8 fetal chest dr ahmed esawy Fetal Chest Biometry Lungs – Sonographic Appearance Diaphragm – Sonographic Appearance Thymus – Sonographic Appearance Fetal cardio-thoracic (C/T) circumference ratio CYSTIC THORACIC MASSES • Diaphragmatic hernia (stomach adj • CCAM, type 1,2 • Cysts: bronchogenic, enteric duplica • cystic hygroma SOLID (ECHOGENIC) MASSES • Diaphragmatic hernia • CCAM, type 3 • Pulmonary sequestration • Tumors • Teratoma • Rhabdomyoma of the heart • Pulmonary hypoplasia 1-Diaphragmatic hernia • 2-Congenital cystic adenomatous malformations • 3-Broncho-pulmonary sequastration • 4-Pleural effusions • 5-Pulmonary hypoplasia • 6-Congenital hydro/chylo thorax • 7-Pulmonary lymphangiectasia • 8-Chondrodysplasia • 9-Bronchogenic cysts and other tumours Fetal hydrops

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

2. Dr. Ahmed Esawy
MBBS M.Sc
MD
Dr/AHMED ESAWY

3. Organs
• Heart
• Lungs
• Pleura
• Oesophagus
• Blood vessels
• Bony cavity
DR/AHMED ESAWY

4. DR/AHMED ESAWY
The Thorax
• Bony Structures
– Clavicles
– Ribs
– Scapulae
– Vertebral bodies
– Sternum

5. DR/AHMED ESAWY
Chest Biometry
• Thoracic Circumference
• Taken at level of fetal heart
• Rules out pulmonary hypoplasia

6. • Normal lung anatomy is difficult to quantify at 18-20 weeks
• Normal lungs produce midrange echoes on U/S
• Note relative proportions of heart:lungs ie 1/3:2/3. this
remains the same since lungs and heart grow at similar
rates
• Gross lung anomalies eg pulmonary hamatoma can be seen
at early gestation
DR/AHMED ESAWY

7. Lungs – Sonographic Appearance
DR/AHMED ESAWY
Two lungs surrounding the heart
Homogeneous echo Texture
Echogenicity dependant on gestational age
Color flow decreased with underdevelopme

8. Lungs – Sonographic Appearance
DR/AHMED ESAWY

9. Lungs – Sonographic Appearance
DR/AHMED ESAWY

10. Lungs – Sonographic Appearance
DR/AHMED ESAWY

11. Diaphragm – Sonographic
Appearance
DR/AHMED ESAWY
Diaphragm - Embryology
• Develops in eighth week
• Fusion of multiple structures

12. Thymus – Sonographic
Appearance
DR/AHMED ESAWY
Thymus - Embryology
• Formed by the third pharyngeal pouch
• Descends to posterior sternum

13. DR/AHMED ESAWY
Larynx
• Anterior to trachea
• Imaged when filled with fluid
• Nontransient fluid raises suspicion for
laryngeal atresia or stenosis

14. DR/AHMED ESAWY
Fetal cardio-thoracic (C/T) circumference ratio is parameter than can be used in
assessment of fetal cardiac and thoracic/chest wall anomalies. It is essentially the ratio
of the cardiac circumference of the thoracic circumference and may be easily measured
on ultrasound/fetal echocardiography.
Radiographic assessment
Ultrasound/echocardiography
The CT circumference ratio should be always less then 0.5 throughout gestation. It
slowly increased through gestation
~ 11 weeks: 0.38
~ 17-20 weeks: 0.45
term: 0.5
Increased C/T circumferential ratios can be be observed with either cardiac or thoracic
pathology:
cardiac: fetal cardiomegally
thoracic: pulmonary hypoplasia

15. CYSTIC THORACIC MASSES
• Diaphragmatic hernia (stomach adj
• CCAM, type 1,2
• Cysts: bronchogenic, enteric duplica
• cystic hygroma
SOLID (ECHOGENIC) MASSES
• Diaphragmatic hernia
• CCAM, type 3
• Pulmonary sequestration
• Tumors
• Teratoma
• Rhabdomyoma of the heart
• Pulmonary hypoplasia
DR/AHMED ESAWY

