journal article·2026-03-19Open access

Practical Guide to Fetal Functional Cardiac Assessment

Anna Erenbourg, Neama Meriki, Hagai Avnet, Fatima Crispi, Alec W. Welsh

Applied Sciences· Volume 16· Issue 6

Abstract

Background: Recent evidence suggests the potential role of fetal cardiac function parameters in the assessment of different obstetrical conditions. Despite this evidence, the application of cardiac function parameters to routine fetal cardiac evaluation is limited. Among other reasons, the lack of accessibility to a simple, practical instrument offering tips on how to carry out a fetal cardiac functional assessment could explain this restricted application. Methods: A narrative review of the available literature on how to practically carry out a fetal cardiac function assessment was reviewed and summarized to offer an instrument to assess fetal cardiac function alongside the classical morphological evaluation. Results: The contents of this guide are focused exclusively on the practical details to carry out a fetal cardiac function assessment and voluntarily exclude the definition of and indications for the parameters assessed. The guide includes the assessment of fetal cardiac morphometry, valvular evaluation and cardiac contractility. Conclusions: The aim of this guide is to make fetal cardiac functional parameters more accessible to maternal and fetal medicine health professionals with a good background knowledge of fetal cardiology.
Source: crossref · Quality: baseline

Research context

OpenAlex topics: Neonatal and fetal brain pathology · Congenital Heart Disease Studies · Fetal and Pediatric Neurological Disorders

SciVX discovery tags are terminology-based. OpenAlex topics are source-provided classifications.

Affiliations

Perinatal Imaging Research Group, Royal Hospital for Women, Barker St., Randwick, Sydney, NSW 2031, Australia

School of Clinical Medicine Level 0, Royal Hospital for Women, University of New South Wales, Barker St., Locked Bag 2000, Randwick, Sydney, NSW 2031, Australia

Department of Maternal Fetal Medicine, King Khalid University Hospital, Riyadh 12372, Saudi Arabia

Institute of Obstetrics and Gynaecological, Imaging and Fetal Therapy Sheba Medical Centre, Tel HaShomer, Tel Aviv 5590500, Israel

Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Deu, 08037 Barcelona, Spain

References (82)

