7 fetal growth restriction part 2 dr ahmed esawy Intrauterine Growth Retardation /Restriction IUGR TYPE 1/ SYMMETRICAL /INTRINSIC IUGR TYPE 2/ aSYMMETRICAL /extrinsic TYPE 3/ intermediate iugr SGA - small for gestational age infants Genetics Low Birth Weight Small for Gestational Age Antenatal Period: • Oligohydraminos • Fetal Distress • IUD During labour: • Still birth • Meconium aspiration • Fetal distress fetal hypoxia Placental Insufficiency MATERNAL SIDE Uterine artery • PLACENTAL SIDE Umbilical artery • FETAL SIDE Arterial:middle cereberal artery ,Venous:ductus,hepatic,umbilical Fetal echocardiography Fetal AORTA Hypoxemia

1. Dr Ahmed Esawy
‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

2. Dr Ahmed Esawy
Dr. Ahmed Esawy
MBBS M.Sc
MD (PhD)
Dr/AHMED ESAWY

3. Dr Ahmed Esawy
Intrauterine Growth
Retardation
/Restriction
IUGR
Part 2

4. Dr Ahmed Esawy
Dr. Ahmed Esawy
MBBS M.Sc MD
Dr/AHMED ESAWY

5. Dr Ahmed Esawy
Pathological changes in
venous flows with FGR
INCREASED PLACENTAL RESISTANCE
INCREASED AFTERLOAD TO RIGHT
VENTRICLE(SYSTEMIC VENTRICLE)
RV DECOMPENSATION
TRICUSPID REGURGITATION
BACK PRESSURE TRANSMITTED TO VENOUS SYSTEM

6. Dr Ahmed Esawy
VENOUS DOPPLER
Venous Doppler
absence, or reversal of the ductus venous a-wave.
biphasic/triphasic umbilical vein pulsations.
these Doppler findings have 65% sensitivity, 95% specificity
abnormal venous Dopplers are associated
with severe fetal acidemia.
pulsations in the umbilical vein occurs just prior to abnormal fetal
heart rate patterns.In growth restricted fetuses,
neonatal mortality is at least 60% compared to 20% in the
absence of venous pulsations.

7. Dr Ahmed Esawy
FETAL VENOUS
CIRCULATION
FORAMEN OVALE
DUCTUS VENOSUS
INFERIOR VENA CAVA
UMBILICAL VEIN
RIGHT HEPATIC VEIN
MIDDLE HEPATIC VEIN LEFT HEPATIC VEIN
PORTAL VEIN

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DUCTUS VENOSUS
REFLECTS : ACIDOSIS
END POINTS : ABSENT FORWARD
FLOW
IN DIASTOLE

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UV
RPV LPV
DV
RA

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SITE DUCTUS VENOSUS

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The Ductus Venosus

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Anatomy

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 Ductus venosus is vascular connection from
umbilical vein to IVC .
It is funnel shaped.
 Ductus venosus develops at 7 wks gestation and
shows minimal increase in diameter
as a result, diameter of DV is approx 1/3 of umbilical
vein after first trimester
so blood coming through umbilical vein accelerates in
DV and this high velocity flow gets directed towards
left atrium from Rt atrium via foramen ovale .

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Oblique transverse view of the fetal
abdomen demonstrating the ductus venosus. Note the
relative positions of the umbilical vein, portal sinus, right
and left portal veins and ductus venosus.

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Color Doppler Energy "Arteriography" showing the anatomy of the vessels at mid-
sagittal plane of the fetal trunk

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Blood flow in the ductus is characterized by high velocity during ventricular systole (S-
wave) and diastole (D-wave) and by the presence of forward flow during atrial
contraction (A-wave). In cardiac failure, with or without cardiac defects, there is absent
or reversed A-wave

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DV waveforms showing reversal of ‘a’ wave

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The upper panel represents the venous
waveform, correlated with the EKG in the lower
panel. A = atrial systole, S = ventricular systole,
D = early ventricular diastole. The colored
portions of the waveform represent the Tamx
for atrial systole (gold), ventricular systole (red),
and early ventricular diastole (blue). The yellow
arrows represent the measurement of the peak
velocity for ventricular systole and early
ventricular diastole. The black arrow represents
the peak velocity for atrial systole.

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Doppler gate placed on ductus venosus in a 30 week fetus.
Waveform obtained from the normal ductus venosus.
Note the triphasic appearance of the normal waveform.

