The fetal venous system, Part II: ultrasound evaluation of the fetus with congenital venous system malformation or developing circulatory compromise

Absence of Ductus Venosus: A Comparison of 2 Distinctive Fetal Autopsy Cases and Embryologic Perspectives

In fetal circulation, oxygenated blood from the placenta flows through the umbilical vein into the ductus venosus (DV), then enters the inferior vena cava, and subsequently reaches the right atrium of the heart. The DV serves as a shunt, allowing this oxygen-rich blood to bypass the liver. The absence of the DV (ADV), also known as agenesis of the DV, is a rare congenital anomaly. Without a DV, blood from the umbilical vein must follow alternative routes to the heart. In ADV cases, blood from the umbilical vein must follow 1 of 2 primary drainage patterns: either an extrahepatic shunt or an intrahepatic shunt. This report details the antenatal ultrasound and postmortem findings of 2 fetuses diagnosed with ADV by prenatal imaging studies. The first case involved a fetus with a persistent right umbilical vein connected directly to the suprahepatic IVC, accompanied by early obliteration of the left umbilical vein and true agenesis of the DV. This fetus also had additional congenital anomalies. In contrast, the second case involved a fetus with a normal left umbilical vein that entered the liver. However, despite an ultrasound diagnosis of "absence" of the DV, a DV was present, though markedly hypoplastic and probably minimally functional or non-functional. In this case, blood from the umbilical vein likely followed an alternate intrahepatic route through the portal and hepatic veins, before reaching the heart (intrahepatic shunt). These contrasting cases emphasize the heterogeneity of vascular anomalies and embryologic origins captured by the term "ADV." Additionally, the terminology of "absence" or "agenesis" may be misleading in some purported ADV cases. Specifically, in the second case, the DV was not absent; it was markedly hypoplastic instead. This also appears to be the first reported case of a hypoplastic DV in a fetus. Both cases underscore the importance of effective collaboration and clear communication between maternal-fetal medicine specialists and pathologists.

Umbilical-portal-systemic venous shunt and intrauterine growth restriction: an inquiry from a prospective study

BACKGROUND

The investigation of the fetal umbilical-portal venous system is based on the premise that congenital anomalies of this system may be related to adverse perinatal outcomes. Several small retrospective studies have reported an association between umbilical-portal-systemic venous shunts and intrauterine growth restriction. However, the prevalence of portosystemic shunts in the fetal growth restricted population is yet to be determined.

OBJECTIVE

The aims of this study were (1) to determine the prevalence of fetal umbilical-portal-systemic venous shunts in pregnancies complicated by intrauterine growth restriction and (2) to compare the perinatal and neonatal outcomes of pregnancies with intrauterine growth restriction with and without umbilical-portal-systemic venous shunts.

STUDY DESIGN

This was a prospective, cross-sectional study of pregnancies diagnosed with intrauterine growth restriction, as defined by the Society for Maternal-Fetal Medicine intrauterine growth restriction guidelines. All participants underwent a detailed anomaly scan, supplemented with a targeted scan of the fetal portal system. Venous shunts were diagnosed using color Doppler mode. The perinatal outcomes of pregnancies with intrauterine growth restriction with and without umbilical-portal-systemic venous shunts were compared.

RESULTS

A total of 150 cases with intrauterine growth restriction were recruited. The prevalence of umbilical-portal-systemic venous shunts in our cohort was 9.3% (n=14). When compared with the control group (intrauterine growth restriction without umbilical-portal-systemic venous shunts, n=136), the study group had a significantly lower mean gestational age at the time of intrauterine growth restriction diagnosis (29.7±5.6 vs 32.47±4.6 weeks of gestation; P=.036) and an earlier gestational age at delivery (33.50±6.0 vs 36.13±2.8; P=.005). The study group had a higher rate of fetal death (21.4% vs 0.7%; P<.001) and, accordingly, a lower rate of live births (71.4% vs 95.6%; P=.001). Additional associated fetal vascular anomalies were significantly more prevalent in the study group than in the control group (35.7% vs 4.4%; P≤.001). The rate of other associated anomalies was similar. The study group had a significantly lower rate of abnormal uterine artery Doppler indices (0% vs 40.4%; P=.011) and a higher rate of abnormal ductus venosus Doppler indices (64.3% vs 23%; P=.001). There were no cases of hypertensive disorders of pregnancy in the study group, whereas the control group had an incidence of 12.5% (P=.16). Other perinatal and neonatal outcomes were comparable.

CONCLUSION

Umbilical-portal-systemic venous shunt is a relatively common finding among fetuses with growth restriction. When compared with pregnancies with intrauterine growth restriction with a normal portal system, these pregnancies complicated by intrauterine growth restriction and an umbilical-portal-systemic venous shunt are associated with a different Doppler flow pattern, an increased risk for fetal death, earlier presentation of intrauterine growth restriction, a lower gestational age at delivery, additional congenital vascular anomalies, and a lower rate of pregnancy-induced hypertensive disorders. Meticulous sonographic evaluation of the portal system should be considered in the prenatal workup of intrauterine growth restriction, as umbilical-portal-systemic venous shunts may affect perinatal outcomes.

In-utero evaluation of the fetal umbilical-portal venous system among fetuses with persistent right umbilical vein: Two-and three-dimensional ultrasonographic study

OBJECTIVE

The aim of this study was to describe the anatomy of the portal system in fetuses with persistent right umbilical vein (PRUV).

METHODS

Prospective observational study of fetuses diagnosed with PRUV. All patients underwent a comprehensive portal system anatomy scan supplemented by two-dimensional (2D) and three-dimensional (3D) color doppler modalities.

RESULTS

29 fetuses with PRUV were studied. We perceived an identical anatomical pattern in 28 fetuses. The right umbilical vein drains to the portal sinus (future right portal vein, RPV), which has a configuration of a left portal vein (LPV) in the normal left portal system, with three emerging branches: inferior (RPVi), medial (RPVm) and superior (RPVs). The RPV then courses to the left, towards the stomach to the point of the bifurcation of the main portal vein (MPV) to become the left portal vein. The LPV has an RPV configuration in a normal portal system with anterior (LPVa) and posterior (RPVp) branches. This anatomical layout mimics a mirror image of the normal anatomy of left portal system.

CONCLUSION

PRUV has unique umbilical portal venous anatomy, which is a mirror image of the normal left portal system. It can be demonstrated prenatally and serve as an additional tool for prenatal diagnosis of PRUV.

