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ENTRE LAS 16 Y LAS 24 SEMANAS DE GESTACION SE OBSERVA UN AUMENTO MUY SIGMIFICATIVO DE LA CANTIDAD Y LA COMPLEJIDAD DE LOS ESPACIOS AEREOS
DESPUES DE TRANSCURRIDAS 24 SEMANAS DE ESTACION OTRO FEMOMENO EVOLUTIVO IMPORTANTE SE SUMA A LAS ALTERACIONES CUNTITATIVAS Y FUNCIONALES DE LOS ESPACIOS AEREOS. ESTA MODIFICACION PERMITE UN MAYOR GRADO DE YUSTAPOSICION ENTRE LOS CAPILARES Y LA LUZ DEL ESPACIO AEREO
FACTORES RESPONSABLES DEL DESARROLLO PULMONAR NORMAL DURANTE LA VIDA FETAL. 1.-ESPACIO TORACICO SUFICIENTE PARA EL CRECIMIENTO. 2.-LOS MOVIMIENTOS RESPIRATORIOS FETALES
3.-LA PRESENCIA DE LIQUIDO EN EL INTERIOR DE LOS PULMONES QUE ACTUA COMO UN stent INTRAPULMONAR LIQUIDO QUE DISTIENDE LAS VIAS AEREAS EN DESARROLLO. 4.-CANTIDAD SUFICIENTE DE LIQUIDO AMNIOTICO
TODA ANOMALIA QUE INTERFIERE EN ALGUNO DE ESTOS FACTORES TAMBIEN OBSTACULIZARA EL DESARROLLO PULMONAR NORNAL
UN BARRIDO DEL TORAX EN LOS PLANOS TRANSVERSALES NOS PERMITE OBTENER IMFORMACION IMPORTANTE
Examination of the lungs in the same section used for the four-chamber view of the fetal heart is sufficient. Under normal condition, the fetal lungs are uniformely echogenic. At 18-23 weeks, the central third of the thoracic area at the level of the four chamber view is occupied by the heart, and the remaining two thirds by the lungs, that are normally uniformely echogenic.
The examination of the fetal heart begins with the assessment of the disposition of abdominal and thoracic organs
CONFIGURACION DEL TORAX EL TAMAO DE TORAX LA SIMETRIA DE TORAX LA ECOTEXTURA PULMONAR EL TAMAO LA LOCALIZACION Y LA DIRECCION DEL EJE CARDICO
Axis
45+20o towards the left Abnormal axis increases the risk of a cardiac malformation The heart may also be displaced from its normal position in dipaphragmatic hernia or cystic adenomatoid malformation
LOS PULMONES NORMALES SON SIMETRICOS Y HOMOGENEOS CON UN NIVEL MEDIO DE ECOGENICIDAD QUE AUMENTA GRADUALMENTE A MEDIDA QUE AVANZA EL EMBARAZO
DESDE UNA PESPECTIVA VOLUMETRICA EL PULMON DERECHO ES LIGERAMENTE MAS GRANDE QUE EL IZQUIERDO LAS VENAS Y ARTERIAS PUEDEN DETECTARSE EN LAS REGIONES CENTRALES DE LOS PULMONES EN LA CONVERGENCIA DE LA AURICULA IZQUIERDA Y LA ARTERIA PULMONAR IZQUIERDA EL TIMO UN ESTRUCTURA SOLIDA HOMOGENEAY RELATIVAMENTE HIPOECOIC A LOCALIZADO EN EL MEDIATINO ANTERIOR
EL PUNTO DE REFERENCIA ANATOMICO MAS NOTABLE DEL TORAX ES EL DEL CORAZON DURANTE EL SEGUNDO Y TERCER TRIMESTRE DEL EMBARAZO SE ENCUENTRA INDICADO OBTENER UNA IMAGEN DE LAS CUATRO CAVIDADES
EN CONDICIONES NORMALES EL CORAZON OCUPA ENTRE LA CUARTA Y LA TERCERA PARTE DE LA CAVIDAD TORAXICA EN UNA IMAGEN TRANVERSAL Y SE ENSCUENTRA UBICADO INMEDIATAMENTE A LA IZQUIERDA DE LA LINEA MEDIA EN EL CUADRANTE ANTERIOR IZQUIERDO
Cardiac axis of greater than 75 to the left - 75% are due to cardiac anomalies - 25% have normal hearts
. Cardiac + extra-cardiac defects. Tetralogy of Fallot + diaphragmatic hernia. Double outlet RV + choroid plexus cyst + abnormal extremities (trisomy 18). Double outlet RV + renal agenesis. Transposition of great vessels + omphalocele. VSD + omphalocele. LV aneurysm and omphalocele (trisomy 13). Cardiomegaly + VSD + vein of Galen AVM
Done on a 4 chamber view Heart mostly in left chest Occupies 1/3 of thoracic area Normal cardiac situs, axis and position No pericardial effusion
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ES IMPORTANTE EVALUAR CUIDADOSAMENTE LAS CAMARAS VENTRICULARES PARA DETERMINAR EL GRADO DE SIMETRIA
LA PRESENCIA DE ASIMETRIA DEBE ORIENTAR HACIA UNA POSIBLE HIPOPLASIA VENTRICULAR LA IMAGEN DE LAS CUATRO CAMARAS CARDIACAS TAMBIEN PERMITE DETECTAR LESIONES OCUPANTES CARDIACAS
LA HIPOPLASIA PULMONAR Y SUS COMPLICACIONES REPRESENTAN LA PRINCIPAL RAZON POR LA CUAL FETOS DE MENOS DE 24 SEMANAS DE DESARROLLO SE CONSIDERA INVIABLES. LA HIPOPLASIA PULMONAR CONDUCE A INSUFIENCIA RESPIRATORIA DESPUES DEL NACIMIENTO. LA AGENESIA PULMONAR BILATERAL ES INCOMPATIBLE CON LA VIDA POSTNATAL
Displasia tanatofrica
De todas las situaciones clnicas en las que existe riesgo de HIPOPLASIA PULMONAR, la ms frecuente es el OLIGOHIDRAMNIOS secundario a una Ruptura Prematura de las membranas Amniticas.