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Calculation of ratios for fetal venous blood flow waveforms. S
indicates peak systolic velocity; D, peak diastolic velocity; a, peak
reverse velocity or nadir during atrial contraction; and TAMX, time
average maximum velocity.

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Ductus Venosus Flow Waveform
Hecher, Circulation, 1995

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Ductus Venosus Flow
• Modulated by:
– DV diameter
– Portal venous resistance
– Increased Hct increased DV shunt.
– Humoral factors:
• PGs
• NO
• Adrenergic stimulus

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NORMAL & ABNORMAL WAVEFORM

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Doppler Flow Velocity in
Ductus venosus

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How to spot the Normal ductus venosus

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(A) Ductus venosus (DV) Doppler
waveforms at 12 weeks gestation.
(B) At 12 weeks gestation, an abnormal
a-wave (a), correctly predicted
anomalous pulmonary and systemic
venous return, proven by fetal
echocardiography at 24 weeks.
(C) DV at 26 weeks, with 4-phase
waveform. (1) atrial contraction (2)
ventricular systole, (3) return (ascent) of
the annulus (called the y-descent of the
DV waveform), & (4) diastole.
(D) Normal waveform from the
middle hepatic vein which, is only a
few millimeters from the DV.

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DV

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Doppler examination of the ductus venosus with
normal flow velocity waveforms & Abnormal
waveform with reversal of flow during atrial
contraction in a growth-restricted fetus.

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Abnormal ductus venosus Doppler and trisomy .
retrograde flow during atrial contractions.

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Doppler examination of the ductus venosus with normal flow
velocity waveforms (top).
Abnormal waveform with reversal of flow during atrial
contraction in a growth-restricted fetus (bottom).

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Duration of persistent abnormal ductus
venosus flow and its impact on perinatal
outcome in fetal growth restriction.
• The duration of absent or reversed flow
during atrial systole in the DV is a strong
predictor of stillbirth that is independent of
gestational age. While prematurity remains
the strongest predictor of neonatal risks it is
unlikely that pregnancy can be prolonged by
more than 1 week in this setting.

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ASSESSMENT OF DUCTUS
VENOSUS NORMAL WAVE
FORM  s, d, a

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ASSESSMENT OF DUCTUS VENOSUS
b-reduced a wave to base line
c-reversed a wave
.

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OTHER USES
Abnormal DV waveforms in first trimester
should arise suspicion for
 Presence of aneuploidy
 Risk of CHD even if chromosomal study is normal

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UMBILICAL VEIN

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Venous Doppler
The commonly studied vessels include:
•Umbilical vein
•Ductus venosus
The fetal venous system Doppler waveforms evaluates the fetal
heart compensation to severe growth restriction.

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Relation between UA and UV
• AEDF in UA no pulsation: at U V
19% mortality
pulsation : at UV
63% mortality
Intra-abdominal part is more sensitive than the free loop, pulsation in the
free loop is a very bad sign.

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UMBILICAL VEIN
REFLECTS : MYOCARDIAL FUNCTION
END POINTS : DOUBLE PULSATILE PATTERN

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Of interest is the abrupt change of a
nonpulsatile flow pattern in the umbilical
vein into a clearly pulsatile flow pattern in
the ductus venosus and inferior vena
cava.
During ventricular systole, the right atrium
unfolds after its contraction,which, in turn,
will lead to a passive suction in compliant
afferent vessels.

57. Dr Ahmed Esawy
 Umbilical vein shows monophasic , continous non-pulsatile
flow after first trimester in uncomplicated pregnancy.
 It shows pulsatile waveforms at the portal sinus.
 Fetuses with pulsations in the free floating umbilical vein in
the second and third trimester have a higher morbidity and
mortality, even in the setting of normal UA blood flow.
 Single pulsations correlate with cardiac systole while
double pulsations result from significant cardiac
insufficiency

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Pathological pulsations a result from the decompensation of
the fetal right heart in (nonimmune) hydrops, severe growth-
retardation, and arrythmias.in these conditions, it is probably
reflect a high placental vascular resistance
a sign that the fetal heart function deteriorates and right
atrial filling patterns are disturbed. The pooling of blood and the
increase of obstructed venous inflow causes reversed flow at
the level of the vessels responsible for the venous return,
including the umbilical vein.