16. Abnormalities
• 1-Diaphragmatic hernia
• 2-Congenital cystic adenomatous malformations
• 3-Broncho-pulmonary sequastration
• 4-Pleural effusions
• 5-Pulmonary hypoplasia
• 6-Congenital hydro/chylo thorax
• 7-Pulmonary lymphangiectasia
• 8-Chondrodysplasia
• 9-Bronchogenic cysts and other tumours
DR/AHMED ESAWY

17. DIAPHRAGMATIC HERNIA
• Herniation of the abdominal viscera into the thorax at
about 10–12 weeks, when the intestines return to the
abdominal cavity from the umbilical cord. However,
intrathoracic herniation of viscera may be delayed until
the second or third trimester of pregnancy
DR/AHMED ESAWY

18. DIAPHRAGMATIC HERNIA
• Findings on U/S
– Fluid filled thoracic mass caused by stomach or
bowel
– Solid organs such as liver and spleen in the chest
– Abnormal cardiac position
– Decreased abd circumfrence
– Viscera can slide btn abd and chest.
DR/AHMED ESAWY

19. DIAPHRAGMATIC HERNIA
• -shift of mediastinum to right with cystic
lesion (stomach) in left side of the chest in
case of left sided hernia. this confirmed by
absent stomach in abdomen.
• -observation of peristaltic bowel in chest or of
paradoxical visceral movement with fetal
breathing movements.
DR/AHMED ESAWY

20. •Differencial diagnosis
– Eventration
– CCAM
– Bronchopulmonary sequastration
– Tumour
DIAPHRAGMATIC HERNIA
DR/AHMED ESAWY

21. • ¾ involve the left side due to foramen of
Bochdalec
• Herniation may cause pulmonary hypoplsia
• May be ass with hydramnios
• Colour Doppler has a role in diagnosis since
the liver and lungs have same texture
• Absence of gastric bubble in upper abd may
be a sign of DH
DIAPHRAGMATIC HERNIA
DR/AHMED ESAWY

22. DIAPHRAGMATIC HERNIA
DR/AHMED ESAWY

23. DR/AHMED ESAWY

24. Congenital diaphragmatic hernia- Left (CDH):
DR/AHMED ESAWY

25. Left-sided CDH in a fetus at 26 weeks gestation. (a, b) Color Doppler sonogram (a) and axial T2-weighted
MR image (b) of the chest show herniated content (straight arrow) displacing the heart and compressing
the left lung (curved arrow). (c, d) Sagittal (c) and coronal (d) T2-weighted MR images show portions of
the bowel (arrow) and stomach (S) occupying the left hemithorax
DR/AHMED ESAWY

26. Right-sided CDH
Sagittal (a) and axial (b) T2-weighted MR images show the liver (arrow) occupying
the right hemithorax. Note the ascites around the liver (*).
DR/AHMED ESAWY

27. DR/AHMED ESAWY
Pleural effusions

28. Unilateral Bilateral
Primary
most often chylous;
often on the right
Secondary
Clear; as part of non-immune hydrops
Isolated
usually associated with an underlying structural anomaly:
 pulmonary lymphangiectasia
 cystic adenomatoid malformation of the lung
 bronchopulmonary sequestration
 diaphragmatic hernia
 chest wall hamartoma
 pulmonary vein atresia
Associated with other manifestations of
hydrops
 subcutaneous skin oedema
 pericardial effusion
 ascites
Pleural effusions
DR/AHMED ESAWY

29. Fetal Hydrops
• Pathological Accumulation
Fluid Tissues
– Ascites
– Pleural Effusions
– Pericardial Effusions
– Subq Edema
• Two Types
– Immune Hydrops
• Blood Grp Incompatibility
• mother & fetus
• Tx: Fetal Transfusion
– Non-Immune Hydrops
• Prognosis is Poor
• Causes:
– Cardiac
– Infections
– Chromosome
Abnormalities
– Twins
– Urine Obstruction
– UC Compromise
DR/AHMED ESAWY

30. Heart failure
cardiac defects
arrhythmias
myocarditis
fetal anemia
arteriovenous shunts
mediastinal compression
twin/twin transfusion
Hypoproteinemia
Renal defects
Gastrointestinal defects
Hepatic infiltrations
Anemia
red cell isoimmunisation
Parvovirus B19
Cytomegalovirus
Alpha talassemia
Fetomaternal hemorrhage
G-6-PD deficiency
Hepatic infiltrations
Fetal anemia
Fetal infection
Metabolic disorder
Causes of fetal
hydrops
DR/AHMED ESAWY

