Abnormal Ductus Venosus Blood Flow Research Articles

EP10.22: Prenatal diagnosis of pulmonary stenosis

Pulmonary stenosis is obstruction of the right ventricular outflow tract caused primarily by narrowing of the infundibulum or valve stenosis. Right ventricular outflow tract obstructions with an intact ventricular septum account for about 1–5% of all fetal congenital heart disease. Patient referred to fetal echocardiography after abnormal ultrasound. Fetal echocardiography demonstrated: hypoplastic right ventricle, with hypertrophic wall, increased right atrium and pericardial effusion. Pulmonary valve was thickned and with low mobility. After pulmonar valve, there was a proximal dilatation of pulmonar artery. The flow throw pulmonar valve was manteined antegrade only few milimeters from the valve, demonstrating small valve permeability. Both branches from the pulmonary arteries were demonstrated in a three vessel view. Colour Doppler highlights the presence of tricuspid regurgitation, a reverse flow into ductus arteriosus. an abnormal Ductus venosus blood flow. Prenatal diagnosis is uncommon and include assymetry in ventricular size, right atrial enlargement, thickening of the pulmonar valve and Doppler abnormalities. Routine ultrasonography does not detect mild or moderate pulmonar stenosis. Delivery should occur in a terciary centre with cardiology backup and prostaglandine infusion. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Fetale Nackentransparenz und weitere Ersttrimester Marker: Screening auf fetale Herzfehler

The present article summarises current knowledge on the risk of fetal cardiac malformations in fetuses with increased nuchal translucency (NT), abnormal ductus venosus blood flow pattern and tricuspid regurgitation. The risk of congenital heart disease (CHD) increases with increasing NT. However, nuchal translucency screening is only modestly efficient in the detection of congenital heart disease in low-risk pregnancies. If the nuchal translucency is normal, abnormal ductus venosus blood flow and tricuspid regurgitation show low sensitivities as single screening parameters. The combination of all 3 markers might increase the detection rates. Fetal echocardiography at 20 weeks of gestation is recommended in foetuses with an NT ≥95th percentile, as the incidence of CHD increases 2.5-fold. When the NT measurement is ≥99th percentile, the risk of CHD increases 10-fold. In this high-risk group and in fetuses with tricuspid regurgitation and/or an abnormal DV flow pattern along with an increased NT, first or early second trimester echocardiography performed by experts is warranted. The early examination of the fetal heart should be completed by a detailed echocardiogram at around 20 weeks of gestation.

First‐trimester detection of structural abnormalities and the role of aneuploidy markers

To determine the sensitivity of first-trimester ultrasound for diagnosing different structural anomalies in chromosomally normal pregnancies, and to establish the role of aneuploidy markers in the detection of abnormalities. This was a retrospective study of chromosomally normal singleton pregnancies with an 11-14-week scan performed in our center during 2002-2009. The ultrasound examination included an early fetal anatomy survey and assessment of nuchal translucency, ductus venosus blood flow and nasal bone. Among 13 723 scanned first-trimester pregnancies with no genetic anomalies and complete follow-up, 439 fetuses (3.2%) were found to present with structural anomalies (194 with major anomalies and 245 with only minor anomalies). Forty-nine per cent of major structural anomalies were detected during the first-trimester scan, the highest rates corresponding to acrania (17/17), holoprosencephaly (three of three), hypoplastic left heart syndrome (10/10), omphalocele (six of six), megacystis (seven of eight) and hydrops (eight of nine). Higher than expected detection rates were obtained for skeletal (69%) and cardiac (57%) defects, coincidentally showing the highest presence of an increased nuchal translucency or abnormal ductus venosus blood flow (38% and 52%, respectively). The finding of an absent nasal bone did not appear to be associated with structural defects. About half of major structural abnormalities can be diagnosed in the first trimester. Increased nuchal translucency or abnormal ductus venosus blood flow appear to be associated with cardiac and skeletal defects and may facilitate early detection.

Abnormal first‐trimester ductus venosus blood flow: a marker of cardiac defects in fetuses with normal karyotype and nuchal translucency