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U V DOPPLER

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SITE

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ABNORMAL WAVEFORM

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U V PULSATION

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Pathologic Venous Doppler
• Late sign of CV decompensation
• Reflects decreased ability to handle venous return
• Increase in RAP causes a-wave
• Accentuated A-wave may be:
– Transmitted to DV
– Transmitted to UV
• Precedes FHR decels & fetal death
• Present in 37% of preterm IUGR
Baschat, O&G, 2007

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IVC
Flow velocities in the inferior vena cava are
similar to those obtained at the superior vena
cava, so that the same interpretations can be
performed on both vessels.
They show a gestational age dependent increase
without a change in the typical three-
component waveform.
The retrograde flow component represents
the performance of the right atrium.

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IVC

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COMPARISON
NORMAL PATTERN ABNORMAL PATTERN
IVC shows triphasic pulsatile
waveforms
 first forward wave during
ventricular systole
 second forward wave during
early diastole
 third wave characterised by
reversed flow in late diastole
due to atrial contraction
In IUGR fetuses the IVC
shows increase in
reversed flow during
atrial contraction

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IVC

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IVC

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IVC

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Venous Doppler studies
• Reflects fetal cardiac function
• Most commonly used Venous Doppler
indices:
Ductus Venosus
Inferior vena cava
Hepatic vein
Umbilical vein(Intra abdominal portion)

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VENOUS DOPPLER
All venous Doppler have this type of waveform except for Umbilical vein
waveform

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Ductus venosus doppler
PERINATAL MORTALITY IN ABSENT OR REVERSE FLOW OF DV IS 63-100% (IAN DONALD’S)

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HYPOXIA
INC BLOOD SHUNTING THROUGH DV B/W
UMBILICAL VEIN & IVC
INC. PULSATILITY INDEX FOR
VEINS (PIV)
PSV-ATRIAL CONTRACTION
VELOCITY
Avg. Vel. Drng cardiac cycle
REVERSED a WAVE IN DV PULSATION
PULSATIONS IN THE
UMBILICAL VEIN
REVERSAL OF FLOW IN IVC
DURING ATRIAL
CONTRACTION

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ABNORMAL WAVEFORM IN
UMBILICAL VEIN

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Important points on
venous Doppler
• Especially useful in early onset IUGR
Reason: In Term /near term fetuses there is
shorter interval & delivery is often indicated
With advancing GA cardiac activity
becomes more efficient  slow Steady decline in Doppler indices
• When DV & Umbilical vein Doppler- Sensitivity inc to 70-80%.

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Important points on venous
Doppler
• Especially useful in early onset IUGR
Reason: In Term /near term fetuses there is
shorter interval & delivery is often indicated
With advancing GA cardiac
activity becomes more efficient  slow Steady decline
in Doppler indices
• When DV & Umbilical vein Doppler- Sensitivity inc to
70-80%.

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Decompensation

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FETAL HYPOXIA-
ACIDOSIS
AORTIC BODY
CHEMORECEPTOR STIMULATION
REFLEX REDISTRIBUTION OF
FETAL CARDIAC OUTPUT

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REFLEX REDISTRIBUTION OF
FETAL CARDIAC OUTPUT
INCREASED FLOWDECREASED FLOW
 KIDNEYS (OLIGURIA)
(OLIGOAMNIOS)
 LUNGS (RDS)
 GUT (NEC)
 LIVER/MUSCLE (IUGR)
BODY FAT/
GLYCOGEN STORES
 BRAIN
 ADRENALS
 HEART

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1. Uterine arteries depict maternal vascular
effects of the invading placenta
2. Umbilical artery Doppler reflects downstream
placental vascular resistance
3. Middle cerebral artery changes begin when
the redistribution of cardiac output reflects
rising placental resistance
4. precordial veins illustrate fetal cardiac function
Which Doppler Tests Should be Performed?

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Doppler of umbilical artery

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Doppler evaluation of the MCA (middle cerebral artery)

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Aortic isthmus blood velocity
waveform a) normal blood flow
pattern in an uncomplicated
pregnancy
In the sagittal view of the fetus, the
aortic arch and the location of the
aortic isthmus (white triangle) are
shown.
b) antegrade net blood flow
(antegrade/retrograde ratio of
2.0)
c) retrograde net blood flow
with a corresponding value of
0.54 in pregnancies
complicated by placental
insufficiency.