31. Arteriovenous shunts
vein of Galen aneurysm
placental chorioangioma
acardiac twin
fetal tumor
Fetal infection
Cytomegalovirus
Toxoplasmosis
Rubella
Syphilis
Hepatitis
Mediastinal compression
skeletal dysplasia
diaphragmatic hernia
cystic adenomatoid malformation of the lung
pulmonary sequestration
laryngeal obstruction
Metabolic disorder
mucopolysaccharidosis
Gaucher’s disease
Gangliosidosis
Sialidosis
Neuromuscular disorder
fetal akinesia deformation sequence
Chromosomal disorder
Trisomies 21, 18, 13
Turner syndrome
Triploidy
Causes of fetal hydrops
DR/AHMED ESAWY

32. PLEURAL EFFUSIONS
Fetal pleural effusions, which may be unilateral or bilateral, may be an isolated
finding or they occur in association with generalized edema and ascites
DR/AHMED ESAWY

33. DR/AHMED ESAWY

34. DR/AHMED ESAWY

35. Hydrothorax in a fetus at 32 weeks gestation. Sagittal (a) and axial (b) T2-weighted MR
images show a small, hyperintense pleural fluid collection (H) in the right
hemithorax. No mediastinal shift or other pulmonary abnormalities are seen.
DR/AHMED ESAWY

36. CHAOS in a fetus at 27 weeks gestation. (a) Sonogram shows enlarged lungs (arrow) and
massive ascites (A). (b) Coronal T2-weighted MR image shows bilateral enlarged and
hyperintense lungs (arrow), consistent with lung overdistention by the alveolar fluid. Note the
severe mass effect with everted hemidiaphragms and ascites (A). Although a dilated airway
was not seen at fetal MR imaging in this case, it was revealed at autopsy.
DR/AHMED ESAWY

37. Differential diagnosis: The differential diagnosis between the primary pleural effusion causing
the fetal hydrops and the secondary one, caused by the hydrops, may be based on the finding
on everted diaphragm that occurs in the case of primary effusion
DR/AHMED ESAWY

38. Pleural effusion in fetus
DR/AHMED ESAWY

39. Normal lung & rib
shadow
Diaphragm, liver
& pleural effusion
Small pleural
effusion
Septations
Compressive
atelectasis
Consolidation with
air bronchograms
DR/AHMED ESAWY

40. DR/AHMED ESAWY

41. technique of pleural-amniotic shunting
to drainage pleural effusion
DR/AHMED ESAWY

42. DR/AHMED ESAWY
through a double pigtail silastic catheter (external diameter of 0.2mm).
- Ultrasound scanning is first carried out to obtain a transverse section of the
fetal thorax. With the transducer in one hand, held parallel to the intended
course of the cannula,
-the chosen site of entry on the maternal abdomen is cleaned with antiseptic
solution and local anesthetic is infiltrated down to the myometrium.
-Under ultrasound guidance, a metal cannula with a trocar (external diameter
3mm, length 15cm) is introduced transabdominally into the amniotic cavity and
inserted through the fetal chest wall, in the midthoracic region, into the effusion
or cyst.
-The trocar is removed and the catheter inserted into the cannula. A short
introducer rod is then used to deposit half of the catheter into the effusion or
cyst.
-Subsequently, the cannula is gradually removed into the amniotic cavity where
the other half of the catheter is pushed by a longer introducer.
-If drainage of the contralateral lung is also needed the appropriate fetal
position is achieved by rotation of the fetal body using the tip of the canula.
-This is an outpatient procedure and after monitoring for 1-2 hrs the patients are
allowed home. Subsequently, ultrasound scans are performed at weekly
intervals to determine if the effusions reaccumulate, in which case another
shunt may be inserted. After delivery the chest drains are immediately clamped
and removed to avoid development of pneumothorax