The Incidence of the Agenesis of Fetal Ductus Venosus at the 11-13 Weeks' Ultrasound Examination

OBJECTIVE

The objective is to examine the incidence of agenesis of fetal ductus venosus (DV) at the routine ultrasound examination at 11-13 weeks.

MATERIALS AND METHODS

This is a retrospective study on women presenting for screening for chromosomal abnormalities. The fetal DV was routinely examined by color Doppler in the sagittal view.

RESULTS

Out of 8,304 fetuses examined, there were 13 cases of DV agenesis (0.15%). The umbilical vein drainage was intra-hepatic in two-thirds of the cases, and all resulted in normal live births. In the remaining one-third of cases, the umbilical vein drained to the inferior vena cava and all had a poor outcome because of aneuploidies, cardiac defects, and Noonan syndrome.

CONCLUSION

Fetal DV agenesis occurs in about one in 650 fetuses and the majority of cases have a benign course and a favorable outcome. Failure to identify the DV should prompt a detailed ultrasound examination, identification of the drainage site of the umbilical vein, and genetic testing.

Fetal cardiac sectional schemas - Normal and abnormal. Part 1: Upper abdominal and thoracic sections

Background

A representational illustrated cardiac schema is useful for understanding and interpreting normal and abnormal fetal echocardiographic findings.

Aim

Normal and abnormal fetal echocardiographic images can be better appreciated with the support of sectional schemas.

Settings and Design

An attempt is made to include normal and abnormal variations in both grayscale and color images for easy understanding with the help of the schemas.

Materials and Methods

The fetal cardiac sectional schemas are drawn by the author, using Microsoft Office Word drawing canvas. It is based on the best grayscale, color Doppler, power-angio, 3-dimensional, and high definition flow ultrasound images, supported by embryological and anatomic specimens in literature. Different sections are drawn in accordance with the planes suggested by Society for Maternal-Fetal Medicine, Society of Radiologists in Ultrasound, American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American College of Radiology, and American Society of Echocardiography. Every effort has been meticulously pursued to match with the best ultrasound images with minor modifications for better clarity, understanding, and reproducibility.

Results

The drawings include normal and most of the common cardiac anomalies depicting different sectional views starting from the abdomen and upward. Each drawing complies with the ultrasound images. Users with basic computer knowledge can easily modify these images using them as templates for reference, reporting, and publications.

Conclusions

An attempt is made to represent the fetal echocardiographic images by simplified memorable sectional schemas. These schemas will facilitate a better understanding and interpretation of various normal and abnormal fetal echocardiographic images. Being electronically transmittable, these schemas can be used as templates for further modifications.

Ductus Venosus Agenesis and Portal System Anomalies-Association and Outcome

To evaluate the prenatal diagnosis of agenesis of ductus venosus (ADV) and portal venous system (PVS) anomalies and describe the outcome of these cases, either isolated or associated. We evaluated the intrahepatic vascular system regarding the presence of normal umbilical drainage and PVS characteristics in the second and third trimester of pregnancy. The associated anomalies and umbilical venous drainage were noted. Follow-up was performed at six months follow-up. Ultrasonography was performed in 3517 cases. A total of 19 cases were prenatally diagnosed: 18 ADV cases, seven abnormal PVS cases, and six associations of the two anomalies. We noted an incidence of 5.1‱ and 1.9‱ for ADV and PVS anomalies, respectively. Out of the 18 ADV cases, 27.7% were isolated. Five cases (26.3%) presented genetic anomalies. PVS anomalies were found in 33.3% of the ADV cases. ADV was present in 85.7% of the PVS anomalies. DV and PVS abnormalities were found with a higher than reported frequency. Normal DV is involved in the normal development of the PVS. Additional fetal anomalies are the best predictor for the outcome of ADV cases. Evaluation of PVS represents a powerful predictor for ADV cases and addresses the long-term prognosis.

Imaging of fetal precordial venous system by four-dimensional ultrasound with spatiotemporal image correlation technology

Despite the use of two- and three- dimensional color Doppler ultrasonography, the prenatal sonographic evaluation of precordial venous system remains difficult. Spatiotemporal image correlation (STIC) technology has been well described for the assessment of the fetal heart, but not of precordial venous system. As demonstrated in this report, it is feasible to use four-dimensional ultrasound with STIC rendered volume in glass-body mode and tomographic ultrasound imaging to image this system including the connection and drainage of the ductus venosus, hepatic veins and inferior vena cava to the fetal heart. This novel approach can increase the understanding of this venous system.

Ultrasound Pitfalls in a Complex Fetal Cardiac Malformation—Case Report of a New Arteriovenous Central Communication

Cardiac and cardiovascular malformations are of real interest in terms of definition, epidemiology, and means of early diagnosis by imaging. Although ultrasound examination reaches exceptional performance nowadays, unusual pathologies are still exposed to the risk of either incorrect acquired image or misinterpretation by the specialist in a routine scan. Herein, we present a case of a 20-week-old fetus (from an apparently low-risk pregnancy) with complex cardiac and vascular abnormalities, including an arteriovenous malformation along with ventricular septal defect, ductal coarctation of the aorta, aneurysm of a brachiocephalic vein, and dilation of the entire neck and upper mediastinum venous system, and the limitations that were encountered in the process of diagnosis and management of the case.

Fetal-TAPSE for Surveillance of Cardiac Function in Growth-Restricted Fetuses With a Portosystemic Shunt

OBJECTIVES

Congenital portosystemic shunt (CPSS) in a growth-restricted fetus may lead to cardiac overload and ultimately hemodynamic imbalance. The aim of the study was to describe the application of tricuspid annular plane systolic excursion (TAPSE) for surveillance of cardiac function in growth-restricted fetuses diagnosed with CPSS.

METHODS

The study group consisted of 7 fetuses with growth restriction diagnosed with CPSS between 2018 and 2020. Patients were followed longitudinally every 2 weeks. Sonographic fetal-TAPSE (f-TAPSE) was performed every 2 weeks. At each visit, the following parameters were recorded: estimated fetal weight, biophysical profile, nonstress test, Doppler flow indices, and fetal cardiothoracic index. Postnatal laboratory and imaging tests were retrieved from the medical files.

RESULTS

Mean gestational age at diagnosis of CPSS was 32 + 1 weeks. Cardiomegaly was observed in all cases. All portosystemic shunts were classified as intrahepatic. Values of f-TAPSE were above the 95th percentile in 6/7 fetuses at presentation and throughout follow-up. Gestational age at delivery ranged between 36 + 5 and 38 + 5 weeks. Postnatally, spontaneous closure of the shunt was noted in 2 infants. Transient hyperammonemia was diagnosed in 2 neonates, with no signs of the characteristic complication.