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Atrial pressure changes
Umbilical vein blood flow is constant towards the fetus. With
this notable exception,
all venous vessels have a complex waveform pattern that is
related to the pressure changes in the atria throughout the
cardiac cycle.
• The events of the cardiac cycle that are of importance in
this context are:
• ventricular systole,(pressure drop in both atria) with
greatest forward flow S waves
• the early phase of ventricular diastole (before atrial systole),
(intraatrial pressures increase) with next greatest forward
flow D waves
• atrial systole (rapid rise in intraatrial pressure)

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Color Doppler Energy "Arteriography" showing the anatomy of the vessels at mid-
sagittal plane of the fetal trunk

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Blood flow in the ductus is characterized by high velocity during ventricular systole (S-
wave) and diastole (D-wave) and by the presence of forward flow during atrial
contraction (A-wave). In cardiac failure, with or without cardiac defects, there is absent
or reversed A-wave

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RA
RV
HV
DV
RA
RV
HV
DV
Growth RetardationDr/AHMED ESAWY

96. Dr Ahmed Esawy
Pathological pulsations a result from the
decompensation of the fetal right heart in
(nonimmune) hydrops, severe growth-retardation,
and arrythmias.in these conditions, it is probably
reflect a high placental vascular resistance
a sign that the fetal heart function
deteriorates and right atrial filling patterns are
disturbed. The pooling of blood and the increase
of obstructed venous inflow causes reversed flow
at the level of the vessels responsible for the
venous return, including the umbilical vein.

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U V PULSATION

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The clinical utility of venous Doppler velocimetry is
greatest in fetal conditions with cardiac
manifestations and/or marked placental
insufficiency. These conditions include
fetal growth restriction due to placental insufficiency,
twin-twin transfusion,
fetal hydrops, and fetal arrhythmia.

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Upper panels: Normal waveforms of inferior vena cava
(a) and right hepatic vein (b). Lower panels (c and d):
Corresponding waveforms in a compromised fetus.
There is a considerable increase in reverse velocities
during atrial contraction, which exceed forward velocities
during early diastole.

100. Dr Ahmed Esawy
Flow velocity waveforms of the ductus venosus with low pulsatility (top) and
high pulsatility (bottom), which is caused by a decrease of early diastolic
forward flow (D) and in particular by very low velocities during atrial contraction.

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Severe arterial blood flow redistribution with high diastolic and high mean (21
cm/s) velocities in the middle cerebral artery (a) and absence of diastolic and
low mean (8 cm/s) velocities in the thoracic descending aorta (b). The ductus
venosus shows reverse blood flow during atrial contraction (c), which causes
synchronic end-diastolic pulsations in the umbilical vein (d). The biophysical
profile score was abnormal.
A B

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Fetal growth restriction
Reversed umbilical artery end-diastolic velocity,
abnormal venous Doppler indices
(Increasing venous Doppler indices are the
hallmark of advancing circulatory deterioration
since they document the decreasing ability of
the heart to accommodate venous return )
development of oligohydramnios are
characteristic manifestations of ineffective
downstream delivery of cardiac output

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Progression of fetal growth restriction

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Sequence of Doppler changes in IUGR
Death within 96 hours
Constriction of cerebral circulation
Pulsatile UV
Visualization of coronary circulation
Reverse "a" wave in DV
DV and IVC velocity
Absent EDF in UA and AO
Ao indices
MCA resistance
UA indices
Velocity
Brain sparing
Asymmetrical IUGR
Oligohydramnios
2 weeks prior
to CTG
changes
Possibly with
CTG changes
Sequence of Doppler Changes in IUGR

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Staging of growth restricted fetus
Intrauterine growth restriction was defined
as the presence
of an estimated fetal weight below the 10th
percentile. Intrauterine growth-restricted
fetuses
were staged according to the following
parameters, with the presence of any 1
parameter in a stage
placing the fetus in that stage

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stage I
• an abnormal umbilical artery or middle
cerebral artery pulsatility index;

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 GROWTH RESTRICTION:
It is involved in severely growth restricted
fetus after involvement of Umbilical artery.
It is the progression of the Doppler finding &
is due to the adaptive compensatory
mechanism in the fetus against increasing
hypoxia (Brain sparing effect)

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Umbilical artery involved
Increasing hypoxia
Inc. blood flow to Vital Organs(Brain,
Heart& Adrenals)
BRAIN SPARING EFFECT
Or
CEPHALISATION
Dec. blood flow to
Abdominal Organs(Liver &
Kidneys)
OLIGOHYDRAMINOS
Inc. Diastolic Flow
Dec. RI/PI/SD ratio & abn MCA-PSV

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MCA WAVEFORM IN IUGR
INCREASED FLOW DURING
DIASTOLE

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CEREBRO-PLACENTAL RATIO(CPR):
MCA Pulsatility Index
Umbilical A. Pulsatility Index
It is more sensitive index for detecting poor
perinatal outcome than UA or MCA Doppler
alone, but due to non standardized technique
of calculating CPR limit its clinical utility.

