Venous Doppler Flow Research Articles

Secondary Budd–Chiari syndrome complicating calcified right atrial thrombosis related to ventriculoatrial shunt

A 33-year-old female patient underwent diagnostic gynecologic laparoscopy for assessment of a cystic ovarian mass and moderate amounts of ascites. Operative exploration, unexpectedly, uncovered a coarsely multinodular liver surface suspicious of cirrhosis, and surgery was terminated by resection of the left adnexa. Histopathology of the surgical specimen and ascitic fluid analysis yielded no indication of underlying malignancy, and the patient was referred for hepatology work-up. Liver function tests were unremarkable; however, ultrasound revealed an inhomogeneous, nodular liver parenchyma with portal vein dilation and reduced portal venous flow suggestive of portal hypertension. Furthermore, the hepatic veins appeared compressed and duplex sonography failed to trace an unequivocal hepatic venous Doppler flow signal. Upper gastrointestinal endoscopy identified small esophageal varices. Comprehensive serological work-up was negative with respect to viral, metabolic, hereditary, or autoimmune liver disease. Given the insufficient visualization of hepatic veins on ultrasound, the patient underwent magnetic resonance imaging (MRI) indicating inhomogeneous hepatomegaly with regenerative nodules. Furthermore, hepatic vein and, in part, inferior vena cava (IVC) obstruction by a calcified mass extending up towards the right heart was detected. To better characterize the cardiac mass, transthoracic and transesophageal echocardiogram as well as cardiac MRI were performed. Echocardiography depicted a tumor-like right atrial (RA) structure spreading alongside the tricuspid valve (Fig. 1a, Supplemental Videos 1–2). Continuous-wave Doppler across the structure and along the right ventricular inflow tract demonstrated a pressure gradient of 8 mmHg, comparable to a relevant tricuspid stenosis. Likewise, cardiac MRI and CT reinforced the suspicion of a large calcified thrombus arising from the basal RA with appositional growth into the IVC and the hepatic veins (Fig. 1b–d, Supplemental Video 3). No signs of pulmonary embolism were found. Given the clinical diagnosis of subacute Budd–Chiari syndrome (BCS), a comprehensive laboratory assessment for potential prothrombotic conditions including JAK2 V617F testing remained without pathological finding [1]. However, a thorough review of medical history revealed that the Electronic supplementary material The online version of this article (doi:10.1007/s00392-012-0510-9) contains supplementary material, which is available to authorized users.

Pulsatile venous waveform quality in Fontan circulation-clinical implications, venous assists options and the future

Functionally univentricular heart (FUH) anomalies are the leading cause of death from all structural birth defects. Total cavopulmonary connection (TCPC) is the last stage of the palliative surgical reconstruction with significant late hemodynamic complications requiring high-risk heart transplantation. Alternative therapeutic options for these critically ill patients are crucial. In Phase I, we investigated the effect of pulsatility of venous flow (VF) waveform on the performance of functional and "failing" Fontan (FF) patients based on conduit power loss. In phase 2, the effect of enhanced external counter pulsation on Fontan circulation flow rates is monitored. In phase 1, Doppler VFs were acquired from FF patients with ventricle dysfunction. Using computational fluid dynamics (CFD), hemodynamic efficiencies of the FF, functional and in-vitro generated mechanically assisted VF waveforms were evaluated. In phase 2, Fontan circulation on sheep model was created and enhanced external counter pulsation (EECP) applied. Variations in the pulsatile content of the VF waveforms altered conduit efficiency notably. High frequency and low amplitude oscillations lowered the pulsatile component of power losses in FF VF waveforms. The systemic venous flow, pulmonary artery and aorta flows increased by utilizing EECP. Our data highlighted the significance of VF pulsatility on energy efficiency inside SV circulation and the feasibility of VF waveform optimization. EECP assist in Fontan circulation can result in venous flow augmentation.