CONCLUSIONS

In growth-restricted fetuses diagnosed concomitantly with CPSS, f-TAPSE offers a practical sonographic tool for assessment of cardiac function and may serve as an additional clinical marker for follow-up. The appearance of cardiomegaly in growth-restricted fetuses should prompt a dedicated sonographic evaluation of the fetal portal system.

A new classification of congenital abnormalities of UPVS: sonographic appearances, screening strategy and clinical significance

The umbilical–portal venous system (UPVS) plays an important role in embryonic development, as well as a significant blood circulation system to ensure the normal blood supply of fetal heart and brain and other vital organs. Congenital anomalies of UPVS contain many subtypes with a broad spectrum of manifestations and prognoses. Furthermore, because of fetal small lumen of UPVS, the sonographic evaluation remains difficult in utero. Appreciation of normal embryology and anatomy of UPVS is essential to an understanding of sonographic characteristics of anomalies of UPVS and fetal sequential changes. Through reviewing previous references and our experience with congenital abnormalities of UPVS, a new comprehensive classification is proposed. The new classification identifies three types of congenital abnormalities of UPVS based on morphological abnormalities and shunts. The embryology and etiology, sonographic, clinical and prognostic characteristics of each subtype of the new classification are described in detail. Knowledge of congenital abnormalities of UPVS can give sonographers a clue and aid prenatal sonographic diagnosis. The purpose of this article is to help the sonographers to understand the new classification of congenital abnormalities of UPVS, master the sonographic characteristics of each subtype and prenatal ultrasonographic screening strategy, and guide subsequent appropriate counseling and management.

Prenatal diagnosis of the persistent right umbilical vein, incidence and clinical significance

Prenatal diagnosis of persistent right umbilical vein (PRUV) is important due to accompanying malformations. Pregnant women diagnosed with PRUV were analysed retrospectively. Intrahepatic PRUV was seen in 12 of 10.743 foetuses and its incidence was found to be 0.11%. The gestational week at the time of diagnosis was between 20 and 35 weeks. Six of the cases had additional abnormal sonographic findings (50%) and six cases (50%) were isolated. Major congenital malformations were seen in four (33.3%) foetuses, 75% of which were congenital heart disease (CHD). Genitourinary system anomaly accompanied in two cases (16.6%). Invasive diagnostic tests were applied to three pregnant women and the results were reported as normal karyotype. In PRUV cases, a detailed sonographic examination should be performed, especially the cardiovascular system. Although PRUV cases do not appear to be associated with chromosomal abnormalities, invasive diagnostic tests should be recommended in the presence of concomitant anomalies.Impact statementWhat is already known on this subject? The persistent right umbilical vein (PRUV) is a pathological vascular anomaly, in which the left umbilical vein regresses and the right umbilical vein remains open. PRUV can occur in an isolated form that represents its normal variant or be associated with other major or minor anomalies.What do the results of this study add? Additional abnormal sonographic findings were accompanied in 50% of PRUV, major anomaly was detected in 33.3% of them and cardiovascular abnormalities constituted 75% of foetuses with major anomalies.What are the implications of these findings for clinical practice and/or further research? The presence of concomitant anomalies in PRUV cases is not rare and detailed anatomy screening should be done. The most common accompanying abnormality is seen in the cardiovascular system, so foetuses with PRUV should be evaluated by foetal echocardiography.

Intracardiac relation of extrahepatic persistent right umbilical vein

Persistent extrahepatic right umbilical vein without ductus venosus is a rare anomaly of systemic venous drainage and is reported to be associated with cardiac anomalies. We report the case of an 8-year-old boy diagnosed to have an ostium secundum atrial septal defect, in whom an abnormal vascular channel and its opening in the right atrium in close relationship to the inferior vena cava and coronary sinus opening was identified at operation. Post-operative evaluation of this vascular channel was diagnosed to be an extrahepatic persistent right umbilical vein.

Ultrasonic detection of fetal persistent right umbilical vein and incidence and significance of concomitant anomalies

BACKGROUND

Persistent right umbilical vein (PRUV) is characterized by atresia of the left umbilical vein while the right umbilical vein remains open. Given the limited sample size of most studies, the incidence of PRUV and the status of concomitant anomalies may not be fully reflected. Thus, we studied the incidence of fetal PRUV and its concomitant anomalies on a larger scale using our hospital database. This study hoped to address the following questions: Does PRUV increase the risk of fetal anomalies? If the PRUV fetus also has a single umbilical artery (SUA), does the risk of fetal anomaly increase further? What is the positive predictive value of PRUV for fetal anomalies?

METHODS

This retrospective study analyzed 756 cases of fetal PRUV at our hospital from January 2007 to April 2017. Prenatal ultrasound and color Doppler images were assessed. All PRUV fetuses underwent echocardiography and detailed ultrasound examinations of other systems. Newborn status was obtained via the database or by telephone follow-up.

RESULTS

A total of 435,428 pregnant women underwent prenatal ultrasonography at 16-40 weeks, the incidence of fetal PRUV was 0.17%, and 102 fetuses (13.5%) developed other anomalies. Two complicated cases had trisomy 18. PRUV was associated with a higher incidence of fetal anomalies. When fetal anomalies were classified by body systems, PRUV was associated with a higher incidence of cardiovascular, nervous, urinary, skeletal, digestive, and respiratory system anomalies. The positive predictive values of a PRUV for any fetal anomalies and cardiovascular anomalies were 13.5% (95%CI, 11.2-16.2%) and 5.4% (95%CI, 4.0-7.3%), respectively. SUA further increases the risk of PRUV fetuses with other anomalies and cardiovascular anomalies.

CONCLUSIONS

Detailed prenatal ultrasonography and echocardiography should be performed in fetuses with PRUV to rule out anomalies in other systems. When the PRUV is combined with SUA, echocardiography is particularly important. Fetuses with complicated PRUV should undergo chromosomal examination. Although isolated fetal PRUV prognosis is good, complicated PRUV prognosis depends on the type and severity of the concomitant anomalies.