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• Abnormal MCA reflects inc risk of adverse perinatal
outcome(PTL, Intrapartum acidemia & inc NICU admission)
• Not superior to Umbilical artery Doppler
• High negative predictive value for adverse outcome
• Normal UA & MCA Doppler indices & normal AFI in growth
restricted fetus <32 wks have negative predictive value of 97% for
adverse outcome

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Umbilical artery involved
Increasing hypoxia
Inc. blood flow to Vital Organs(Brain,
Heart& Adrenals)
BRAIN SPARING EFFECT
Or
CEPHALISATION
Dec. blood flow to Abdominal
Organs(Liver & Kidneys)
OLIGOHYDRAMINOSInc. Diastolic Flow
Dec. RI/PI/SD ratio &
Abn MCA-PSV
INCREASING HYPOXIA
DECOMPENSATION
NORMALSATION OF MCA DOPPLER
INDICES EXCEPT FOR
MCA-PSV
MCA-PSV IS THE
BETTER TOOL TO
FOLLOW THE
PROGRESSION OF
THE DISEASE

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SUMMARY OF MCA:
Despite the association of abn. MCA &
adverse perinatal outcome, there are no
specific interventions to improve
outcome based on abn. findings.
However abn. values should prompt more
frequent fetal survillence

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stage II
an abnormal MCA PSV,
absent/reversed diastolic velocity in the UA,
UV pulsation and an abnormal DV PI
(an absent DV A wave is considered part of this
(stage)

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stage III
• reversed flow at the ductus venosus or reversed flow
at the umbilical vein,
• An abnormal tricuspid E wave (early ventricular
filling)/A wave (late ventricular filling) ratio, and
tricuspid regurgitation.

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Each stage divided in A & B
• A is AMNIOTIC FLUID INDEX <5
• B is AMNIOTIC FLUID INDEX OF >5

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Phases of placental dysfunction causing FGR

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Patterns of clinical progression in early FGR

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Patterns of clinical progression in late FGR

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• Mild utero-placental insufficiency
• No effect is seen on Doppler and growth until
26-32 weeks gestation.
• The umbilical artery and the middle cerebral
artery waveforms may be abnormal
• However process is not severe enough to
stop fetal growth completely or to deteriorate
• These cases may be followed with outpatient
monitoring and they often deliver at term.
MANAGEMENT STRATEGIES

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How to Judge
Degree of Hypoxia?
Fetal arterial doppler
Cut off Line

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MCA flow
PI
More than 1.45 before term
Fall down to 1
If less than 1 peak of redistribution

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How to Judge degree
of Acidemia?
Fetal Venous doppler

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Fetal Venous Doppler
• The PI of the middle cerebral was the best
predictors of hypoxemia,
• DV flow was the best predictor of Acidemia and
hyper capnia.
Fetal Venous Doppler
IVC
Ductus Venosus
Umbilical Vein
SVC

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RA
RV
HV
DV
RA
RV
HV
DV
Growth RetardationDr/AHMED ESAWY

128. Dr Ahmed EsawyPulsatile Umbilical vein Flow

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Timing of Delivery
The risk of death or cerebral palsy reduces as each week
goes by, but if delivery is delayed until there is fetal
circulatory collapse (very abnormal venous blood flows), the
risk of death is also increased.
Harnington, Ultra OB Gyn 2000;16:399-401

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• Management algorithm depends heavily on
 Gestation age(upto 29 wks)
 Umbilical A. Doppler
Difficult
extrauterin
e
environme
nt
Hostile
intrauterin
e
environme
nt

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MODE OF DELIVERY
UMBILICALA. DOPPLER
RAISED AREDF
VAGINAL CAESAREAN
CAESAREAN