The Use of Reconstructive Surgery to Improve Quality of Life and Survival in Prenatal Hypoplastic Left Heart Syndrome

Outcomes for hypoplastic left heart syndrome have improved substantially in the era of prenatal diagnosis. Current stage 1 survival rates are in excess of 90% in the absence of risk factors. However, fetuses with an intact atrial septum continue to have poor postnatal survival. Accurate diagnosis of these fetuses with an intact atrial septum relies upon careful assessment of the patent foramen ovale, pulmonary venous Doppler flow patterns and branch pulmonary artery Doppler flow patterns. Prenatal and perinatal interventions, such as the placement of an atrial stent in utero or delivery at a center where a stent may be placed immediately after birth to relieve left atrial hypertension, may improve survival in this particularly high-risk group.

360 Fetal pulmonary vein doppler flow pattern: Predicting the need for immediate left atrial decompression in hypoplastic left heart syndrome with restrictive atrial septum

BACKGROUND: Fetal pulmonary venous (PV) Doppler flow has been correlated with the severity of atrial septal restriction (ASR) and the need for emergent atrial septostomy (EAS) in newborns with HLHS. According to Michelfelder et al (JTCS 2011), a fetal forward/reverse PV Doppler flow velocity-time integral (PV VTI) ratio 5 predicted the need for EAS, required in 21% of their 39 HLHS cases, with a sensitivity of 100% and a specificity of 94%. We reviewed our contemporary institutional experience with this entity. METHODS: Echocardiograms and outcomes of 67 consecutive fetal HLHS cases with active postnatal management were reviewed. PV Doppler assessments included maximal S-, Dand A-wave flow velocities (cm/s); A-wave duration (ms), S/D wave and forward/reverse PV VTI ratios. EAS 1 days of age and survival to infancy were used as clinical outcome variables. RESULTS: Four (6%) of the 67 cases required an EAS for an intact (n 1) or severely restrictive atrial septum. The table indicates the median (range) fetal PV Doppler indices at the pre-delivery echocardiogram of newborns with/without EAS:

Role of dysfunctional maternal venous hemodynamics in the pathophysiology of pre‐eclampsia: a review

The venous compartment has an important function in regulation and control of cardiac output. Abnormalities of cardiac output have been found in early gestational stages of both early- and late-onset pre-eclampsia. The venous compartment also maintains the balance between circulating and non-circulating blood volumes and regulates the amount of reserve blood stored in the splanchnic venous bed. It is well known that adaptive regulation of maternal blood volume is disturbed in pre-eclampsia. Abnormal venous hemodynamics and venous congestion are responsible for secondary dysfunction of several organs, such as the kidneys in cardiorenal syndrome and the liver in cardiac cirrhosis. Renal and liver dysfunctions are among the most relevant clinical features of pre-eclampsia. Doppler sonography studies have shown that the maternal venous compartment is subject to gestational adaptation, and that blood flow characteristics at the level of renal interlobar and hepatic veins are different in pre-eclampsia compared with uncomplicated pregnancy. In comparison to late-onset pre-eclampsia, in early-onset pre-eclampsia venous Doppler flow abnormalities are more prominent and present up to weeks before clinical symptoms. This paper reviews the growing evidence that dysfunction of maternal venous hemodynamics is part of the pathophysiology of pre-eclampsia and may perhaps be more important than is currently considered. Doppler sonography is a safe and easily performed method with which to study maternal venous hemodynamics. Therefore, exploring the role of maternal venous hemodynamics using Doppler sonography is an exciting new research topic for those who are interested in cardiovascular background mechanisms, as well as prediction and clinical work-up of pre-eclampsia.

Use of Thermotherapy in Management of Lymphedema: Clinical Observations.