Show source-provided references
1. Main Patterns of Fetal Cardiac Remodeling10.1159/000506047 ↗
2. Effect of maternal diabetes on fetal heart function on echocardiography: Systematic review and meta-analysis10.1002/uog.22163 ↗
3. Fetal cardiac remodeling and dysfunction is associated with both preeclampsia and fetal growth restriction10.1016/j.ajog.2019.07.025 ↗
4. Drug exposure during pregnancy and fetal cardiac function—A systematic review10.1515/jpm-2019-0402 ↗
5. Fetal cardiac function at midgestation and conception by in-vitro fertilization10.1002/uog.26207 ↗
6. Cardiac function and dysfunction in the fetus10.1111/echo.13654 ↗
7. Reference ranges for fetal cardiac, ventricular and atrial relative size, sphericity, ventricular dominance, wall asymmetry and relative wall thickness from 18 to 41 gestational weeks10.1002/uog.23127 ↗
8. How to define end-diastole and end-systole? Impact of timing on strain measurements10.1016/j.jcmg.2014.10.010 ↗
9. International Society of Ultrasound in Obstetrics and Gynecology, Carvalho, J.S., Allan, L.D., Chaoui, R., Copel, J.A., DeVore, G.R., Hecher, K., Lee, W., Munoz, H., and Paladini, D. (2013). ISUOG Practice Guidelines (updated): Sonographic screening examination of the fetal heart. Ultrasound Obstet. Gynecol., 41, 348–359.10.1002/uog.12403 ↗
10. Nomograms of fetal cardiothoracic ratio from 17 to 37 weeks’ gestation as assessed by three different measurement techniques and their correlation with gestational age10.1002/pd.6057 ↗
11. Fetal Heart Size: A Comparison Between the Point-to-Point Trace and Automated Ellipse Methods Between 20 and 40 Weeks’ Gestation10.7863/ultra.16.02019 ↗
12. Assessment of the intraobserver variability in the measurement of fetal cardiothoracic ratio using ellipse and diameter methods10.1002/uog.2813 ↗
13. Nomograms of Fetal Cardiac Dimensions at 18–41 Weeks of Gestation10.1159/000494838 ↗
14. Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging10.1016/j.echo.2014.10.003 ↗
15. Recommendations for quantification methods during the performance of a pediatric echocardiogram: A report from the Pediatric Measurements Writing Group of the American Society of Echocardiography Pediatric and Congenital Heart Disease Council10.1016/j.echo.2010.03.019 ↗
16. Reference Ranges and Z-Score Equations for 19 Fetal Cardiac Biometry Structures from 18 to 34 Weeks’ Gestation10.1002/jum.16609 ↗
17. Fetal cardiac function evaluation: A review10.1002/jcu.23421 ↗
18. 24-segment sphericity index: A new technique to evaluate fetal cardiac diastolic shape10.1002/uog.17505 ↗
19. Left ventricular wall thickness determined by ultrasound in 100 subjects without heart disease10.1378/chest.60.4.341 ↗
20. Noninvasive assessment of left ventricular function
21. Echocardiography-based left ventricular mass estimation. How should we define hypertrophy?10.1186/1476-7120-3-17 ↗
22. Crispi, F., Nogué, L., Pérez, M., Masoller, N., Escobar-Díaz, M.C., Bennasar, M., Martínez, J.M., and Gómez, O. (2014). Protocolo Ecocardiografia Functional Fetal, BCNatal Fetal Medicine Research Center.
23. Fetal cardiac filling and ejection time fractions by pulsed-wave Doppler: Reference ranges and potential clinical application10.1002/uog.22152 ↗
24. Prenatal three-vessel and tracheal view: Normal features10.1016/j.gyobfe.2014.01.023 ↗
25. Abuhamad, A.Z., and Chaoui, R. (2009). A Practical Guide to Fetal Echocardiography: Normal and Abnormal Hearts, Wolters Kluwer.
26. Evaluation of conventional Doppler fetal cardiac function parameters: E/A ratios, outflow tracts, and myocardial performance index10.1159/000330792 ↗
27. Ultrasound assessment of fetal cardiac function10.1002/j.2205-0140.2013.tb00242.x ↗
28. Simpson, J., Zidere, V., and Miller, O. (2018). Fetal Cardiology: A Practical Approach to Diagnosis and Management, Springer.10.1007/978-3-319-77461-9 ↗
29. Second trimester echocardiography10.1016/j.bpobgyn.2025.102592 ↗
30. Assessing fetal cardiac ventricular function10.1016/j.siny.2005.08.009 ↗
31. Normal fetal pulmonary venous blood flow velocity10.1046/j.1469-0705.1995.06040277.x ↗
32. Fetal atrioventricular and outflow tract flow velocity waveforms during normal second half of pregnancy10.1016/0002-9378(91)90306-C ↗
33. Reference ranges for the pulsatility index of the fetal aortic isthmus in singleton and twin pregnancies10.7863/ultra.34.4.577 ↗
34. Doppler velocimetry of the ductus arteriosus in normal fetuses and fetuses suspected for pulmonary hypoplasia10.1159/000243713 ↗
35. The Aortic Isthmus: A Significant yet Underexplored Watershed of the Fetal Circulation10.1159/000446942 ↗
36. Blood flow velocity waveforms of the fetal pulmonary artery and the ductus arteriosus: Reference ranges from 13 weeks to term10.1046/j.1469-0705.2000.00082.x ↗
37. Variations in ductus arteriosus Doppler parameters in different sonographic views during the second half of gestation
38. Doppler assessment of fetal aortic isthmus blood flow in two different sonographic planes during the second half of gestation10.1002/uog.1955 ↗
39. Methods for prenatal assessment of fetal cardiac function10.1002/pd.2379 ↗
40. The use of biplane angiocardigraphy for the measurement of left ventricular volume in man10.1016/0002-8703(60)90359-8 ↗
41. Problems in echocardiographic volume determinations: Echocardiographic-angiographic correlations in the presence or absence of asynergy10.1016/0002-9149(76)90491-4 ↗
42. Beyond Simpson s Rule: Accounting for Orientation and Ellipticity Assumptions10.1016/j.ultrasmedbio.2022.07.013 ↗
43. Determination of ventricular volumes in human fetal hearts by two-dimensional echocardiography10.1016/S0002-9149(99)80365-8 ↗
44. Two-dimensional echocardiographic determination of ventricular volumes in the fetal heart. Validation studies in fetal lambs10.1161/01.CIR.81.1.325 ↗
45. Nomograms of Fetal Right Ventricular Fractional Area Change by 2D Echocardiography10.1159/000503228 ↗