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TAKE HOME MESSAGES
• Umbilical artery Doppler can help to guide decision making and the
need for further fetal monitoring.
• Absent/ reversed EDF when linked with abnormal CTG increases the
risk of poor cognitive outcome in childhood.
• Arterial redistribution predicts hypoxemia.
• Venous Doppler abnormalities predicts heart failure.
• Venous system is the fine tuning area for planning the delivery.
• Appearance of a reverse a wave in the DV or pulsation in the
umbilical vein is a strong indication for delivery.
• Gestational age has the greatest influence on fetal wellbeing

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• Overall survival of IUGR at < 26 weeks is <50%, intact survival is <50%.
• Gestational age is more important than Doppler at < 26 weeks.
• Intact survival are not much related to birth weight.
• Outcome is better if less obvious CTG/ Doppler abnormalities are present.
• Waiting reduces the risk of lung complications, but not NEC or IVH
• Long term outcome: higher rates of disability in the earlier delivery group-
mostly in < 30 weeks fetuses.
• Once severe redistribution occurs, further follow-up with arterial Doppler is
not very helpful for timing of delivery.
• Between 26 and 29 weeks: each day in utero has been estimated to
improve survival by 1-2%
• Arterial changes have been reported to last for up to 6 weeks, depending
on gestational age, presence of venous pulsation, and maternal disease.
Practical Points

137. Dr Ahmed Esawy
PERINATAL MORTALITY RATES
DOPPLER PARAMETER PERINATAL MORTALITY
INC. UMBLICAL A. RESISTANCE 5-6%
ABSENT UMBLICAL A. EDF 11-13%
REVERSED UMBLICAL A. EDF 20-24%
DECREASED MCA 21%
ABN. DV a WAVE 30-38%
INTRAABD. UMBLICAL VEIN
PULSATIONS
35%

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OTHER USES OF DOPPLER IN OBS.
 Fetal Anemia
 Effect of drugs
 In multiple pregnancy
 Fetal anomaly
 Efffect of medicines on maternal and fetal
circulation
 Chronic maternal diseases such as
nephropathy,autoimmune disease,coagulation
disorders,diabetes and hypertension

139. Dr Ahmed Esawy
OTHERS
FETAL ANOMALIES
Doppler used to asses;
 Vein of galen
malformation
 Renal agenesis
 Sacrococcygeal teratoma
 Sequestration of lung
 Congenital diapharamatic
hernia
Assesment of a two or
three vessel umbilical cord
EFFECT OF DRUGS
Changes in ductus
arteriosus doppler after use
of indomethacin for preterm
labour and polyhydramnios
(with increasing severity)
 raised PSV
 raised EDV
 features of TR

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VEIN OF GALEN ANEURYSM

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RENAL AGENESIS

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SINGLE UMBILICAL ARTERY
It is diagnosed by imaging the origin of umbilical
artery adjacent to fetal urinary bladder.
ASSOCIATIONS:
1. Chromosomal defects(autosomal trisomies)
2.Cardiac and renal anomalies
3.Normal variant (1%)

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CORD COILING AROUND NECK
Generally harmless.
Multiple(>2) loops of
nuchal cord observed in
3rd trimester are
relevant especially in
breech presentation
because then External
CephalicVersion is
contraindicated

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3 FOLD NUCHAL CORD

145. Dr Ahmed Esawy
Fetal Anemia
• Red cell immunization
• Parvovirus infection
• Massive fetomaternal hemorrhage
• Hematologic disorders: Alpha-thalassemia, G6PD
• Large placental chorioangioma
• Twin-twin transfusion syndromes
• Intracranial hemorrhage

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What are the Effects of Severe Fetal Anemia

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Prediction of Fetal Anemia
A variety of ultrasonographic parameters have been used to detect fetuses at
risk of anemia:
• Placental thickness: not been considered to be very reliable and
reproducible in clinical practice.
• Hepatic length greater than or equal to the 95th percentile: the liver is
difficult to visualize and measure adequately, particularly when the fetus is
in an unfavorable position (back up or right side up).
• Splenic enlargement: a splenic perimeter greater than 2 SD has predicted
severe fetal anemia with a positive predictive value of 94%. It was found to
be an excellent predictor of severe fetal anemia in cases before the first
transfusion, with sensitivity and specificity of 100 and 94.7%, respectively,
but the predictive value was not as good in patients with prior transfusion or
with mild anemia.
• Main splenic artery PSV: there was no risk of severe anemia with PSV
below the median for gestational age, but the prediction is not good for mild
anemia.