To evaluate the independent contribution of ductus venosus (DV) blood flow assessment at 11-14 weeks' gestation to the prediction of congenital heart defects (CHD) in chromosomally normal fetuses, irrespective of the value of the nuchal translucency thickness (NT). During a 4-year period, all singleton pregnancies from 11 + 0 to 13 + 6 weeks' gestation were scanned for NT and DV blood flow in a tertiary center. Abnormal DV blood flow was defined as either absent or reversed flow during atrial contraction (AR-DV). Fetal echocardiography was performed in all cases with either NT > 99(th) percentile or AR-DV. Follow-up was assessed by postnatal examination or autopsy in cases of termination of pregnancy or perinatal death. A total of 6120 pregnancies were scanned at a median gestational age of 12 weeks, and 45 cases of CHD were detected. AR-DV was found in 206 fetuses, of which 145 (70.4%) had a normal karyotype. Among fetuses with AR-DV and normal karyotype, 11 cases of CHD were diagnosed, giving a sensitivity of 24.4%, a positive predictive value of 7.6% and an odds ratio of 9.8. Increased NT (> 99(th) centile) was present in 55 of the 145 (37.9%) cases with AR-DV and normal karyotype, and in 6/11 (54.5%) of those with CHD. Thus, the group of 90 fetuses with abnormal DV blood flow and normal NT contained five cases of CHD, for a sensitivity of 11.1%, a positive predictive value of 5.5% and an odds ratio of 8.5. Right-heart anomalies were predominant in those cases with isolated AR-DV (4/5), but no specific CHD pattern was found in those with increased NT. The detection rate of CHD by the combined use of increased NT and/or AR-DV in the first trimester improved from 28.9% (13/45) to 40.0% (18/45). In experienced hands, abnormal DV blood flow in the first trimester is an independent predictor of CHD and should constitute an indication for early echocardiography. In this study, the use of DV blood flow assessment increased early detection of CHD by 11% with respect to the use of NT measurement alone.

Screening for twin–twin transfusion syndrome at 11–14 weeks of pregnancy: the key role of ductus venosus blood flow assessment

A discrepancy in crown-rump length (CRL) and/or nuchal translucency thickness (NT) between monochorionic twins has been found to be associated with an increased risk of twin-twin transfusion syndrome (TTTS). As one of the most plausible mechanisms for increased NT is hemodynamic imbalance and cardiac dysfunction, indirectly manifested by abnormal blood flow in the ductus venosus (DV), we aimed to clarify the role of DV blood flow assessment in identifying those monochorionic twins more prone to develop TTTS. We present 99 cases of monochorionic diamniotic twin pregnancies in which CRL, NT and DV blood flow were evaluated at 11-14 weeks' gestation. Discrepant values of CRL were not predictive of TTTS development. Intertwin NT discrepancy >or= 0.6 mm had a sensitivity of 50.0% and a specificity of 92.0%. The presence of at least one abnormal blood flow waveform in the DV was associated with a relative risk for developing TTTS of 11.86 (95% CI, 3.05-57.45), with a sensitivity of 75.0% and a specificity of 92.0%. The combination of abnormal DV blood flow with NT discrepancy >or= 0.6 mm yielded a relative risk for the development of TTTS of 21 (95% CI, 5.47-98.33). Both intertwin discrepancy in NT and abnormal flow in the DV in monochorionic twins may represent early manifestations of hemodynamic imbalance between donor and recipient. In these pregnancies, in addition to NT measurement at 11-14 weeks, the Doppler assessment of DV blood flow significantly increases the performance of screening for those at risk of developing TTTS.

OP21.01: Congenital heart disease in fetuses with abnormal ductus venosus blood flow and normal karyotype

To evaluate the role of ductus venosus (DV) blood flow assessment at 11–14 weeks gestation to predict congenital heart defects (CHD) in chromosomally normal fetuses. During a three-year period, fetal echocardiography was performed in 140 chromosomally normal fetuses with abnormal ductus venosus blood flow at 11–14 weeks, which was defined as either absent or reverse flow during the atrial wave (AR-DV). Nuchal translucency (NT) measurement was noted. Fetuses in which other structural malformations were detected or an spontaneous abortion occurred were excluded from the analysis. Follow-up was assessed by postnatal examination and autopsy in cases of termination of pregnancy or perinatal death. The median maternal age was 33 years-old (range 17–45) and the median gestational age at DV scan was 12 weeks. Increased NT > 99th percentile was associated with AR-DV in 53 cases (37.8%). Eleven (7.8%) CHD were detected: hypoplastic left heart syndrome (n = 1), atrioventricular septal defect (n = 1), transposition great arteries (n = 2), Fallot + pulmonary atresia (n = 2), left isomerism + AVSD (n = 2), tricuspid atresia (n = 1), pulmonary atresia intact septum (n = 1) and atrial septal defect (n = 1). The prevalence of CHD was higher if AR-DV was associated with increased NT (6/53, 11.3%) than when NT was normal (5/87, 5.7%), though it was not stastitically significant (P = 0.2). Cases with CHD had significant (P = 0.002) higher NT (4.6 ± 4.2 mm) than those with normal heart (2.4 ± 1.9 mm). Right heart anomalies were predominant in those cases with isolated AR-DV (4/5), unlike those with increased NT in which no specific pattern of CDH was shown. The predictive value of finding AR-DV at 11–14 weeks' scan to detect CHD is about 1/20. If NT > 99th percentile is associated, the risk increases up to about 1/10. Fetal echocardiography should be offered in such high-risk populations

The ductus venosus in early pregnancy and congenital anomalies.