Society for Maternal-Fetal Medicine Consult Series #52: Diagnosis and management of fetal growth restriction: (Replaces Clinical Guideline Number 3, April 2012)

Fetal growth restriction can result from a variety of maternal, fetal, and placental conditions. It occurs in up to 10% of pregnancies and is a leading cause of infant morbidity and mortality. This complex obstetrical problem has disparate published diagnostic criteria, relatively low detection rates, and limited preventative and treatment options. The purpose of this Consult is to outline an evidence-based, standardized approach for the prenatal diagnosis and management of fetal growth restriction. The recommendations of the Society for Maternal-Fetal Medicine are as follows: (1) we recommend that fetal growth restriction be defined as an ultrasonographic estimated fetal weight or abdominal circumference below the 10th percentile for gestational age (GRADE 1B); (2) we recommend the use of population-based fetal growth references (such as Hadlock) in determining fetal weight percentiles (GRADE 1B); (3) we recommend against the use of low-molecular-weight heparin for the sole indication of prevention of recurrent fetal growth restriction (GRADE 1B); (4) we recommend against the use of sildenafil or activity restriction for in utero treatment of fetal growth restriction (GRADE 1B); (5) we recommend that a detailed obstetrical ultrasound examination (current procedural terminology code 76811) be performed with early-onset fetal growth restriction (<32 weeks of gestation) (GRADE 1B); (6) we recommend that women be offered fetal diagnostic testing, including chromosomal microarray analysis, when fetal growth restriction is detected and a fetal malformation, polyhydramnios, or both are also present regardless of gestational age (GRADE 1B); (7) we recommend that pregnant women be offered prenatal diagnostic testing with chromosomal microarray analysis when unexplained isolated fetal growth restriction is diagnosed at <32 weeks of gestation (GRADE 1C); (8) we recommend against screening for toxoplasmosis, rubella, or herpes in pregnancies with fetal growth restriction in the absence of other risk factors and recommend polymerase chain reaction for cytomegalovirus in women with unexplained fetal growth restriction who elect diagnostic testing with amniocentesis (GRADE 1C); (9) we recommend that once fetal growth restriction is diagnosed, serial umbilical artery Doppler assessment should be performed to assess for deterioration (GRADE 1C); (10) with decreased end-diastolic velocity (ie, flow ratios greater than the 95th percentile) or in pregnancies with severe fetal growth restriction (estimated fetal weight less than the third percentile), we suggest weekly umbilical artery Doppler evaluation (GRADE 2C); (11) we recommend Doppler assessment up to 2-3 times per week when umbilical artery absent end-diastolic velocity is detected (GRADE 1C); (12) in the setting of reversed end-diastolic velocity, we suggest hospitalization, administration of antenatal corticosteroids, heightened surveillance with cardiotocography at least 1-2 times per day, and consideration of delivery depending on the entire clinical picture and results of additional evaluation of fetal well-being (GRADE 2C); (13) we suggest that Doppler assessment of the ductus venosus, middle cerebral artery, or uterine artery not be used for routine clinical management of early- or late-onset fetal growth restriction (GRADE 2B); (14) we suggest weekly cardiotocography testing after viability for fetal growth restriction without absent/reversed end-diastolic velocity and that the frequency be increased when fetal growth restriction is complicated by absent/reversed end-diastolic velocity or other comorbidities or risk factors (GRADE 2C); (15) we recommend delivery at 37 weeks of gestation in pregnancies with fetal growth restriction and an umbilical artery Doppler waveform with decreased diastolic flow but without absent/reversed end-diastolic velocity or with severe fetal growth restriction with estimated fetal weight less than the third percentile (GRADE 1B); (16) we recommend delivery at 33-34 weeks of gestation for pregnancies with fetal growth restriction and absent end-diastolic velocity (GRADE 1B); (17) we recommend delivery at 30-32 weeks of gestation for pregnancies with fetal growth restriction and reversed end-diastolic velocity (GRADE 1B); (18) we suggest delivery at 38-39 weeks of gestation with fetal growth restriction when the estimated fetal weight is between the 3rd and 10th percentile and the umbilical artery Doppler is normal (GRADE 2C); (19) we suggest that for pregnancies with fetal growth restriction complicated by absent/reversed end-diastolic velocity, cesarean delivery should be considered based on the entire clinical scenario (GRADE 2C); (20) we recommend the use of antenatal corticosteroids if delivery is anticipated before 33 6/7 weeks of gestation or for pregnancies between 34 0/7 and 36 6/7 weeks of gestation in women without contraindications who are at risk of preterm delivery within 7 days and who have not received a prior course of antenatal corticosteroids (GRADE 1A); and (21) we recommend intrapartum magnesium sulfate for fetal and neonatal neuroprotection for women with pregnancies that are <32 weeks of gestation (GRADE 1A).

Gradual diagnosis and clinical importance of prenatally detected persistent left superior vena cava with absent right superior vena cava - a case report and literature review

Persistent left superior vena cava is a malformation of cardinal veins. We report a case of a secundigravida who had many fetal ultrasound examinations – first performed by an obstetrician (who described fetal mediastinum as “abnormal”), second by other obstetrician, who performed basic fetal echocardiographic examination and diagnosed persistent left superior vena cava. The woman was referred to a tertiary center for detailed fetal echocardiography. The diagnosis of persistent left superior vena cava with agenesis of the right superior vena cava was confirmed. The anomaly had no influence on fetal hemodynamic stability, fetal life, delivery and early postnatal period. After delivery, the neonate was under observation for further anomalies, aortic coarctation in particular. Prenatal and postnatal management was summarized. Literature review is presented.

Preeclampsia: Risk Factors, Diagnosis, Management, and the Cardiovascular Impact on the Offspring

Hypertensive disorders of pregnancy affect up to 10% of pregnancies worldwide, which includes the 3%–5% of all pregnancies complicated by preeclampsia. Preeclampsia is defined as new onset hypertension after 20 weeks’ gestation with evidence of maternal organ or uteroplacental dysfunction or proteinuria. Despite its prevalence, the risk factors that have been identified lack accuracy in predicting its onset and preventative therapies only moderately reduce a woman’s risk of preeclampsia. Preeclampsia is a major cause of maternal morbidity and is associated with adverse foetal outcomes including intra-uterine growth restriction, preterm birth, placental abruption, foetal distress, and foetal death in utero. At present, national guidelines for foetal surveillance in preeclamptic pregnancies are inconsistent, due to a lack of evidence detailing the most appropriate assessment modalities as well as the timing and frequency at which assessments should be conducted. Current management of the foetus in preeclampsia involves timely delivery and prevention of adverse effects of prematurity with antenatal corticosteroids and/or magnesium sulphate depending on gestation. Alongside the risks to the foetus during pregnancy, there is also growing evidence that preeclampsia has long-term adverse effects on the offspring. In particular, preeclampsia has been associated with cardiovascular sequelae in the offspring including hypertension and altered vascular function.