We report clinical observations in 67 patients with chronic lymphedema undergoing hyperthermia. Our technique of hyperthermia is an alternative to microwave therapy, particularly where lymphangitis coexists in the same limb. Preoperative diagnostic evaluation including lymphatic and venous isotopic scintigraphy, Doppler venous flow metrics, and pressure manometry play an essential role in delineating the status of both the lymphatic and venous systems and in determining if hyperthermia is indicated. Our method of treatment consists of producing hot and humid ambience inside the chamber where the limb is situated. The data demonstrate the feasibility of our method of hyperthermia in 67 patients with postlymphangitis lymphedema (either arm or leg). Using this technique, improvement was seen in both limb function and edema.

Venous Doppler studies in low-output and high-output hydrops fetalis

The objective of the study was to compare fetal venous Doppler flow reflecting cardiac function in fetuses with hydrops fetalis between a group of congenital heart defect (low cardiac output) and a fetal anemia group (high cardiac output). This was a prospective cross-sectional analysis. It was conducted at the Maharaj Nakorn Chiang Mai Hospital, Tertiary center, Medical School. The study included fetuses with hydrops fetalis secondary to cardiac causes (low output group) and anemia (high output group). All fetuses underwent ultrasound examination to assess ductus venosus (DV) and umbilical vein (UV) Doppler indices. The results were related to normal reference range and were also compared between the group of high-output and the low-output group. Sixty-nine hydropic fetuses were available for analysis, 50 in the high-output group and 19 in the low-output group. The peak velocity index, preload index, and the pulsatility index of the DV were significantly low in the high-output group, whereas they were significantly high in the low-output group. The umbilical vein pulsations were found in 78.9% of the fetuses with low-output hydrops fetalis but only 28.0% of fetuses in the high output group (P < .001). New insights gained from this study are that hydrops caused by severe anemia because of hemoglobin Bart's is not associated with high central venous pressures as is seen in hydropic fetuses with coronary heart disease. This suggests that cardiac decompensation is not the primary mechanism of hydrops in these anemic fetuses. Additionally, umbilical vein pulsations are not a sign of cardiac failure in the anemic group.

Reproducibility and repeatability of maternal venous Doppler flow measurements in renal interlobar and hepatic veins

[Mesens, T.; Gyselaers, W.] St Jans Hosp, Ziekenhuis Oost Limburg, Dept Obstet & Gynaecol, B-3600 Genk, Belgium. [Tomsin, K.; Gyselaers, W.] Hasselt Univ, Dept Physiol, Diepenbeek, Belgium. [Molenberghs, G.] Hasselt Univ, Ctr Stat, Diepenbeek, Belgium. tinnemesens@hotmail.com

Antepartum fetal testing: a critical appraisal

Recognition of the fetus at risk for death or damage in utero, quantifying the risk, balancing fetal risk against the risk of neonatal complications from immaturity and determining optimal time and mode of intervention, is a cornerstone of modern perinatal medicine. Antepartum fetal testing is essential in making these crucial decisions. The art and science of fetal assessment is fluid. In this treatise, the evolution of testing is reviewed, test accuracy results examined and suggestions for future applications are considered. Composite testing of a range of fetal biophysical variables is an excellent predictor of fetal acidemia and risk of death or damage. Confusion regarding the optimal means of measuring one of these variables, amniotic fluid volume, has been addressed in the literature and contemporary studies from several independent sources indicate that the amniotic fluid index method should be abandoned in favor of the maximal vertical pocket method. It is becoming increasingly more evident that a spectrum of fetal testing modalities based on interrogation of different aspects of fetal adaptive responses to adversity is preferable in fetal testing. Further it is evident that in some fetal diseases, such as intrauterine growth restriction, fetal condition may change acutely and accordingly best outcome is achieved by much more frequent testing. The question of whether intervention for fetal compromise can prevent subsequent neurological sequelae remains open. There has been remarkable advancement in identifying the fetus at risk. The concept of multispectral combined fetal testing including acute biophysical variables, amniotic fluid volume and arterial and venous Doppler flow velocity waveforms is established.