The ductus venosus (DV) is a tiny vessel leading oxygenated blood from the placenta to the fetal heart and its flow assessment has been used as an indicator of fetal acidemia. At 11 to 14 weeks, the fetuses with increased nuchal translucency also showing an abnormal DV blood flow were consistently found to be aneuploid. Early cardiac dysfunction, signaled by abnormal DV blood flow, was suggested as the underlying cause of increased nuchal translucency. Detection rates for aneuploidy with the use of DV blood flow studies range from 59 to 93% with 2 to 21% false-positive rates. In fetuses with normal karyotype, an abnormal DV flow pattern signals cardiac defects or adverse perinatal outcome.

OC227a: Abnormal DV blood flow in the first trimester and detection of complications in monochorionic twins

Abnormal nuchal translucency and the reversed flow in the ductus venosus (DV) seem to be a good predictor of certain complications of monochorionic pregnancies, namely: twin-to-twin transfusion syndrome (TTTS), congenital heart diseases or early fetal demise. We analysed 19 monochorionic twin pregnancies at 12–14 weeks of pregnancy. Nuchal translucency thickness (NT1, NT2) was measured and the difference between both twins (NT1–NT2) was calculated. We also studied Doppler blood flow velocimetry in the ductus venosus (ACUSON 128 XP). The appearance of reversed blood flow in the DV during atrial systole was marked. We were able to visualize the DV by colour Doppler facilities and measure the blood flow by applying pulsed wave Doppler (angel of insonation < 30.0). A right ventral mid-sagittal plane of the fetal body was obtained and pulsed wave Doppler was performed in order to record the Doppler blood flow waveforms in the DV. A biweekly ultrasound scanning of the patients followed. We found four cases of abnormal blood flow in the DV and/or abnormal NT1-NT2 (> 0.5). Three of them were associated with cardiac anomaly, TTTS and fetal demise. Abnormal flow in the DV may be an early sign of not only chromosomal abnormalities but also cardiac anomalies or early cardiac dysfunction resulting in TTTS development.

Cardiac defects in chromosomally normal fetuses with abnormal ductus venosus blood flow at 10-14 weeks.

To assess a possible relationship between ductus venosus blood flow abnormalities and cardiac defects in chromosomally normal fetuses with increased nuchal translucency thickness at 10-14 weeks of gestation. Ductus venosus Doppler ultrasound blood flow velocity waveforms were obtained at 10-14 weeks' gestation immediately before fetal karyotyping in 200 consecutive singleton pregnancies with increased nuchal translucency. Fetal echocardiography was subsequently carried out in those with normal fetal karyotype. Reverse or absent flow during atrial contraction was observed in 11 of the 142 chromosomally normal fetuses with increased nuchal translucency. Major defects of the heart and/or great arteries were present in seven of the 11 with abnormal ductal flow and increased nuchal translucency, but in none of the 131 with normal flow. These preliminary results suggest that abnormal ductus venosus blood flow in chromosomally normal fetuses with increased nuchal translucency identifies those with an underlying major cardiac defect.

Abnormal ductus venosus blood flow in trisomy 21 fetuses during early pregnancy

Objective: Our purpose was to assess the ductus venosus blood flow in trisomy 21 fetuses in the first half of pregnancy and the relation of this blood flow to nuchal thickness. Study Design: The ductus venosus blood flow has been studied in 534 consecutive fetuses between 10 and 18 weeks of gestation who were undergoing prenatal invasive diagnostic procedures. Before the sampling, the velocity during atrial contraction, the pulsatility index for veins, and the ratio of systole–end-systole to diastole were established in the Doppler waveforms and eventually correlated with the fetal karyotype. Results: Ductus venosus waveforms were successfully obtained in 82% of the pregnancies. Eleven fetuses were found to have trisomy 21; the pulsatility index was abnormally increased (>95th percentile) in 73% (8/11), the ratio of systole–end-systole to diastole was abnormally increased in 45% (5/11), and the velocity during atrial contraction was decreased (<5th percentile) in 27% (3/11). Conclusions: An abnormally increased ductus venosus pulsatility index was found in a substantial proportion of early trisomy 21 fetuses, and this was apparently independent of nuchal thickening. (Am J Obstet Gynecol 1998;179:1612-7.)