Una MASA OCUPANTE DEL TORAX puede inducir a una hipoplasia pulmonar grave por un efecto de compresin del pulmn en desarrollo. Las masas ocupantes del trax diagnosticadas con mayor frecuencia antes del nacimiento son; La HERNIA DIAFRAGMATICA CONGENITA Y MALFORMACION ADENOMATOIDE QUISTICA CONGENITA.
MAQ
ES LA MALFORMACION DIAFRAGMATICA MAS FECUENTE AFECTA A 1 A 4.5 DE CADA 10 000 NACIDOS VIVOS
El desarrollo del diafragma se completa las 9 semanas En falla del desarrollo del mismo hay herniacin a 10-12 semanas a trax cuando el intestino retorna a la cavidad abdominal En ocasiones las herniacin aparece en el 2o o 3r trimestre
HERNIA DIAFRAGMATICA CONGENITA ETIOLOGIA Por lo general es una anormalidad espordica 50% de los fetos asociados con anormalidades cromosmicas (trisoma 13 y 18 y Pallister-Killian) Craneoespinal defectos: espina bfida, hidrocefalia e iniencefalia) Defectos cardiacos. Sndromes genticos: Fryns, Langer y Marfan)
BOCHDALEK HERNIA
Male:Female ratio is 2:1.
Comprises >90% of all diaphragmatic abnormalities. 80% are on the left, 15% are on the right and 5% are bilateral (1,2)
Left sided hernias contain small intestine (88%), stomach (60%), colon (56%), liver (51%), gallbladder, spleen (45%), kidney (22%), pancreas (24%) or omental fat less commonly (2-4).
Increased nuchal translucency in the first trimester may be the first indirect sign that a diaphragmatic hernia is present. Solid or multicystic complex chest mass. Contents of the hernia. Bowel (especially with left sided lesions). Peristalsis of bowel within the fetal chest confirms the diagnosis, however this finding is not always present.
Bochdalek Hernia (on the left side) Stomach bubble in the chest cavity at the level of the heart. Dextraposition of the heart into right chest cavity. Mesocardia (axis alteration of heart).
GRAN TAMAO EG TEMPRANA EN EL MOMENTO DEL DX ANTES DE LAS 24 SEMANAS HIGADO ARRIBA PULMON CONTRALATERAL PEQUEO ANOMALIAS ASOCIADAS BILATERAL
HISTOLOGICAMENTE ESTAS LESIONES SE CARACTERIZAN POR UNA PROLIFERACION ANORMAL DE ESPACIOS AEREOS DE TIPO BRONQUIOLAR Y LA AUSENCIA DE ALVEOLOS NORMALES QUE SUGIEREN LA INTERRUPCION DEL DESARROLLO CELULAR NORMAL
ES UNA LESION HAMARTOMATOSA PULMONAR HISTOLOGICAMENTE ESTAS LESIONES SE CARACTERIZAN POR UNA PROLIFERACION ANORMAL DEL ESPACIO AEREO DEL TIPO BRONQUIOLAR Y LA AUSENCIA DE ALVEOLOS NORMALES
Type I: Has large cysts (often > 2 cm) that appear macrocystic on ultrasound examination this type accounts for about 50% of the cases and is reported to have the best prognosis. Type II: Has medium-sized cysts that are usually between 0.5 and 1.5 cm in diameter this type accounts for about 40% of the cases. Type III: Are microcystic growths that typically appear as large hyperechoic masses this type accounts for about 10% of the cases. They are thought to appear solid, secondary to the numerous reflections from interfaces of the myriad of very tiny cysts (cysts are 0.5 to 3 mm in size).
Single cyst or more commonly multiple cysts (>2 cm) within the hemithorax. Cysts may involve an entire pulmonary lobe. Cysts are clustered with one or more 2-10 cm cyst(s) surrounded by multiple smaller cysts The larger cysts contain respiratory epithelium whereas the smaller ones resemble dilated bronchioles (1). Most frequent type (75%), and 75% are right sided. Mediastinal shift in about 80%. Survival rate is high (90%).