46. Right ventricular function in preterm and term neonates: Reference values for right ventricle areas and fractional area of change10.1016/j.echo.2015.01.024 ↗
47. Clinical utility of right ventricular fractional area change in preterm infants10.1016/j.earlhumdev.2015.10.015 ↗
48. Fetal cardiac function by three-dimensional ultrasound using 4D-STIC and VOCAL—An update10.15557/JoU.2019.0043 ↗
49. Examination of the fetal heart by four-dimensional (4D) ultrasound with spatio-temporal image correlation (STIC)10.1002/uog.2724 ↗
50. Three-dimensional (3D) and 4D color Doppler fetal echocardiography using spatio-temporal image correlation (STIC)10.1002/uog.1075 ↗
51. Fetal cardiac ventricle volumetry in the second half of gestation assessed by 4D ultrasound using STIC combined with inversion mode10.1002/uog.4036 ↗
52. A novel method to improve prenatal diagnosis of abnormal systemic venous connections using three- and four-dimensional ultrasonography and ‘inversion mode’10.1002/uog.1877 ↗
53. 3D and 4D ultrasound in fetal cardiac scanning: A new look at the fetal heart10.1002/uog.3912 ↗
54. Three- and four-dimensional reconstruction of the aortic and ductal arches using inversion mode: A new rendering algorithm for visualization of fluid-filled anatomical structures10.1002/uog.1754 ↗
55. Inversion mode: A new volume analysis tool for 3-dimensional ultrasonography10.7863/jum.2005.24.2.201 ↗
56. Fetal ventricular shortening fraction in hydrops fetalis10.1097/AOG.0b013e3181fc3887 ↗
57. A modified myocardial performance (Tei) index based on the use of valve clicks improves reproducibility of fetal left cardiac function assessment10.1002/uog.1959 ↗
58. Gestational-age-adjusted reference values for the modified myocardial performance index for evaluation of fetal left cardiac function10.1002/uog.3947 ↗
59. The (Pulsed-Wave) Doppler Fetal Myocardial Performance Index: Technical Challenges, Clinical Applications and Future Research10.1159/000363181 ↗
60. Reproducibility of constituent time intervals of right and left fetal modified myocardial performance indices on pulsed Doppler echocardiography: A short report10.1002/uog.10049 ↗
61. Comparison of tissue Doppler velocities obtained by different types of echocardiography systems: Are they compatible?10.1111/j.1540-8175.2009.01018.x ↗
62. Technical considerations for measurement of the fetal left modified myocardial performance index10.1159/000334385 ↗
63. Spectral Doppler, tissue Doppler, and speckle-tracking echocardiography for the evaluation of fetal cardiac function: An update10.1590/0100-3984.2020.0052 ↗
64. Assessment of fetal cardiac function using tissue Doppler techniques10.1159/000335028 ↗
65. Tissue Doppler imaging in the normal fetus10.1016/S0167-5273(99)00152-7 ↗
66. Reference ranges for the fetal mitral, tricuspid, and interventricular septum annular plane systolic excursions (mitral annular plane systolic excursion, tricuspid annular plane systolic excursion, and septum annular plane systolic excursion) between 20 and 36 + 6 weeks of gestation10.1515/jpm-2020-0002 ↗
67. Value of annular M-mode displacement vs tissue Doppler velocities to assess cardiac function in intrauterine growth restriction10.1002/uog.12374 ↗
68. Measurement of atrioventricular annular plane displacement has been revived: Will it prove to be useful in assessing fetal cardiac function?10.1002/uog.12542 ↗
69. Agreement between anatomical M-mode and tissue Doppler imaging in the assessment of fetal atrioventricular annular plane displacement in uncomplicated pregnancies: A prospective longitudinal study10.1111/jog.14068 ↗
70. Tissue Doppler imaging measurement of left ventricular systolic function in children: Mitral annular displacement index is superior to peak velocity10.1016/j.echo.2009.01.008 ↗
71. Fetal cardiac function by mitral and tricuspid annular plane systolic excursion using spatio-temporal image correlation M-mode and left cardiac output in fetuses of pregestational diabetic mothers10.5468/ogs.20274 ↗
72. Fetal Heart Function by Tricuspid Annular Plane Systolic Excursion and Ventricular Shortening Fraction Using STIC M-Mode: Reference Ranges and Validation10.1055/s-0037-1603652 ↗
73. Development of Z-scores for fetal cardiac dimensions from echocardiography10.1002/uog.2597 ↗
74. Reference Ranges for the Size of the Fetal Cardiac Outflow Tracts from 13 to 36 Weeks Gestation: A Single-Center Study of over 7000 Cases10.1161/CIRCIMAGING.118.007575 ↗
75. Reference ranges for the left ventricle modified myocardial performance index, respective time periods, and atrioventricular peak velocities between 20 and 36 + 6 weeks of gestation10.1080/14767058.2019.1609933 ↗
76. Z-score reference ranges for pulsed-wave Doppler indices of the cardiac outflow tracts in normal fetuses10.1007/s10554-018-01517-1 ↗
77. Reference values for fetal aortic isthmus blood flow parameters at 24 to 38 weeks’ gestation10.1002/pd.4296 ↗
78. Heart stroke volume and cardiac output by four-dimensional ultrasound in normal fetuses10.1002/uog.5374 ↗
79. Heart stroke volume, cardiac output, and ejection fraction in 265 normal fetus in the second half of gestation assessed by 4D ultrasound using spatio-temporal image correlation10.3109/14767058.2010.545921 ↗
80. Development of normal gestational ranges for the right myocardial performance index in the Australian population with three alternative caliper placements10.1159/000362388 ↗
81. Reference ranges for left, right and interventricular septum indices at 20 to 36 + 6 weeks of gestation derived using spectral myocardial tissue Doppler on Voluson ultrasound machines10.11152/mu-1945 ↗
82. Fetal tricuspid annular plane systolic excursion (f-TAPSE): Evaluation of fetal right heart systolic function with conventional M-mode ultrasound and spatiotemporal image correlation (STIC) M-mode10.1002/uog.12375 ↗