Detailed Fetal Anatomic Ultrasound Examination: Effect of the 2014 Consensus Report on a Tertiary Referral Center

This study evaluates the impact of extended cardiac views on examination time, repeat imaging, and anomaly detection before and after implementation of 76811 guidelines (American Institute of Ultrasound in Medicine Consensus 2014). It is a retrospective study of singleton pregnancies undergoing detailed ultrasound imaging at 18 weeks' gestation or greater before and after the protocol change in an academic, tertiary care fetal center. Views required prior to 2014: 4-chamber, left outflow tract, right outflow tract. Additional views required after 2014: bicaval, aortic arch, 3-vessel, and 3-vessel trachea. Fetuses with known anomalies were excluded. Rates of detection of congenital heart disease (CHD), examination completion, repeat examination recommendation, fetal echocardiogram recommendation, completion by body mass index, and cardiac examination time were determined. Six hundred twenty-four subjects were included, 217 before and 407 after protocol change. Views obtained were as stated in the American Institute of Ultrasound in Medicine/Society for Maternal-Fetal Medicine consensus. Detection of CHD was not improved. Examination times increased by 20% (6.4 vs 7.7 minutes, P < 0.05). Number of incomplete studies increased by 130% (11% to 26%, P < 0.05). Twice as many patients were referred for repeat examination (6% vs 13%, P < 0.05). Completion rates were negatively correlated with body mass index. Recommendations for fetal echocardiogram were unchanged (5% vs 6%, P = 0.6). Additional imaging did not increase detection rate of CHD (3% vs 2%, P = 0.3). Extended cardiac views resulted in increased examination time, more incomplete examinations, and more repeat examinations without changing detection rates of CHD.

Ductus Venosus Agenesis as a Marker of Pallister-Killian Syndrome

The ductus venosus (DV) is a shunt that allows the direct flow of well-oxygenated blood from the umbilical vein (UV) to the coronary and cerebral circulation through the foramen ovale. Its agenesis has been associated with chromosomal abnormalities and rare genetic syndromes, structural defects, intrauterine growth restriction (IUGR) and even antepartum fetal demise. Pallister–Killian Syndrome (PKS) is a rare sporadic disorder with specific tissue mosaic distribution of an extra 12p isochromosome (i(12p)). Its main clinical features are moderate to severe intellectual disability/neuromotor delay, skin pigmentation abnormalities, typical facial appearance, variable association with multiple congenital malformations and epilepsy. Though prenatal findings (including congenital diaphragmatic hernia, ventriculomegaly, congenital heart disease, polyhydramnios, and rhizomelic shortening) have been described in literature, prenatal diagnosis is difficult as there are no associated identification signs no distinctive or pathognomonic signs, and some of these malformations are hard to identify prenatally. The tissue mosaicism linked to this syndrome and the decrease of the abnormal clone carrier of the i(p12) after successive trypsinizations of cultured cells makes the diagnosis even more challenging. We present the case of a 27.5 weeks pregnant woman with a fetal ductus venosus agenesis (DVA) as the main guide marker. To our knowledge this is the first case published in literature reporting a DVA as a guide sign to diagnose a complex condition as Pallister–Killian syndrome. We also underscore the key role of new genetic techniques as microarrays to avoid misdiagnosis when only a subtle sonographic sign is present in complex conditions like this.

Modern Ultrasonography of the Umbilical Cord: Prenatal Diagnosis of Umbilical Cord Abnormalities and Assessement of Fetal Wellbeing

The umbilical cord is the only connection between the mother and the fetus, through which it is possible to transport respiratory gases, nutrients, and metabolites. Thanks to the umbilical cord, the fetus has also the ability to move, which is necessary for its proper psychomotor development. The correct structure and function of umbilical vessels and the entire umbilical cord determine the possibility of proper development and survival of the fetus. Umbilical cord anatomy should be assessed in the ultrasound examination in the first trimester. It is of vital importance to confirm the correct number of umbilical vessels and their intra-abdominal course, as well as carefully assessing the abdominal and placental insertion sites. In the latter half of pregnancy, the use of the Doppler imaging enables assessment of the function of the fetal-placental vessels, thus providing valuable information about the condition of the fetus.

Ductus venosus-systemic shunt. Report of six cases and systematic review of the literature

Objective: To evaluate the ultrasonographic features and pregnancy outcomes in women with ductus venosus-systemic shunt and systematic review of the literature.Method: A computerized search was conducted to identify cases of ductus venosus-systemic shunt between September 2016 and January 2018. Six patients were identified. Antenatal records and neonatal outcomes are presented. A systematic Embase, SCOPUS, and Medline search of published literature from 1991 to 2018 was performed using the terms "ductus venosus," "agenesis," "absence," "absent," "missing," "aberrant," and "variant."Results: Additional structural anomaly such as esophageal atresia with tracheoesophageal fistula was observed in one case. In other case, termination of pregnancy was performed due to Down syndrome. Other two of the six fetuses were monochorionic multiple pregnancies. In our review of the literature, additional anomalies were observed in 9 (42%) of the 21 cases.Conclusion: Our observation suggests that ductus venosus-systemic shunt can be associated with Down syndrome. Detailed examination should be performed to rule out additional abnormalities. Prognosis is good if the pathology is isolated.