43. Chylothorax
Definition
Chylothorax is an accumulation of chyle in the pleural
Cavity
Incidence
Chylothorax is a common cause of pleural effusion
during
the first days of neonatal life.
Prevalence 1:10,000 deliveries
Male to Female ratio is 2:1.
Etiology
Accumulation of lymph within the pleural cavity can
result from overproduction or impaired re absorption
of lymph. The latter could be due to an obstruction
DR/AHMED ESAWY

44. Pathology
Chylothorax occurs usually as a unilateral pleural
effusion involving the right side of the lung in most
instances.
In rare cases, pleural effusions can be bilateral.
Unilateral pleural effusion can also shift the
mediastinum, impair venous return, and lead to
congestive heart failure and hydrops
DR/AHMED ESAWY

45. Associated Anomalies
Chylothorax may be associated with trisomy 21.
Anomalies reported in association with chylothorax
include
• congenital pulmonary lymphangiectasis,
• tracheoesophageal fistula,
• extralobar lung sequestration
• and a multiple malformation
complex (anemia, tracheoesophageal fistula).
DR/AHMED ESAWY

46. Differential Diagnosis
The differential diagnosis of congenital chylothorax is
problematic:
• Isolated pleural effusions
• or non immune hydrops.
N B: Biochemical or cytological examination of the
pleural fluid can permit a differential diagnosis
between the effusion seen in congenital chylothorax
and that seen in other causes of non immune hydrops.
DR/AHMED ESAWY

47. Congenital left
chylothorax Chylothorax,ascites
DR/AHMED ESAWY

48. Bilateral
chylothorax
DR/AHMED ESAWY

49. Congenital pulmonary lymphangiectasia in a fetus at 34 weeks gestation. Coronal T2-weighted
MR image shows the lung parenchyma with heterogeneous signal intensity. Several
hyperintense linear structures are also seen (arrows), suggesting enlargement of the lymphatic
vessels.
DR/AHMED ESAWY

50. • Congenital Cystic Adenomatoid
Malformation of the Lung
DR/AHMED ESAWY

51. Congenital Cystic Adenomatoid
Malformation of the Lung
Synonym
Adenomatoid hamartoma.
Definition
Benign tumour of the lung
characterized by disordered
overgrowth of terminal bronchioles
CCAML is a rare malformation of the lung
DR/AHMED ESAWY

52. • U/S features
– Intrathoracic lung mass
– Abnormal cardiac position
– Hydramnois and hydrops
Classification of CCAML into three subtypes according to the
size of the cysts:
• Type III: echogenic solid mass (microscopic cysts,
• type II has multiple small cysts
of less than 2 cm in diameter
• type III consists of a noncystic lesion producing
mediastinal shift greater than 2 cm in diameter
The worst prognosis is seen in type III lesions.
DR/AHMED ESAWY

53. CYSTIC ADENOMATOID MALFORMATION (CAM)
DR/AHMED ESAWY

54. TYPE I
CCAM,displaced
heart to right side
DR/AHMED ESAWY

55. Multiple large cysts Microcystic variety type II
DR/AHMED ESAWY

56. Congenital Cystic
Adenomatoid Malformation: CCAM
• Congenital Hamartoma Lung Lesion
– Affects only one lobe
– Lesion consists of cysts
DR/AHMED ESAWY

57. CCAM type I in a fetus at 27
weeks gestation. (a)
Transverse sonogram shows
multiple large anechoic
cysts in the left hemithorax
(straight arrows) with
dextroposition of the heart
(curved arrow). (b, c) Axial (b) and coronal (c) T2-
weighted MR images show a
large multicystic mass with
high signal intensity
occupying the left
hemithorax (straight arrow).
Note the mass effect, with
mediastinal shift to the right
(curved arrow).
DR/AHMED ESAWY

58. CCAM type I hybrid condition in a fetus at 31 weeks gestation. (a) Coronal color Doppler
sonogram shows an enlarged and hyperechoic left lung, with an anechoic cyst in the upper
lobe (arrow). Note the feeding vessel that arises from the aorta. (b, c) Coronal (b) and axial (c)
T2-weighted MR images show an asymmetric enlarged left lung that is hyperintense relative to
the right lung, and a large systemic vessel in the base of the left hemithorax (arrow), findings
that confirm the presence of a hybrid condition. Note also the cystlike lesion in the left upper
lobe on the coronal image (* in b).
DR/AHMED ESAWY

