dia- stole and showed a slight systolic motion which
*Correspondence: F. W. Morgos, Assistant Pro- fessor, Department of Obstetrics and Gynaecology, King Abdulaziz University Hospital, PO BOX 6615, Jeddah, Saudi Arabia.
0 1983 British Journal of Obstetrics and Gynaecology 0306-5456/83/0700-0683$02.00
did not exactly follow the right ventricular sys- tolic movement. Echoes from the other cardiac structures and the posterior left ventricular wall were just identifiable. These features persisted with different gain rejection and depth compen- sation settings and strongly suggested that the echo-free space was a pericardial effusion. Using the method of Horowitz et al. (1974) the amount of the pericardial effusion was estimated to be about 44 ml. Two weeks later (at 38 weeks) the patient said that fetal movements had not been felt for 2 days, the fetal heart sounds could not be detected by the Doppler technique and the fetal cardiac movements were absent in a real-time ultrasound scan. Intrauterine fetal death was diagnosed and labour was induced with oxytocin infusion and artificial rupture of the membranes;
8 h later she was delivered vaginally of a macro- somic ( 5 kg) male macerated fetus with no ob- vious external congenital abnormalities. The peri- cardium of the stillbirth was exposed through an intercostal incision and was found to be dis- tended with blood-stained fluid and 100 ml were aspirated with a syringe and needle. On opening the pericardium the heart was found to be very small and occupied only a small space compared with the total size of the pericardium.
Comment
Fetal cardiac dynamics has been studied by the combined B-mode real-time ultrasound and M- mode (Winsberg 1972; Bears & Merkus 1977;
Ianniruberto et al. 1977; Hobbins et ul. 1978:
Wladimiroff et al. 19816). Congenital heart disease associated with fetal ascites has been diagnosed using ultrasound (Lindsey et al. 198 I).
They suggested that real-time fetal cardiac scanning may prove useful in diagnosing con- genital heart defects. Since there are no previous 683
684 M . 0. Hassan et al.
Fig. 1. Fetal echocardiogram showing an echo-free space (e@ between the anterior right ventricular wall ( A R V ) and the chest wall (CW). PER, Pericardium; eff, effusion; R V , right ventricule; IVS, intraventricular septum: LV, left ventricle; PLV, posterior left ventricular wall.
reports and because of the different dynamics of the fetal heart we suggest that echo-cardio- graphic features of fetal pericardial effusion may differ from those of adults. In our patient the peri- cardium showed a slight systolic motion during ventricular systole but remained flat during diastole. On the other hand, the gradual decrease in the intensity of the echoes posteriorly is a n indication of a large effusion in the adult heart (Feigenbaum et al. 1966) and this was clearly demonstrated in our patient. It is interesting that the pericardial effusion was not suspected on the real-time B-mode ultrasound. This could be attri- buted t o the rapid movements of the cardiac wall against the pericardium which can hinder clear visualization of the echo-free space between them.
In contrast M-mode can detect even a small effusion since all echoes and echo-free zones are recorded and are observer independent. T h e cause of intrauterine fetal death in our patient was most likely due t o cardiac tamponade by the peri- cardial effusion. The cause of the pericardial effusion is not known but might be due t o poorly controlled diabetes, or to a viral infection associa- ted with the maternal hepatitis (probably a con- sequence of the blood transfusion she received earlier in the pregnancy). This is the first report of the diagnosis of a fetal pericardial effusion by M - mode echo-cardiography. This method of investi- gation could be useful when fetal infection is sus- pected and in conditions causing generalized fetal oedema such as erythroblastosis fetalis, congeni- tal cardiac abnormalities and maternal diabetes mellitus.
References
Bears, A. M. & Merkus, J. M. W. M. (1977) Fetal echocardiography: a new approach to the study of the fetal heart and its component parts. Eur J Obstet Gynecol Reprod Biol I, 91-100.
Feigenbaum, H., Zaky, A. & Crabhorn, L. L. (1966) Cardiac motion in patients with pericardial effusion:
a study using ultrasound cardiography. Circulation Hobbins, J. C., Kleinman, C. & Creighton, D. (1978)
Fetal echocardiography. Indirect evaluation of in utero fetal flow patterns. In Proceedings of the Society f o r Gynaecologic Investigations: 25th Annual Meeting, Atlanta, Georgia, p. 48.
Horowitz, M. S., Schultz, C. S., Stinson. E. B..
Harrison, D. C. & Popp, R . L. (1974) Sensitivity and specificity of echocardiographic diagnosis of pericardial effusion. Circulation 50,239-247.
lanniruberto, A,, Iaccarino, M., De Luca. I . &
Gianfrate, P. (1977) Analisi ecogrofie delle struct- ture cardiache fetali nota tecnica. In Atti Congresso Narzoinale (Ianniruberto, A. Ed.), SISUM, Terilizi, Italy, pp. 285-289.
Lindsey A., Little, D., Campbell, S. & Whitehead, M. I . (198 1) Fetal ascities associated with congenital heart disease. Br J Obstet Gynaecol88,453-455.
Winsberg, F. (1972) Echocardiography of the fetal heart and newborn heart. Invest Radio1 7 , 152-158.
Wladimiroff J . W. & McGhie, J. ( 1 9 8 1 ~ ) . Ultrasono- graphic assessment of cardiovascular geometry and function in the human fetus. Br J Obstet Gynaecol Wladimiroff, J . W. & McGhie, J . S. (1981b). M-mode ultrasonic assessment of fetal cardiovascular dyna- mics. BrJObstet Gynaecol88, 1241-1245.
34,611-619.
88,870-875.
Received 13 January 1983 Accepted I 7 March 1983