Prenatal sonographic characteristics and postnatal outcomes of umbilical-portal-systemic venous shunts under the new in-utero classification: A retrospective study

An in-utero re-classification of umbilical-portal-systemic venous shunt (UPSVS) has recently been proposed. We retrospectively reviewed the sonograms of a large cohort of fetuses, identified and analyzed UPSVS cases, and presented the prenatal sonographic characteristics, birth outcomes, and follow-up results following the new classification system.Sonograms and clinical data of all participants who visited our departments from April 2016 to July 2018 were retrospectively reviewed. Identified cases of UPSVS were analyzed according to the new classification: Type I: umbilical-systemic shunt (USS); Type II: ductus venosus-systemic shunt (DVSS); Type IIIa: intrahepatic portal-systemic shunt (IHPSS) and Type IIIb: extrahepatic portal-systemic shunt (EHPSS). Postnatal follow-ups ranged from 3 months to 1 year.A total of 10 UPSVS cases were identified in 61,082 fetuses: 4 with Type I, 3 with Type II and 3 with Type IIIa. All 4 cases of USS had complete agenesis of the portal venous system, and had the umbilical vein drained into the inferior vena cava. Two USS cases also had trisomy 21. Pregnancy was terminated in all cases with a Type I shunt. Two fetuses with DVSS had normal portal venous system and were born full term. The pregnancy of 1 DVSS case was terminated due to the detection of trisomy 21. Three cases were IHPSS with full-term birth. One had chromosomal abnormality and 1 had surgery to repair the shunt 12-days post birth. In the 2 cases that did not receive repair surgery, sonographic examination revealed the portal-hepatic venous shunt was not closed at the 6-month follow-up period. However, the 1 case that had repair surgery appeared healthy at the 3-month follow-up period.UPSVS is extremely rare. Type I shunts have the poorest prognosis, and the presence of the intrahepatic portal venous system is key to live birth in UPSVS regardless of types. Chromosomal abnormalities and other organ anomalies can occur in any types of UPSVS. Therefore, karyotyping and examination of other organs should be performed once UPSVS is detected.

Ductus venosus agenesis and fetal malformations: what can we expect? - a systematic review of the literature

Background The ductus venosus agenesis (DVA) is a rare condition with a variable prognosis that relies partly on the presence of associated conditions. The purpose of our study was to analyze the literature regarding the post-natal outcome of fetuses with DVA associated with fetal malformations, in order to discuss the best management options for couples. Methods We performed a systematic review of the literature of MEDLINE and SCOPUS electronic databases in a 25-year period from 1992 to September 2017. Methods We found 340 cases of DVA associated with fetal abnormalities. The most common chromosomal abnormalities were: monosomy X (12/48, 25%), trisomy 21 (11/48, 22.9%) and trisomy 18 (6/48, 12.5%). From the 340 cases with DVA, in 31 cases the umbilical venous shunt type was not reported. Of the fetuses, 60.8% (188/309) had an extrahepatic umbilical venous drainage while 39.2% (121/309) presented an intrahepatic connection. The DVA was associated in 71 cases (23.0%) with cardiac abnormalities, in 82 cases (26.5%) with extracardiac abnormalities and in 85 cases (27.5%) with both cardiac and extracardiac abnormalities. Conclusion DVA associated with both cardiac and extracardiac malformations may confer a poorer fetal outcome, a clinically relevant fact that should clarify what can be expected from this entity and help prenatal counseling.

Anatomy of the Right Anterior Sector of the Liver and Its Clinical Implications in Surgery

BACKGROUND

Surgery remains the gold standard both for delimited hepatocellular carcinoma by selective anatomic liver segentectomy and for colorectal liver metastases by parenchymal sparing liver resection. Right anterior sector (RAS) (segments V-VIII; Couinaud) is the largest and most difficult sector to operate on. A better knowledge of its segmentation could prevent postoperative remnant liver ischemia and its impacts on patient's survival.

METHODS

A literature search was conducted in PubMed for papers on anatomy and surgery of the right anterior sector.

RESULTS

Segmentation of the RAS depended of the anatomic variations of the third-order portal branches. Cranio-caudal segmentation was the most commonly found (50-53%), followed by ventro-dorsal (23-26%), trifurcation (13-20%), and quadrifurcation types (5-11%). Ventral and dorsal partial or total subsegmentectomy seemed accessible in 47 to 50% of patients, including bifurcation, trifurcation, and quadrifurcation types, and could spare up to 22% of the total liver volume. The RAS hepatic vein was present in 85-100% of the patients and could be used as a landmark between RAS dorsal and ventral part in 63% of patients. Reported overall morbidity rate of RAS subsegmentectomy ranged from 33 to 59% among studies with a postoperative major complication rate (Clavien-Dindo ≥ III) ranging around 18% and a biliary leakage rate from 16 to 21%. In-hospital reported mortality rate was low (0-3%), and results were comparable to "classic" liver resections. RAS subsegmentectomy remains a complex procedure; median operating time ranged from 253 to 520 min and median intraoperative blood loss reached 1255 ml.

CONCLUSION

Better knowledge of RAS anatomy could allow for parenchymal preservation by using subsegmentectomy of the RAS, selective or as a part of a major hepatectomy.

Prenatal diagnosis of persistent right umbilical vein - Incidence and clinical impact. A prospective study

Background

Persistent right umbilical vein (PRUV) is usually an isolated finding but it may be accompanied by other fetal malformations.

Aims

We aimed to determine the incidence of prenatally diagnosed PRUV in a referral population, assess the neonatal outcome and discuss the findings together with those from previous publications.

Materials and methods

A total of 2360 women with low‐risk singleton pregnancies were examined in the second and third trimesters. A transabdominal convex volume transducer was used. B‐mode was applied in each patient. Scanning of the venous system included imaging of the target vessels with two‐dimensional colour Doppler mapping. The diagnosis of PRUV was made in a transverse section of the fetal abdomen. Three‐dimensional ultrasounds were performed as necessary, when anomalous cases were encountered.

Results

The incidence of PRUV in our population was 12/2360 = 0.5%, and it was higher than in other retrospective studies. In 75% (n = 9), PRUV was an isolated finding where delivery was uneventful and the postnatal outcome was favourable. In two cases PRUV was accompanied by omphalocele, and in one case by tetralogy of Fallot and single umbilical artery.

Conclusions

PRUV is an uncommon prenatal finding. Screening for this anomaly can be easily performed in all pregnant patients. A diagnosis of PRUV should be followed by a thorough fetal morphology scan in order to exclude any other malformations, especially those of the cardiovascular system.

A Rare Vascular Anomaly during Central Venous Catheterization: A Persistent Left-Sided Superior Vena Cava

A persistent left-sided superior vena cava (PLSVC) is the most frequent abnormality of the venous system; however, it is not a very well-known variation among physicians. Herein we report the case of a patient with a PLSVC who was diagnosed after central venous catheterization (CVC). An 80-year-old man was admitted to the emergency room with cardiopulmonary arrest. After the return of spontaneous circulation, CVC was blindly performed from the left jugular vein without any complications. However, routine chest X-ray after catheterization revealed that the catheter was moving down directly to the left heart. Thoracic computed tomography showed the right brachiocephalic vein draining into the left brachiocephalic vein and forming the left superior vena cava in front of the aortic arch. The left superior vena cava merged into the right atrium after crossing the left pulmonary artery. CVC is widely used in clinical practice, and therefore clinicians should be aware of possible variations in central veins, particularly during blind catheterization.