59. Differential diagnosis
Diaphragmatic hernia
Bronchopulmonary sequastration
Eventration
Tumour
DR/AHMED ESAWY

60. Lung Sequestration
Synonyms
Bronchopulmonary sequestration and accessory lung.
Definition
Congenital anomaly in which a mass of pulmonary
parenchyma is separated from the normal lung
It usually does not communicate with an
airway and receives its blood supply from the systemic
circulation.
DR/AHMED ESAWY

61. Pulmonary Sequestration
• Lung Tissue supplied by Systemic
Arteries
– Lung Tissue separated from
vascular connections
– Two types:
• 1. Intralobar -- adults
• 2. Extralobar -- fetus
• In the extralobar
variety(most common) the
sequestered lung is covered
by its own visceral pleura
• US Findings:
– Homogenous
– Echogenic
– Solid Lung Mass
– Displaces Mediastinum
– Color Doppler
• Systemic blood supply
demonstrated
• Arises from Thoracic Aorta
Rare anomaly without familial
predispositions
In the extralobar variety, male to
female 3DR/AHMED ESAWY

62. SEQUESTRATION OF THE LUNGS
The sequestrated portion of the lung appears as a homogeneous, brightly echogenic mass in the
lower lobes of the lungs or in the upper abdomen (infradiaphragmatic sequestration). The
diagnosis is confirmed by color Doppler demonstration that the vascular supply of the
sequestered lobe arises from the abdominal aorta
DR/AHMED ESAWY

63. DR/AHMED ESAWY

64. Extralobar
pulmonary
sequestration with
non-immune hydrops
Right pulmonary
sequestration with bilateral
hydrothorax
DR/AHMED ESAWY

65. Bronchogenic Cyst
Definition
A bronchogenic cyst is a cystic structure lined by
bronchial epithelium.
Incidence
The incidence of bronchogenic cysts is unknown, since
a large number of them are asymptomatic. They are
extremely rare in the neonatal period.
DR/AHMED ESAWY

66. Two bronchogenic cysts
DR/AHMED ESAWY

67. dumbbell-shaped cystic structure that extended both in the chest and in
the abdomen Bronchgenic cyst DR/AHMED ESAWY

68. Bronchogenic cyst in a fetus at 28 weeks
gestation. (a) Transverse color Doppler
sonogram shows a bronchogenic cyst
(cursors) in the left hemithorax, adjacent
to the heart. (b–d)
Axial (b), coronal (c), and sagittal (d) T2-
weighted MR images demonstrate a
markedly hyperintense fluid-filled cyst
within the left lung parenchyma (*).
DR/AHMED ESAWY

69. chest wall
DR/AHMED ESAWY

70. Prenatal and postnatal features of mesenchymal hamartoma of the
chest wall
Ultrasound at 32 weeks gestation
showing a mass consisting of solid and
cystic components, with calcified borders
(black arrows) and a hyperechoic focus
(white arrow), suggesting internal
hemorrhage
DR/AHMED ESAWY

71. Chest X-ray at birth showing bilateral rib abnormalities, in addition to a small right-
sided mass and a much larger left sided one displacing the heart
DR/AHMED ESAWY

72. Two coronal views of CT scan of the chest showing one lesion arising from
the right, and multiple lesions arising from the left chest wall.
The large left-sided mass contains a hemorrhagic component
DR/AHMED ESAWY

73. Prenatal Diagnosis of Fetal Chest Lymphangioma
Axial image of the fetal chest at
15 weeks’ gestation, at the
level of the 4-chamber view,
showing a symmetric mass,
honeycombed in appearance,
with multiple echo-free areas
of varying size in the mass.
DR/AHMED ESAWY

74. Axial image of a fetus at 22 weeks’ gestation
showing a mass connected to the chest wall.
DR/AHMED ESAWY

75. Axillary cystic hygroma
Ultrasonography showing a large multiseptate cystic mass(C)in
the right axilla (Ch=chest, A=arm)
DR/AHMED ESAWY

