Reference Values and Z Scores for Pulsed-Wave Doppler and M-Mode Measurements in Fetal Echocardiography

J Am Soc Echocardiogr. 2016 May;29(5):448-460.e9. doi: 10.1016/j.echo.2016.01.002. Epub 2016 Mar 9.


Background: Fetal echocardiography is now the standard approach for detailed investigations of fetal cardiac anatomy and function. Available studies proposing reference values for pulsed-wave Doppler (PWD) measurements are often focused on few parameters. Furthermore, the methodology used for validating these proposed reference values is sometimes insufficiently described, and parameters necessary to compute Z scores are not always available. Improved definition of reference values with adequate statistical validation is needed for proper interpretation of PWD measurements in a clinical setting. In this study, the authors propose a comprehensive set of reference values and Z score equations for fetal PWD and M-mode measurements with thorough assessment of Z score quality and validity.

Methods: Women with normal singleton pregnancies between 18 and 39 weeks of gestational age were included. A set of 57 measurements was performed, including PWD, M-mode measurements, and calculation of systolic, diastolic, and global function indices. Several parametric regressions were tested to model each measurement against gestational age. The SD was also modeled to account for heteroscedasticity. Z score equations were computed, and the proposed reference values were tested for residual association, residual heteroscedasticity, and departure from the normal distribution.

Results: One hundred four uncomplicated singleton pregnancies with normal fetal hearts were included. Nonlinear relationships with gestational age were found for most measurements. Parametric normalization was successful for most measurements analyzed, and it was possible to compute Z score equations with minimal residual association with gestational age, no residual heteroscedasticity, and no significant departure from the normal distribution.

Conclusions: The authors propose a comprehensive set of Z score equations for 57 fetal functional measurements, some of which do not have any published reference values. These Z score equations will allow echocardiographers to more accurately identify measurements that diverge from normal and thus detect earlier potential alterations in fetal heart function.

Keywords: Fetal echocardiography; Fetal heart function; Reference values; Z score.

Publication types

  • Evaluation Study
  • Validation Study

MeSH terms

  • Echocardiography, Doppler, Pulsed / methods
  • Echocardiography, Doppler, Pulsed / standards*
  • Female
  • Heart Ventricles / diagnostic imaging*
  • Humans
  • Image Interpretation, Computer-Assisted / methods
  • Image Interpretation, Computer-Assisted / standards*
  • Male
  • Quebec
  • Reference Values
  • Reproducibility of Results
  • Sensitivity and Specificity
  • Stroke Volume*
  • Ultrasonography, Prenatal / methods
  • Ultrasonography, Prenatal / standards*
  • Ventricular Function, Left / physiology*