Congenital absence of the portal vein in a cat

CASE SUMMARY

A 9-month-old female neutered domestic shorthair cat presented with a history of episodic ptyalism, lethargy and abnormal behaviour. The clinical signs together with elevated pre- and post-prandial bile acid concentrations were consistent with hepatic encephalopathy (HE). In the absence of a portosystemic shunt (PSS) on abdominal ultrasound, medical management of HE was established with a protein-restricted diet and lactulose and the neurological signs resolved. Following an episode of acute vomiting and haemorrhagic diarrhoea at 19 months of age abdominal ultrasonography was repeated. The portal vein could not be demonstrated ultrasonographically; instead, portal vein tributaries were tortuous and communicated with the caudal vena cava (CdVC) at the level of the left kidney. CT angiography (CTA) confirmed the absence of the portal vein. CTA demonstrated the tortuous terminations of the portal tributaries, and several systemic veins, draining into the CdVC via a large-diameter paracaval vessel at the level of the left kidney. Gastrointestinal signs were stabilised and medical management for HE of a protein-restricted diet and lactulose was re-established.

RELEVANCE AND NOVEL INFORMATION

Congenital absence of the portal vein has not been described previously in the cat and should be considered in cats presenting with signs suggestive of a PSS and HE. The portal vein in the cat can be demonstrated using ultrasound, but complex congenital vascular malformations of the portal or systemic abdominal veins should be characterised using CTA and further distinguished from other vascular anomalies that may present with similar ultrasonographic features.

Intrauterine Growth Restriction. Guideline of the German Society of Gynecology and Obstetrics (S2k-Level, AWMF Registry No. 015/080, October 2016)

AIMS

The aim of this official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG) was to provide consensus-based recommendations obtained by evaluating the relevant literature for the diagnostic treatment and management of women with fetal growth restriction.

METHODS

This S2k guideline represents the structured consensus of a representative panel of experts with a range of different professional backgrounds commissioned by the Guideline Committee of the DGGG.

RECOMMENDATIONS

Recommendations for diagnostic treatment, management, counselling, prophylaxis and screening are presented.

Echographic features and perinatal outcomes in fetuses with congenital absence of ductus venosus

INTRODUCTION

The purpose of this study was to describe the echographic features and perinatal outcomes of fetuses with absence of ductus venosus.

MATERIAL AND METHODS

Retrospective review of 10 cases with absence of ductus venosus diagnosed by prenatal ultrasonography between January 2014 and February 2016 at a single referral center. Prenatal findings, umbilical shunting type, perinatal outcomes, and autopsy reports were reviewed.

RESULTS

A total of 11 491 fetuses underwent a first- and second-trimester screening during the study period. Ten cases of absence of ductus venosus were diagnosed. All of the fetuses presented an extrahepatic shunt: three fetuses from the umbilical vein to the right atrium and the seven remaining fetuses from the umbilical vein to the inferior vena cava. Major structural defects and fetal effusions were detected in six fetuses. There were two cases of chromosomal abnormalities. Five patients underwent legal termination of pregnancy and five decided to carry to term. In two of these, the absence of ductus venosus anomaly was isolated and had a normal outcome. In the remaining three cases, a follow up of the children showed a variety of adverse outcomes.

CONCLUSIONS

The absence of ductus venosus is associated with high rates of adverse perinatal outcomes. The prognosis for this group of anomalies depends on the additional findings with targeted ultrasound. This pathology should lead to a detailed anatomical study and affected fetuses should be closely monitored for signs of congestive heart failure.

Organogenesis and foetal haemodynamics during the normal gestation of healthy black-rumped agoutis (Dasyprocta prymnolopha, Wagler, 1831) bred in captivity

The objective of this study was to define the patterns of organogenesis and foetal haemodynamics during the normal gestation of healthy agoutis (Dasyprocta prymnolopha) kept in captivity. Thirty pregnant agoutis that ranged in size from small to medium and weighed between 2.5 and 3 kg underwent B-mode and Doppler ultrasonography for the biometric evaluation of the foetal organs. The foetal aortic blood flow proved to be predominantly systolic, and the measured flow velocity was 78.89 ± 2.95 cm/s, with a maximum pressure gradient of 2.12 ± 0.27 mmHg. The liver was characterized by its large volume, occupying the entire cranial aspect of the abdominal cavity, and it was associated cranially with the diaphragm and caudally with the stomach. The flow velocity in the portal vein was estimated to equal 12.17 ± 2.37 cm/s, with a resistivity index of 0.82 ± 0.05. The gallbladder was centrally located and protruded cranially towards the diaphragm. The spleen was visualized as an elongated structure with tapered cranial and caudal extremities, and the foetal kidneys were visualized bilaterally in the retroperitoneal region, with the right kidney positioned slightly more cranially than the left. The morphological characterization and hemodynamic analysis of the foetal organs of black-rumped agoutis via B-mode and Doppler ultrasonography allow determination of the vascular network and of reference values for the blood flow required for perfusing the anatomical elements essential for maintaining the viability of foetuses at different gestational ages.

Intrauterine Growth Restriction: Antenatal and Postnatal Aspects

Intrauterine growth restriction (IUGR), a condition that occurs due to various reasons, is an important cause of fetal and neonatal morbidity and mortality. It has been defined as a rate of fetal growth that is less than normal in light of the growth potential of that specific infant. Usually, IUGR and small for gestational age (SGA) are used interchangeably in literature, even though there exist minute differences between them. SGA has been defined as having birth weight less than two standard deviations below the mean or less than the 10th percentile of a population-specific birth weight for specific gestational age. These infants have many acute neonatal problems that include perinatal asphyxia, hypothermia, hypoglycemia, and polycythemia. The likely long-term complications that are prone to develop when IUGR infants grow up includes growth retardation, major and subtle neurodevelopmental handicaps, and developmental origin of health and disease. In this review, we have covered various antenatal and postnatal aspects of IUGR.

Fetal umbilical-portal-systemic venous shunt: in-utero classification and clinical significance

OBJECTIVES

To review our experience with fetal umbilical-portal-systemic venous shunts (UPSVS), to devise an in-utero classification system, and to analyze their clinical and prognostic characteristics.