Preoperative Sonographic and Clinical Characteristics as Predictors of Ovarian Torsion

The purpose of this study was to determine the most closely associated sonographic and clinical characteristics of ovarian torsion. The medical records and sonographic studies of 39 patients with pathologically proven ovarian torsion diagnosed at our institution from July 1, 2000, through December 31, 2005, were retrospectively reviewed. The volumes of the affected ovaries and ovary/mass complexes were compared with an age-appropriate standard. Statistical significance of the data was assessed by a likelihood ratio chi(2) analysis. All patients (100%) had a chief symptom of abdominal pain. Thirty-three (85%) reported vomiting; 22 (56%) had leukocytosis; and 7 (18%) had a documented elevated temperature. All affected ovaries and ovary/mass complexes were enlarged. Twenty-one (54%) had arterial flow on Doppler interrogation, and 18 (46%) had no arterial flow. Thirteen (33%) had venous flow, and 26 (67%) had no venous flow. Differences in the arterial and venous flow patterns between the premenarchal and reproductive age groups were not statistically significant. Abdominal pain, vomiting, ovarian enlargement, and absence of ovarian venous Doppler flow are the most frequently shown clinical and sonographic indicators of ovarian torsion. However, ovarian enlargement, even in the presence of arterial and venous Doppler flow, is the most commonly associated sonographic finding. Suspicion of ovarian torsion should be high in the setting of clinical symptoms and ovarian enlargement regardless of the presence or absence of an ovarian Doppler signal.

Digoxin for the treatment of fetal congestive heart failure with sinus rhythm assessed by cardiovascular profile score

Objective. To evaluate the effects of digoxin on the progression of congestive heart failure (CHF), and to determine the best predictors of perinatal death in fetuses with sinus rhythm and CHF.Methods. This was a retrospective case series of fetuses with CHF treated with transplacental digoxin, evaluated at baseline (before treatment), weekly during treatment, and prior to death or delivery, using a 10-point cardiovascular profile score (CVPS) consisting of echocardiographic markers of cardiac dysfunction: cardiomegaly, valve insufficiency, hydrops, and abnormal venous and arterial Doppler flow profiles. Composite CVPS and component markers were compared before and after digoxin treatment by nonparametric testing and best predictors of perinatal survival assessed by regression analysis and receiver operating characteristics.Results. The overall mortality of the 28 subjects was 32%. First, last, and CVPS after 1 week of treatment predicted survival (odds ratio 2.34, 95% confidence interval 1.10–4.96) with a CVPS of ≥6 being the best predictor of survival (sensitivity 0.83, specificity 0.75). All fetuses that died had notching of the umbilical venous flow. CVPS increased from baseline during treatment (p = 0.003) in all subjects.Conclusions. The CVPS score is useful in assessing therapeutic effects of digoxin in the fetus with multiple etiologies for CHF. Further studies are needed to test the efficacy of digoxin in specific defects causing CHF.

Is hydrops fetalis a manifestation of fetal pulmonary edema caused by impaired lymphatic drainage?

Hydrops fetalis is the final common hemodynamic pathway for a variety of fetal cardiovascular pathologies, including high-output states associated with fetal anemia or arteriovenous fistulas, and abnormalities of both cardiac structure and rhythm. Hydrops fetalis secondary to cardiovascular decompensation is usually accompanied by increases in fetal systemic venous pressure as evidenced by alterations in venous Doppler blood flow velocities. We present two cases of severe fetal aortic stenosis with left ventricular fibroelastosis and mitral regurgitation, and in-utero closure or stenosis of the foramen ovale, with severe hydrops fetalis, despite normal systemic venous Doppler flow profiles. These cases have led us to reconsider the presumed etiology of cardiovascular-based hydrops fetalis in fetuses with severely impaired left ventricular pump function and secondary mitral regurgitation. We hypothesize that raised pulmonary venous pressure, with only mildly increased central venous pressure, may impact negatively on pulmonary lymphatic flow, decrease serum oncotic pressure, increase venous hydrostatic pressure, and lead to hydrops fetalis.