76. Atresia,agenesis
DR/AHMED ESAWY

77. Bronchial atresia. (a) Axial color Doppler sonogram obtained in a fetus at 28 weeks gestation
shows a hyperechoic lesion in the lower lobe of the left lung. (b, c) Axial (b) and coronal (c) T2-
weighted MR images obtained the same day show the lesion with high signal intensity
(arrow). Postnatal chest radiography showed no significant abnormalities. (d, e) Axial chest
computed tomographic scan (d) and coronal maximum intensity projection image (e) obtained
in the neonate at 15 days show a hypoattenuating mass in the left lower lobe, with dilatation
of the segmental bronchus inside the hypoattenuating area.
DR/AHMED ESAWY

78. DR/AHMED ESAWY

79. DR/AHMED ESAWY

80. PAVM in a fetus at 34 weeks gestation. (a) Color Doppler sonogram shows a vascular lesion
(arrow) in the right hemithorax, adjacent to the heart. (b) Coronal T2-weighted MR image
reveals a hypointense lesion in the middle of the right lung (arrow).
DR/AHMED ESAWY

81. DR/AHMED ESAWY
Fetal pneumonia

82. DR/AHMED ESAWY
The images show transverse and parasagittal
scans of the fetal chest with the hyperechoic
appearance of the fetal lungs
The images show transverse and
parasagittal scans of the fetal chest with
the hyperechoic appearance of the fetal
lungs

83. DR/AHMED ESAWY
The image A shows hypoechoic amniotic fluid. The
image B shows postnatal X-ray of the fetal chest with
the dispersed small opacities at the level of the lungs

84. DR/AHMED ESAWY
The echogenic appearance of the lungs is can be
operator dependant. Many pitfalls make impossible to
standardize the fetal lungs changes during gestation. In
our case the lungs appeared more echogenic than the
liver, with a contrast of the shadows of the ribs.
bilateral hyperechoic appearance of the fetal lungs
associated with echogenic appearance of the amniotic
fluid can be the sign of early fetal lung inflammation due
to chorioamnionitis

85. DR/AHMED ESAWY
The differential diagnosis of sonographic appearance of bilateral echogenic
lungs includes:
Bilateral microcystic congenital adenomatoid malformation Stocker type III ,
Achiron type IV . It is usually associated with the fetal ascites and
placentomegaly. The prognosis is poor .
Airway obstruction as prenatal tracheal obstruction caused by cartilaginous
bar or possibly associated with maternal pertussis infection .
Chicken pox during pregnancy may lead to the lung hyperechogenicity .
Fetal Candida infection due to retained intrauterine contraceptive device .
Congenital syphilis is an unusual cause of bilateral pulmonary spirochete"s
abscesses , but no prenatal description was made.

86. DR/AHMED ESAWY
Fetal Lung Maturity
Ultrasound
Image Features

87. Sonograms representative of classification of lung echogenicity as
cornpared with that of liver. A, Lung is hypedense as compared with, B,
isodense, C,slightly hyperdense, and D, definitely hyperdense.
I = lung; h = liver.
DR/AHMED ESAWY

88. DR/AHMED ESAWY
Samples of fetal echogram with lung and
liver regions and ROIs. (a) 30
weeks and (b) 26 weeks

89. DR/AHMED ESAWY
The ratios of fetal lung to liver feature values
were investigated as possible indexes
for classifying the images into those from
mature (reduced pulmonary
risk) and immature (possible pulmonary risk)
lung. The features used are fractal dimension,
lacunarity, and features derived
from the histogram of the images

90. DR/AHMED ESAWY
comparing the frequency characteristics
of lung echoes to those from the fetal
liver as a reference organ,

91. DR/AHMED ESAWY
four ultrasound parameters
Echogenic thalamus
Placental calcification grade 2 and 3
Biparietal diameter above 9.2 cm
Presence of amniotic fluid vernix

92. DR/AHMED ESAWY

93. DR/AHMED ESAWY
Evaluation of thalamus echogenicity
by ultrasound as a marker of fetal
lung maturity

94. DR/AHMED ESAWY
Ultrasonograph shows echogenic thalamus (T)
at 38 weeks of gestation (white arrows).

95. DR/AHMED ESAWY
Fetal pulmonary artery Doppler waveform
acceleration/ejection time [PATET] measurement
may provide a noninvasive means of determining
FLM with relatively acceptable levels of sensitivity,
specificity, and predictive values