DIFFERENTIAL DIAGNOSIS
1.The multiple large cysts differentiate bit from a bronchogenic cyst which is small, solitary and situated near the midline. 2-The delicate internal septations distinguish Type I CAML from a duplication cyst.
Large bulky non-cystic echogenic mass. The solid appearance is due to the specular reflections of multiple interfaces between the tiny cysts (microcystic = <3-5 mm). May involve an entire lung or lobe. The majority (68%) may be diagnosed at 22 weeks gestation or earlier (1) Equal frequencies in left and right lungs (1,2). Color doppler imaging is important to distinguish this from bronchopulmonary sequestration. Survival rate 50%.
Type I
Sonographic Appearance
Usually unilateral May involve all or part of a lung lobe Single large cyst with small cystic out pouchings Echogenicities may be seen within the cyst Similar to Type 1 except there are numerous similar sized cysts
Histologic Findings
Single large cyst that is 2 cm or greater in size Trabeculated cyst walls with smaller out pouching cysts Mass consists of multiple similar sized cysts that are 0.5 to 1.5 cm
Differential Diagnosis
Congenital diaphragmatic hernia Bronchogenic cyst Mediastinal mass Pleural or Pericardial effusions Congenital diaphragmatic hernia Bronchogenic cyst Mediastinal mass Pleural or Pericardial effusions Pulmonary Sequestration Lung tumors such as teratoma / rhabdomyoma Herniated liver or spleen
II
III
Cysts that are too small to be distinctly identified sonographically Appears as a solid echogenic mass
SECUESTRO PULMONAR QUISTES BRONCOGNICOS ATRESIA BRONQUIAL ENFISEMA LOBULAR CONGENITO OBSTRUCCION DE LAS VIAS AEREAS ALTAS O ATRESIA LARINGEA
ECOGRAFRIA DEL TORAX FETAL SECUESTRO PULMONAR Portion of the lung develops without connection to the airways The blood supply arise from the descending aorta. This condition is divided into intralobar (about 75%) and extralobar (about 25%). Diagnosis: 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).
SECUESTRO PULMONAR
Large lung sequestration may act as an arteriovenous fistula and cause high-output heart failure and hydrops. Intralobar sequestrations are usually isolated, whereas more than 50% of extralobar sequestrations are associated with other abnormalities (mainly diaphragmatic hernia and cardiac defects).
QUISTES BRONCOGNICOS
1. Mediastinum Bronchogenic Cyst Pericardial (52%), paratracheal (19%), esophageal wall (14%), retrocardiac
(9%). Usually on the right side, single and centrally located. May communicate with tracheal lumen. Males = females. Intrapulmonary Bronchogenic Cyst Centrally within the lung (lower lobe:upper lobe = 2:1). Rarely below the diaphragm. Males more common than females. Does not usually communicate with the tracheobronchial tree. Well circumscribed and hyperechogenic on ultrasound. Can cause more diffuse pulmonary hyperechogenicity. Ectopic intra-abdominal bronchogenic cyst has been described (10). Other ectopic locations include the cervical and retroperitoneal regions.
2.
3.
ULTRASOUND Well defined unilocular mass within the mediastinum or lung parenchyma Cystic in nature and adjacent to the mediastinum. Usually single. mm to over 5cm and may adhere to the bronchial or bronchiolar wall, or communicate via a pedicle. No mediastinal shift, polyhydramnios or fetal hydrops is present. Compression of the adjacent lung (large cysts) with subsequent pulmonary hypoplasia. Compression of a mainstem bronchus or esophagus has been described (5) Compression of the intrathoracic great vessels and lymphatics producing ascites and nonimmune hydrops may occur (7). The cyst usually increases in size with advancing gestation.
ASSOCIATED ANOMALIES
Usually isolated. Reece and co-workers (6) reported on two cases with severe associated anomalies, however this is the exception rather than the rule
ATRESIA BRONQUIAL
Se presenta como lesin de masa ocupante. La masa es el pulmn obstruido ocupado por lquido. El mecanismo es obstruccin focal de un segmento
de luz focal de bronquio. Afecta con mayor frecuencia al lbulo superior izquierdo. Rara vez afecta lbulos inferiores
Frecuencia baja Sobredistencin lobular sin destruccin de los tabiques Predomina en lbulo superior y medio (pred. izquierdo) En el US la imagen de ELC es similar a la MAQC tipo III La localizacin superior permite diferenciarlo de secuestro extralobular (SEL)
OBSTRUCCION
Estenosis o atresia subgltica de la vas area (faringea) o de porcin proximal de traquea. US: aumento de tamao, bilateral y ecognico ambos pulmones con ecotextura homognea y aplanamiento o inversin de cpulas diafragmticas. Se pueden observar los 2 bronquios principales en forma qustica. El corazn no est desplazado, sino en posicin central anterior. 50% presentan otras malformaciones renales o del SNC