How to perform basic antenatal screening with fetal echocardiography

September 1, 2003

A Web exclusive by Drs. Benoit and Copel, and only available online in conjunction with the authors' article, "Antenatal screening with fetal echocardiography: when and how," in our September 2003 issue.


How to perform basic antenatal screening with fetal echocardiography

Jump to:Choose article section...SitusCardiac positionCardiac sizeCardiac axisFour-chamber viewOutflow tracts

By Richard M. Benoit, MD, and Joshua A. Copel, MD

The goal of routine screening of the fetal heart is establishing that cardiac structure and function meet certain criteria (Figure 1). Attention first is focused on confirming that the heart lies on the fetus’s left side and on the same side as the stomach. Completing the four-chamber view allows for assessment of cardiac position, size, axis, chamber structure, septal integrity, and ventriculoarterial connections. The aortic and ductal arches also are assessed.

Both operator skill and image quality affect the accuracy of comprehensive cardiac assessment. Optimal fetal cardiac assessment with ultrasound (U/S) provides a high level of detection of serious cardiac malformations.1 Even when optimal, however, fetal cardiac scanning has limitations, particularly in detecting small septal defects. In addition, certain cardiac abnormalities may develop later in pregnancy, including pulmonary and aortic stenosis, cardiomyopathy, and cardiac tumors.2 Thus is remains important for each examiner to develop a routine that fosters complete assessment of the fetal cardiac structure and function, in standard fashion, with each exam (Figure 2).





Evaluation of fetal situs, the first step in assessing the fetal heart, requires knowledge of fetal position. Situs solitus is characterized by the location of both the heart and stomach on the left side of the fetus.

Cardiac position

Most of the fetal heart should be located in the anterior half of the fetal chest. With a transverse view of the fetal chest, the most posterior aspect of the heart should lie in the right hemithorax, midway between the anterior and posterior sides of the fetus. For the most part, both ventricles are situated in the left anterior quadrant of the chest, with the exception of a small portion of the right ventricle. The atria may be partially located in the right thorax.

Cardiac size

Cardiac size, also an important component of the exam, can be evaluated with the four-chamber view. The heart area should be approximately one third of the total chest area at the level of the four-chamber view.3

Cardiac axis

The cardiac axis refers to the position of the fetal heart in the chest, and can be determined by measuring the angle formed between the interventricular septum and a line from the spine to the anterior chest wall that divides the fetal thorax in half. The fetal heart typically lies at a 45-degree angle from the midline, and 95% of normal hearts are between 30 and 60 degrees of axis.

Four-chamber view

The four-chamber assessment includes apical, basal, and long-axis views (Table 1 and Figure 3). The apical view, with the U/S beam parallel to the interventricular and interatrial septa, allows evaluation of chamber size and of the atrioventricular valves. The long-axis view, with the U/S beam perpendicular to the septa, allows for evaluation of septal integrity.


Components of the four-chamber view

Heart in the left chest

Atria equal size

Ventricles equal size

Heart 1/3 of chest area

Left atrium posterior

Foramen ovale flap in left atrium

Apical offset in tricuspid valve

Intact interventricular septum

Moderator band in right ventricle

Axis 45-60 degrees


The right and left atria and ventricles of the fetal heart typically appear nearly equal in size, although the right ventricle may become larger than the left near term. The ventricular walls also should appear nearly equal in thickness. The moderator band may be seen in the right ventricle (trabeculated appearance), whereas the left ventricular wall appears smooth. The foramen ovale may be visualized in the left atrium, along with the pulmonary veins. The atrioventricular valves may be demonstrated, with the septal leaflet of the tricuspid valve inserting more apical than the mitral valve. Cardiac function is assessed by observing the contractility of the heart and valvular motions. In the long-axis view, the interventricular septum should be seen as continuous from the apex to the atrioventricular valves.

Outflow tracts

Transverse and longitudinal views of the ventriculoarterial outflow tracts are performed. The posterior leaflet of the aortic valve should be seen in continuity with the anterior leaflet of the mitral valve (Figure 3). The anterior wall of the aorta also should be continuous with the ventricular septum and the superior vena cava should be visible. Most importantly, the great artery tracts should cross each other and the vessels should be of normal size and not show regurgitation on color-flow Doppler (Figure 3). To complete the examination, visualize the aortic and ductal arches in transverse or longitudinal views (Figure 4].





1. Achiron R, Glaser J, Gelernter I, et al. Extended fetal echocardiographic examination for detecting cardiac malformations in low risk pregnancies. BMJ. 1992;304:671-674.

2. Yagel S, Weissman A, Rotstein Z, et al. Congenital heart defects: natural course and in utero development. Circulation. 1997;96:550-555.

3. Paladini D, Chita SK, Allan LD. Prenatal measurement of cardiothoracic ratio in evaluation of heart disease. Arch Dis Child. 1990;65:20-23.

Dr. Benoit is Assistant Clinical Professor, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Brown University School of Medicine, Women and Infants’ Hospital, Providence, R.I.
Dr. Copel is Professor, Department of Obstetrics and Gynecology, Section Head, Maternal-Fetal Medicine, and Director of Obstetrics, Yale-New Haven Hospital, New Haven, Conn.


Richard Benoit. How to perform basic antenatal screening with fetal echocardiography.

Contemporary Ob/Gyn

Sep. 1, 2003;48.