504: Indications for delivery of the fetus with isoimmune conduction system disease after optimal in utero management

DISEASE AFTER OPTIMAL IN UTERO MANAGEMENT MAUREEN LEE, JAMES HUHTA, JENNY LESHKO, ANDREA KEMP, BARBARA PARILLA, BETTINA CUNEO, University of Illinois at Chicago, Chicago, Illinois, University of South Florida, St. Petersburg, Florida, University of South Florida, Pediatrics, St. Petersburg, Florida, University of Illinois at Chicago, Park Ridge, Illinois, Society for Maternal-Fetal Medicine, Oak Lawn, Illinois OBJECTIVE: The optimal time for delivery of the fetus with isoimmune 2° or 3° AV block (AVB) is at term and without heart failure. We evaluated the indications for delivery after basing our in utero management on fetal heart rate (FHR) and degree of heart failure, based on a cardiovascular profile score (CVPS). STUDY DESIGN: We retrospectively reviewed medical records, echocardiograms and ultrasounds of fetuses with AVB from 2 perinatal-cardiology centers over 12 years. Weekly, from diagnosis to delivery, we monitored FHR, the CVPS (a 10-point score assessing cardiothoracic area, venous and arterial Doppler flow patterns, hydrops, and valvular insufficiency), the presence of endocardiofibroelastosis (EFE), fetal growth, and after 30 weeks, biophysical profile. Dexamethasone was given to the mother at diagnosis; we added terbutaline if CVPS 8 or FHR 55 bpm; and digoxin if CVPS was 7. Fetuses were divided into group 1 if they delivered at term and group 2 if they delivered at 36 weeks. Groups differences were tested using Fisher Exact’s test. RESULTS: All fetuses (group 1: n 13 with 3° AV block; group 2: n 8; 2 with 2° and 6 with 3° AV block) were born alive. Indications for early delivery were abnormal BPP(2), ventricular dysfunction alone(3) or with abnormal BPP(1) and oligohydramnios (1) or IUGR (1). Both group 2 fetuses with 2° AVB were delivered because of abnormal BPP. More group 2 fetuses required terbutaline (62.5% vs. 37.5%) for low FHR, had EFE (63% vs. 6 %, p .014), had lower pre-delivery CVPS (p .028), and were diagnosed earlier (p .03). CONCLUSION: The CVPS, fetal HR and the presence of EFE, but not the degree of AVB, correlated with the need for early delivery. Ventricular dysfunction is an indication for one third of premature deliveries. The CVPS is useful in monitoring the in utero management of isoimmune AVB.

Incidence and Significance of Abnormal Hepatic Venous Doppler Flow Velocities Before Cardiac Surgery

Survey of Anesthesiology: February 2007 - Volume 51 - Issue 1 - p 4 doi: 10.1097/SA.0b013e31802f8a2b

Interobserver agreement on ultrasound measurements of residual vein diameter, thrombus echogenicity and Doppler venous flow in patients with previous venous thrombosis

Interobserver agreement on ultrasound measurements of residual vein diameter, thrombus echogenicity and Doppler venous flow in patients with previous venous thrombosis

OP04.23: Impaired systolic and diastolic ventricular function after permanent extra‐embryonic venous obstruction, a pressure‐volume loop assessment in the stage‐24 chick embryo

Hydrops fetalis is the final common hemodynamic pathway for a variety of pathological states in the fetus, including high output states associated with fetal anemia or arterio-venous fistulas and abnormalities of both cardiac structure and rhythm. Hydrops fetalis secondary to cardiovascular decompensation is usually accompanied by elevations in fetal systemic venous pressure as evidenced by alterations in venous Doppler waveforms. We present two cases of severe fetal aortic stenosis with left ventricular fibroelastosis and mitral regurgitation and in utero closure or stenosis of the foramen ovale, with severe hydrops fetalis, despite normal systemic venous Doppler flow profiles. Both cases demonstrated markedly abnormal fetal pulmonary venous Doppler waveforms and after birth, both infants were hypoalbuminemic. The presence of normal systemic venous Doppler waveforms in fetuses with severe hydrops fetalis and structural cardiac disease challenges our understanding of the etiology of this pathological state. These cases have led us to reconsider the presumed etiology of cardiogenic hydrops fetalis in fetuses with severely impaired left ventricular pump function and secondary mitral regurgitation. We hypothesize that elevated pulmonary venous pressure, with only mildly increased central venous pressure, may negatively impact pulmonary lymphatic flow, decrease serum oncotic pressure due to loss of protein-rich fluid in the pulmonary interstitium, increase venous hydrostatic pressure, and lead to hydrops fetalis.