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Prediction of Fetal
Anemia
A prospective cohort study compared Doppler and ultrasound
parameters to predict fetal anemia in alloimmunized pregnancies.
Sensitivity
MCA-PSV 100%
Intrahepatic umbilical venous maximal velocity 83%
Liver length 66%
Spleen perimeter 33%
MCA-PSV is the best available noninvasive test
in the prediction of fetuses at risk of anemia

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Prediction of Fetal Anemia
• Multicentric study the sensitivity of MCA-PSV for predictions of moderate and severe
anemia prior to the first cordocentesis:
Sensitivity 100%
False positive rates 12% for 1.50 MoM
• Multicenter trial for timing a cordocentesis:
MCA-PSV is an accurate method of monitoring pregnancies
Number of false positives increased following 35 weeks' gestation
• Prospective study compared MCA-PSV with Delta OD 450:
Both procedures are useful in the prediction of fetal anemia
But Doppler ultrasound is less expensive and noninvasive than amniocentesis

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Fetal congestive heart failure

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Causes of fetal congestive heart failure
• Fetal arrhythmias
• Anaemia
• Congenital heart disease with valvular regurgitation
• Non-cardiac malformations such as diaphragmatic
hernia or cystic hygroma
• Twinetwin transfusion recipient volume and pressure
overload
• Atrioventricular fistula with high cardiac output

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Prognosis of fetal heart failure: markers
of fetal mortality
• Cardiac size/thoracic size: cardiac area:thoracic area
(C/T ) ratio (normal 0.25e0.35) or C/T circumference
ratio (normal!0.5).
• Venous Doppler: inferior caval (or hepatic venous)
• (increased atrial reversal) and umbilical cord vein
(pulsations).
• Four-valve Doppler: any valvular leaks should be
evaluated further.

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Abnormal venous Doppler progresses retrograde
from the heart in the following order:
• Increased atrial reversal in the inferior vena cava.
• Ductus venosus atrial reversal.
• Portal venous atrial pulsations.
• Umbilical venous atrial pulsations.
• The end-stage finding of abnormal venous Doppler is atrial pulsations in the
umbilical cord vein. This finding of so-called ‘diastolic block’ predicts
perinatal mortality. So-called ‘double venous pulsations’ is an ominous sign
(the umbilical vein velocity resembles the inferior vena cava).

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• The technique for
measuring fetal heart size
as the heart area:chest
area ratio is shown in Fig.
• Cardiomegaly is defined as
a heart area:chest area
ratio O 0.35 at any time in
gestation

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• C/T area ratio = cardiac area/chest area
(normal 0.2-0.35).
• C/T circumference ratio = cardiac
circumference/chest circumference
(normal!0.5).
• Mild cardiomegaly: area ratio <35
• Severe cardiomegaly: area ratio. <50 minus
• Small heart ratio (>0.2)

159. Dr Ahmed Esawy
Abnormal myocardial function
• Right ventricle/left ventricle shortening fraction >0.28
• Tricuspid valve regurgitation (holosystolic)
• Mitral regurgitation (holosystolic)
• Ventricular hypertrophy
• Pulmonary or aortic valve regurgitation
• Monophasic ventricular filling
• Atrioventricular valve regurgitation Dp/dt!400 mmHg/s

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Arterial Doppler: redistribution of fetal
cardiac output
• Absent end-diastolic flow in the umbilical Artery+ brain sparing
• Reversed end-diastolic flow in the umbilical artery

161. Dr Ahmed Esawy
Practice points
• Heart failure can be diagnosed in fetuses
and the severity can be estimated.
• Serial studies with emphasis on venous
Doppler can be useful in management.
• Transplacental treatment of fetal heart
failure could result from accurate
diagnosis and fetal/maternal stratification.

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Fetal causes 25-40%
•Chromosomal anomalies
•Birth defects
•Non immune hydrops
•Infections
Placental 25-35%
•Abruption
•Cord accidents
•Placental insufficiency
•Intrapartum asphyxia
•P Previa
•Twin to twin transfusion S
•Chrioamnionitis
Maternal 5-10%
•Antiphospholipid antibody
•DM
•HPT
•Trauma
•Abnormal labor
•Sepsis
•Acidosis/ Hypoxia
•Uterine rupture
•Postterm pregnancy
•Drugs
•Thrombophilia
•Cyanotic heart disease
•Epilepsy
•Severe anemia
Unexplained 25-35%
Causes OF IUFD

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FETAL DOPPLER
PITFALLS

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