METHODS

This was a retrospective review of cases of UPSVS examined at an academic tertiary referral center over the 14-year period from 2001 to 2014 inclusive. The anatomical origin and drainage of the fetal umbilical, portal, ductus venosus and hepatic venous systems, and the integrity of the intrahepatic portal venous system (IHPVS), were assessed using two- and three-dimensional color Doppler sonography. Fetomaternal clinical characteristics and long-term outcome were investigated by means of medical files, imaging documentation and telephone interviews with the mothers.

RESULTS

Forty-four cases with UPSVS were reviewed. Prenatal classification was based on the anatomical origin of the shunt (umbilical, portal or ductal), with cases classified into four types: Type I, umbilical-systemic shunt (n = 9 (20.4%)); Type II, ductus venosus-systemic shunt (n = 19 (43.2%)); and Type III, portal-systemic shunt, divided into two subtypes: Type IIIa, intrahepatic portal-systemic shunt (n = 12 (27.2%)) and Type IIIb, extrahepatic portal-systemic shunt (n = 4 (9.1%)). Each type presented particular clinical and prognostic characteristics. The most important favorable prognostic factors were absence of associated major malformation and presence of the IHPVS. Thus, Type IIIa (intrahepatic portal-systemic shunt) had the best outcome.

CONCLUSIONS

Fetal UPSVS are anomalies with a broad spectrum of manifestations and prognoses. Accurate mapping of the IHPVS is paramount for optimizing prenatal counseling and postnatal care. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Ductus venosus Doppler in the assessment of fetal cardiovascular health: an updated practical approach

The ductus venosus has a central role in the distribution of highly oxygenated umbilical venous blood to the heart. Its waveform is related to the pressure-volume changes in the cardiac atria and it is therefore important in the monitoring of any fetal condition that may affect forward cardiac function. The cardiovascular parameters that can influence forward cardiac function include afterload, myocardial performance and preload. Decreased forward flow during atrial systole (a-wave) is the most sensitive and ubiquitous finding when any of these parameters is affected. In contrast, decreased forward velocities during end-systolic relaxation (v-wave) are more specifically related to myocardial performance. The ductus venosus pulsatility index alone does not accurately reflect cardiac function, and in cases of suspected fetal cardiac dysfunction, echocardiography is required to identify the underlying mechanism. The role of ductus venosus Doppler in the assessment of fetal growth restriction, supraventricular tachycardia, fetal hydrops, complicated monochorionic twins and congenital heart disease is discussed with these considerations in mind.

[Total isolated anomalous pulmonary venous return: Are there any clues for prenatal screening?]

Total anomalous pulmonary venous connection (TAPVC) is a serious congenital anomaly. TAPVC with obstruction of pulmonary venous return is an emergency requiring urgent intervention. Before 2010, very few isolated TAPVC were diagnosed prenatally. It has been suggested in the past literature that the use of Color flow Doppler is particularly useful for the screening of TAPVC prenatally. In fact, although color-Doppler is often useful to confirm a TAPVC diagnosis, it can be quite misleading in the screening process of the condition. Looking at data of missed TAPVC, we describe how to identify TAPVC during routine cardiac screening. Since 2010, our isolated TAPVC prenatal diagnosis rate is more than 40%.

Systematic examination of the fetal abdominal precordial veins: a cohort study

OBJECTIVES

Examination of the fetal venous system is a necessary part of complete fetal organ scanning to confirm landmark anatomy, such as the ductus venosus and course of the umbilical veins, and, whenever cardiovascular anomalies are identified, to exclude associated anomalous development of the fetal veins. We aimed to develop a protocol for systematic examination of the fetal venous system during midtrimester targeted organ scanning.

METHODS

We included low-risk women with a singleton fetus presenting between January 2011 and June 2013 to our center for routine midtrimester (20-24 weeks) targeted organ scanning. Imaging of the venous system was added to the booked scan and comprised two-dimensional color Doppler scanning of the fetal abdomen in three discrete planes, two transverse and one longitudinal. The more caudal plane was obtained in a ventral or lateral transverse abdominal plane to image the umbilical vein, left portal vein, portal sinus, anterior right portal vein, posterior right portal vein, main portal vein and splenic vein and artery. Moving cephalad, a ventral or lateral transverse plane was obtained to image the right, middle and left hepatic veins and inferior vena cava (IVC). Finally, a longitudinal anteroposterior plane showed the umbilical vein, ductus venosus, IVC and left hepatic vein. In some cases the pulsed Doppler waveform of a given target vessel was also examined. Three-dimensional/4D ultrasound was applied as necessary, when anomalous cases were encountered.

RESULTS

We examined 1810 women. Their body mass index ranged from 19 to 40 (mean, 24.7). In 38 (2.1%) women, the target anatomy was not visualized satisfactorily owing to maternal body habitus. A T-shaped configuration of the portal system vessels was observed in 63% of cases, an X-shaped configuration in 25% and an H-shaped configuration in 12%. During the study period, 24 congenital anomalies of the precordial venous system were diagnosed: nine cases of persistent right umbilical vein, seven of agenesis of the ductus venosus, five of anomalous portal venous drainage and three of interrupted IVC with azygos continuation.

CONCLUSIONS

Examination of the fetal venous system is feasible with the application of three abdominal planes. While a venous system scan is not practicable as part of a screening-level examination, mastery of the normal anatomy is an essential part of the professional knowledge base, in order to provide ready and complete scanning of the system in cases of suspected anomalies or disordered cardiac function.

IUGR management: new perspectives

AIM OF THE STUDY

Analyzing velocimetric (umbilical artery, UA; ductus venosus, DV; middle cerebral artery, MCA) and computerized cardiotocographic (cCTG) (fetal heart rate, FHR; short term variability, STV; approximate entropy, ApEn) parameters in intrauterine growth restriction, IUGR, in order to detect early signs of fetal compromise. POPULATION STUDY: 375 pregnant women assisted from the 28th week of amenorrhea to delivery and monitored through cCTG and Doppler ultrasound investigation. The patients were divided into three groups according to the age of gestation at the time of delivery, before the 34th week, from 34th to 37th week, and after the 37th week. Data were analyzed in relation to the days before delivery and according to the physiology or pathology of velocimetry. Statistical analysis was performed through the t-test, chi-square test, and Pearson correlation test (P < 0.05). Our results evidenced an earlier alteration of UA, DV, and MCA. The analysis between cCTG and velocimetric parameters (the last distinguished into physiological and pathological values) suggests a possible relation between cCTG alterations and Doppler ones. The present study emphasizes the need for an antenatal testing in IUGR fetuses using multiple surveillance modalities to enhance prediction of neonatal outcome.