Incidence and Significance of Abnormal Hepatic Venous Doppler Flow Velocities Before Cardiac Surgery

The purpose of this study was to determine the incidence and significance of abnormal hepatic Doppler venous flow velocities as signs of an abnormal right ventricular filling pattern before cardiac surgery. Retrospective and prospective validation study. Tertiary care hospital. Cardiac surgical patients (121 patients). Not applicable. Demographic, hemodynamic, and echocardiographic variables; vasoactive support; and difficult separation from bypass were compared between patients with or without abnormal hepatic venous Doppler flow. Logistic regression analysis was performed to identify predictors of difficult separation from bypass. Abnormal hepatic venous flow was observed in 23 (29%) and 17 patients (41%) in the retrospective and prospective study. Abnormal hepatic venous flow before surgery was associated with more vasoactive support in both the retrospective (p = 0.0362) and prospective study (p = 0.0163). In the prospective study, abnormal hepatic venous flow was associated with a higher Parsonnet score (p = 0.0005), more atrial fibrillation (p < 0.0001), pacemaker requirement (p = 0.0124), mitral valve replacement (p = 0.0325), reoperation (p = 0.0050), lower mean arterial pressure to pulmonary artery pressure ratio (p = 0.0127), higher wall motion score index (p = 0.0491), and higher incidence of abnormal right ventricular systolic function (p = 0.0139). Abnormal hepatic venous flow was not found to be an independent predictor of difficult separation from bypass. Abnormal hepatic venous flow velocities before cardiac surgery are frequent and are associated with increased need for vasoactive support after cardiopulmonary bypass. However, it is not an independent predictor of difficult separation from bypass and worse outcome.

Qualitative Venous Doppler Flow Waveform Analysis in Preterm Intrauterine Growth-Restricted Fetuses with ARED Flow in the Umbilical Artery???Correlation With Short-Term Outcome

Controversy continues about the best time for delivery when intrauterine growth restriction (IUGR) is present. Although many practitioners use arterial and venous Doppler, biophysical parameters, and fetal heart tracings,there is no standard management. The risk of prematurity-usually before 32 weeks gestation-must be balanced against the risks of prolonged fetal exposure to hypoxemia and acidemia with their possible consequences of persistent fetal damage, stillbirth, and neonatal death. This retrospective study enrolled 74 fetuses with IUGR and absent or reversed end-diastolic (ARED) flow in the umbilical artery (UA) with delivery taking place at 24 to 34 weeks gestation. Perinatal outcomes were related to absent or reversed flow during atrial contraction (a-wave) in the ductus venosus (DV) and pulsatile flow in the umbilical vein (UV). Color Doppler imaging was performed, and flow velocity waveforms were recorded from the UA, DV, UV, and middle cerebral artery. End-diastolic flow in the UA was absent in 43% of fetuses and reversed in 57%. Brain sparing was observed in 53% and 90.5% of fetuses, respectively. Flow was absent or reversed during the a-wave in the DV in 41% of cases and UV pulsations in 31%. In 18% of fetuses, Doppler waveforms were abnormal in both the DV and the UV. More than half (54%) of fetuses were acidotic at birth and 6.5% had birth asphyxia. Perinatal mortality was 19% with 12 perinatal and 2 neonatal deaths. Eight of these 12 fetuses were stillborn. On logistic regression analysis, the strongest predictors of perinatal death were abnormal. Only gestational age correlated significantly with neonatal deaths. Abnormal venous Doppler waveforms were more frequent in fetuses with acidemia, oligohydramnios, or intraventricular hemorrhage at birth. In this series, venous Doppler flow patterns predicted stillbirths and perinatal deaths with better specificity and higher positive predictive values than did reversed flow in the UA or brain sparing. Fetal and perinatal deaths were significantly associated with an absent or reversed DV a-wave or UV pulsations, especially before 32 weeks gestation. Preterm IUGR fetuses in this study with severe venous Doppler flow abnormalities were delivered at a time when multiorgan failure and persistent damage were already present. These translate into a high number of stillbirths and perinatal/neonatal deaths. The question of when to deliver preterm infants with IUGR will be addressed in a planned prospective, randomized multicenter trial, the TRUFFLE study.

Predictive Value of Fetal Pulmonary Venous Flow Patterns in Identifying the Need for Atrial Septoplasty in the Newborn With Hypoplastic Left Ventricle

Pulmonary venous Doppler (PVD) flow patterns in the fetus with hypoplastic left heart syndrome (HLHS) have been correlated with restrictive interatrial communication or intact atrial septum (RAS) postnatally; however, the ability of PVD to identify the neonate requiring emergent atrial septoplasty (EAS) for severe left atrial hypertension and hypoxemia has not been critically evaluated. It was the purpose of this study to determine the predictive power of fetal PVD in identifying the need for EAS in newborns with HLHS and RAS. Forty-one patients with fetal PVD flow analysis and postnatally confirmed HLHS were studied. Pulsed-wave assessment of PVD flow included S-, D-, and A-wave velocity, time-velocity integral (VTI) of forward and reverse flow, and S/D velocity and forward/reverse VTI ratio. Neonatal EAS was used as the primary clinical outcome variable. Receiver operating characteristic curves were used to determine cutpoints at which PVD indices best predicted EAS. Cutpoints were evaluated for clinical accuracy and usefulness by use of Bayesian analysis. Eight of 41 subjects underwent EAS. Need for EAS was most accurately predicted by forward/reverse VTI ratio <5 (sensitivity, 0.88, 95% CI, 0.49 to 0.99; specificity, 0.97, 95% CI, 0.82 to 0.99), which, when present, increases the posttest likelihood of EAS to 74%, assuming a pretest prevalence of 10%. Accuracy and usefulness of other PVD indices were affected by false-positive results. In the fetus with HLHS, a PVD forward/reverse VTI ratio of <5 is the strongest predictor of the need for EAS in the newborn period. These observations should improve our ability to identify and expectantly manage the fetus with HLHS and RAS.

OC27.04: Intervention thresholds for severe early onset growth restriction (IUGR)

intraventricular hemorrhagia and elevated nucleated red blood cell counts at delivery. Results: 8 stillbirths (10.7%), 12 perinatal (16%) and 2 neonatal death (2%) occurred among 74 fetuses. Logistic regression analysis confirmed that abnormal Ductus venosus waveforms (R2 = 0.57, p < 0.001) together with gestational age (R2 = 0.57, p < 0.001) showed the strongest association with perinatal death, whereas gestational age only was significantly related with neonatal death (R2 = 0.67, p < 0.05). Abnormal ductus venosus Doppler waveforms (R2 = 0.86, p < 0.001) and gestation age (R2 = 0.49, p < 0.05) were strongly associated with adverse outcome. Abnormal venous Doppler flow patterns performed better in the prediction of fetal or perinatal demise than died ARED flow or brain sparing. Conclusion: Abnormal Ductus venosus waveforms in preterm growth-related fetuses with ARED flow are strongly relates to adverse fetal and perinatal outcomes below 32 weeks of gestational age. The possible benefit of these pregnancies to be prolonged can only be evaluated in a prospective randomized study.